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Jiang W, Liang Y, Long Z, Hu M, Yang H, Qin X. Endovenous radiofrequency ablation vs laser ablation in patients with lower extremity varicose veins: A meta-analysis. J Vasc Surg Venous Lymphat Disord 2024; 12:101842. [PMID: 38316290 DOI: 10.1016/j.jvsv.2024.101842] [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: 09/26/2023] [Revised: 01/17/2024] [Accepted: 01/20/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND Endovenous radiofrequency ablation (RFA) and laser ablation (LA) have been commonly used for treating lower extremity varicose veins (LEVVs). Their therapeutic effects have been widely recognized compared with conventional surgery. However, there have been some controversies regarding the choice between RFA and LA. The objective of our study was to conduct a systematic review and meta-analysis comparing the early and long-term outcomes of RFA and LA. METHODS A comprehensive search was performed in the PubMed, Embase, and Cochrane databases to identify relevant literature on endovenous thermal ablation for primary LEVV up until June 2023. Randomized controlled trials, cohort studies, and case-control studies involving RFA and LA for LEVV treatment were included. The primary endpoints were the occlusion rate of the great saphenous vein (GSV) and occurrence of venous thrombotic events. Secondary outcomes included nerve injury, hyperpigmentation, burns, recurrence of VVs, postoperative pain, and phlebitis. Data were analyzed using Review Manager 5.3 software. RESULTS A total of 29 studies met the inclusion criteria, consisting of 16 randomized controlled trials and 13 cohort studies. At 1 month, the occlusion rates of GSV were 98.35% for RFA and 98.04% for LA, whereas at 1 year, the rates were 93.13% for RFA and 94.18% for LA. Subgroup analyses revealed that RFA had higher GSV occlusion rates at 1 year since 2016 (93.27% vs 91.24%; odds ratio [OR], 1.35; 95% confidence interval [CI], 1.0-1.83; P = .05). The incidence of postoperative venous thrombotic events was 0.78% for RFA and 0.87% for LA at 1 month (OR, 1.46; 95% CI, 0.77-2.74; P = .24). RFA showed a reduced risk of burns and ecchymosis (OR, 0.65; 95% CI, 0.48-0.87; P = .005), postprocedural pain (mean difference, -0.85; 95% CI, -1.06 to -0.64; P < .001), recurrence of VVs (OR, 0.58; 95% CI, 0.36-0.92; P = .02), and paresthesia since 2016 (OR, 0.42; 95% CI, 0.19-0.91; P = .03), but an increased risk of skin pigmentation (OR, 1.75; 95% CI, 1.06-2.9; P = .03) compared with LA therapy. The rate of phlebitis was similar between RFA and LA (OR, 0.87; 95% CI, 0.33-2.27; P = .78). CONCLUSIONS RFA and LA demonstrated similar efficacy in terms of early and long-term occlusion rates of GSV and the incidence of thrombotic and phlebitis complications. However, since 2016, RFA has shown higher GSV occlusion rates compared with LA. Furthermore, RFA was associated with fewer complications such as paresthesia, burns and ecchymosis, and recurrence of VVs when compared with LA.
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Affiliation(s)
- Wenhong Jiang
- Department of Vascular Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Yanying Liang
- Department of Vascular Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Zhen Long
- Department of Vascular Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Ming Hu
- Department of Vascular Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Han Yang
- Department of Vascular Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Xiao Qin
- Department of Vascular Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China.
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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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Zheng G, Xie H, Lai M, Qin B, Liu X. Comparison of two ablation procedures combined with high ligation and foam sclerotherapy and compression therapy for patients with venous leg ulcers. Postgrad Med 2024; 136:514-522. [PMID: 38861319 DOI: 10.1080/00325481.2024.2366155] [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: 01/11/2024] [Accepted: 06/06/2024] [Indexed: 06/13/2024]
Abstract
AIM To compare the ablation techniques' efficacy of endovenous microwave ablation (EMA) combined with high ligation (HL), foam sclerotherapy (FS) and compression therapy (CT) and endovenous laser ablation (EVLA) combined with HL-FS-CT in the treatment of VLUs. METHOD 301 consecutive patients with VLUs from 2013 to 2022 in a 3200-bed hospital were intervened by EMA combined with HL-FS-CT and EVLA combined with HL-FS-CT were retrospectively compared. RESULTS One hundred thirty-four patients underwent EMA+HL-FS-CT and 167 patients underwent EVLA+HL-FS-CT. The primary outcome of the ulcer healing time was 1.45(0.75-1.5) months and 1.86(0.5-2.5) months, respectively, in the two groups (HR for ulcer healing was 1.26, 95% CI [0.96-1.66], p = 0.097). Secondary outcomes included that no significant difference was found in ulcer recurrence and GSV recanalization and complications between the two groups, and the postoperative VCSS and AVVQ were significantly lower than the baseline values in the respective groups (p = 0.0001). CONCLUSION EMA+HL-FS-CT and EVLA+HL-FS-CT are both effective at treating VLUs. Both of the two comprehensive treatments were beneficial to the healing of ulcers, but no evidence showed which one was superior in the ulcer healing time.
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Affiliation(s)
- Guofu Zheng
- Department of General Surgery, Ganzhou People's Hospital, Ganzhou, Jiangxi, People's Republic of China
| | - Hailiang Xie
- Department of General Surgery, Ganzhou People's Hospital, Ganzhou, Jiangxi, People's Republic of China
| | - Minggui Lai
- Department of General Surgery, Ganzhou People's Hospital, Ganzhou, Jiangxi, People's Republic of China
| | - Bao Qin
- Department of General Surgery, Ganzhou People's Hospital, Ganzhou, Jiangxi, People's Republic of China
| | - Xiaochun Liu
- Department of General Surgery, Ganzhou People's Hospital, Ganzhou, Jiangxi, People's Republic of China
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Kikuchi R, Nhuch C, Drummond DAB, Santiago FR, Coelho F, Mauro FDO, Silveira FT, Peçanha GP, Merlo I, Corassa JM, Stambowsky L, Figueiredo M, Takayanagi M, Gomes Flumignan RL, Evangelista SSM, Campos W, Joviliano EE, de Araujo WJB, de Oliveira JCP. Brazilian guidelines on chronic venous disease of the Brazilian Society of Angiology and Vascular Surgery. J Vasc Bras 2023; 22:e20230064. [PMID: 38021274 PMCID: PMC10648055 DOI: 10.1590/1677-5449.202300642] [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: 05/11/2023] [Accepted: 08/01/2023] [Indexed: 12/01/2023] Open
Abstract
The Brazilian Society of Angiology and Vascular Surgery has set up a committee to provide new evidence-based recommendations for patient care associated with chronic venous insufficiency. Topics were divided in five groups: 1. Classification, 2. Diagnosis, 3. Conservative or non-invasive treatment, 4. Invasive treatment and 5. Treatment of small vessels. This last series is closely related to the activities of Brazilian angiologists and vascular surgeons, who are heavily involved in the treatment of small superficial veins. These guidelines are intended to assist in clinical decision-making for attending physicians and health managers. The decision to follow a guideline recommendation should be made by the responsible physician on a case-by-case basis taking into account the patient's specific condition, as well as local resources, regulations, laws, and clinical practice recommendations.
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Affiliation(s)
- Rodrigo Kikuchi
- Sociedade Brasileira de Angiologia e Cirurgia Vascular – SBACV, São Paulo, SP, Brasil.
- Faculdade de Ciências Médicas Santa Casa de São Paulo – FCMSCSP, São Paulo, SP, Brasil.
- Instituto de Excelência Vascular, Londrina, PR, Brasil.
| | - Claudio Nhuch
- Sociedade Brasileira de Angiologia e Cirurgia Vascular – SBACV, São Paulo, SP, Brasil.
- Clínica Vascular, Porto Alegre, RS, Brasil.
| | - Daniel Autran Burlier Drummond
- Sociedade Brasileira de Angiologia e Cirurgia Vascular – SBACV, São Paulo, SP, Brasil.
- Pontifícia Universidade Católica do Rio de Janeiro – PUC-Rio, Departamento de Ciências da Computação, Rio de Janeiro, RJ, Brasil.
| | - Fabricio Rodrigues Santiago
- Sociedade Brasileira de Angiologia e Cirurgia Vascular – SBACV, São Paulo, SP, Brasil.
- Instituto de Excelência Vascular, Londrina, PR, Brasil.
- Instituto de Doenças Venosas e Linfáticas – IDVL, Goiânia, GO, Brasil.
| | - Felipe Coelho
- Sociedade Brasileira de Angiologia e Cirurgia Vascular – SBACV, São Paulo, SP, Brasil.
- Pontifícia Universidade Católica do Paraná – PUCPR, Departamento de Cirurgia, Londrina, PR, Brasil.
| | | | | | | | - Ivanesio Merlo
- Sociedade Brasileira de Angiologia e Cirurgia Vascular – SBACV, São Paulo, SP, Brasil.
| | - Jose Marcelo Corassa
- Sociedade Brasileira de Angiologia e Cirurgia Vascular – SBACV, São Paulo, SP, Brasil.
| | - Leonardo Stambowsky
- Sociedade Brasileira de Angiologia e Cirurgia Vascular – SBACV, São Paulo, SP, Brasil.
| | - Marcondes Figueiredo
- Sociedade Brasileira de Angiologia e Cirurgia Vascular – SBACV, São Paulo, SP, Brasil.
| | - Miriam Takayanagi
- Sociedade Brasileira de Angiologia e Cirurgia Vascular – SBACV, São Paulo, SP, Brasil.
| | - Ronald Luiz Gomes Flumignan
- Sociedade Brasileira de Angiologia e Cirurgia Vascular – SBACV, São Paulo, SP, Brasil.
- Universidade Federal de São Paulo – UNIFESP, Departamento de Cirurgia, São Paulo, SP, Brasil.
| | - Solange Seguro Meyge Evangelista
- Sociedade Brasileira de Angiologia e Cirurgia Vascular – SBACV, São Paulo, SP, Brasil.
- Clínica Varizemed, Belo Horizonte, MG, Brasil.
| | - Walter Campos
- Sociedade Brasileira de Angiologia e Cirurgia Vascular – SBACV, São Paulo, SP, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina, Disciplina de Cirurgia Vascular, São Paulo, SP, Brasil.
| | - Edwaldo Edner Joviliano
- Sociedade Brasileira de Angiologia e Cirurgia Vascular – SBACV, São Paulo, SP, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina – FMRP, Departamento de Cirurgia e Anatomia, São Paulo, SP, Brasil.
| | - Walter Junior Boim de Araujo
- Sociedade Brasileira de Angiologia e Cirurgia Vascular – SBACV, São Paulo, SP, Brasil.
- Universidade Federal do Paraná – UFPR, Residência em Angiorradiologia e Cirurgia Vascular, Hospital de Clínicas, Curitiba, PR, Brasil.
| | - Julio Cesar Peclat de Oliveira
- Sociedade Brasileira de Angiologia e Cirurgia Vascular – SBACV, São Paulo, SP, Brasil.
- Universidade Federal do Estado do Rio de Janeiro – UNIRIO, Departamento de Cirurgia Geral e Especializada, Rio de Janeiro, RJ, Brasil.
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Huang Y, Zhang D, Zhou C, Zhang Y, Shi C, Chen Q. The first meta-analysis research on the effects of endovenous laser ablation combined with sapheno-femoral junction high ligation of the great saphenous vein. Lasers Med Sci 2023; 38:175. [PMID: 37540336 DOI: 10.1007/s10103-023-03833-y] [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: 11/21/2022] [Accepted: 07/19/2023] [Indexed: 08/05/2023]
Abstract
Endovenous laser ablation (EVLA) is a common minimally invasive technique used to treat varicose veins. The most commonly used laser wavelengths for EVLA/EVLT of varicose veins are 810 nm and 1470 nm. The laser pulse frequency is typically set to continuous wave (CW) mode, with a pulse duration of a few milliseconds (ms) delivered in a radial mode. The energy delivered per pulse is typically set between 40 and 120 Joules, with a power setting of 10 to 30 watts and an intensity setting of 40 to 120 J/cm2. The controversy exists regarding the benefits of performing saphenofemoral junction (SFJ) ligation prior to EVLA to decrease the recurrence rate of varicose veins. This meta-analysis aims to investigate the effectiveness of combining EVLA with high ligation versus using EVLA alone in treating lower extremity varicose veins. We conducted a systematic search of four databases from their inception until July 1, 2022, for randomized controlled trials and prospective controlled trials evaluating the advantages and disadvantages of EVLA with or without high ligation for the treatment of lower extremity varicose veins. In analyzing binary data, rate difference (RD) is used, while odds ratio (OR) is used for evaluating the confidence interval (CI) of binary data. A P value of less than 0.05 is deemed statistically significant. Heterogeneity is assessed using the chi-square test. If the I2 statistic, which reflects statistical heterogeneity, is greater than 50%, a random-effects model should be used. In the absence of significant statistical heterogeneity, a fixed-effects model should be used if I2 is less than 50%. We used the Cochrane risk-of-bias tool to assess the quality of the studies and Review Manager 5.4 for the primary and secondary outcome analysis. The meta-analysis was conducted in accordance with the Cochrane Handbook. There were no significant differences in the rate of major complications (RR = 1.63; 95% CI, 0.40-6.69; P = 0.50) or in the frequency of minor complications (RR = 1.07, 95% CI, 0.87-1.31; P = 0.52) between the EVLA with high ligation (EVLA/HL) group and the EVLA group. However, the rate of vein occlusion was significantly lower in the EVLA group than in the EVLA/HL group (RR = 1.06; 95% CI, 1.03-1.09; P = 0.0004). Our meta-analysis indicates that combining EVLA with high ligation provides stable long-term clinical efficacy in treating varicose veins of the lower extremities, although it increases the invasiveness of the surgery. The use of EVLA alone may be less effective in preventing vein occlusion.
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Affiliation(s)
- Yalong Huang
- The First Clinical Medical College, Gansu University of Traditional Chinese Medicine, Lanzhou, China
- Department of Vascular Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Dengxiao Zhang
- Department of Vascular Surgery, Gansu Provincial Hospital, Lanzhou, China
- Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Cong Zhou
- The First Clinical Medical College, Gansu University of Traditional Chinese Medicine, Lanzhou, China
- Department of Vascular Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Yuan Zhang
- Department of Interventional and Vascular Surgery Dongguan People's Hospital, Dongguan, China
| | - Chaohai Shi
- Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Quan Chen
- Department of Interventional and Vascular Surgery Dongguan People's Hospital, Dongguan, China.
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Rits J, Maurins U, Rabe E, Kadiss A, Prave S, Vigants R, Brunenieks I, Pannier F. Lower prevalence of stump reflux after endovenous laser flush ablation of the great saphenous vein. VASA 2022; 51:222-228. [DOI: 10.1024/0301-1526/a001007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Summary: Background: This single center prospective randomized study was performed to compare the effect of endovenous laser flush ablation (EVLAf) of the great saphenous vein (GSV) close to the sapheno-femoral junction (SFJ) with a standard ablation (EVLAs) up to two cm distally of the SFJ on reflux in the GSV stump. Patients and methods: Between April 2013 and January 2016, 146 legs in 146 consecutive patients, meeting the inclusion/exclusion criteria, were treated by EVLA. All patients were randomized into 2 groups. In group 1 EVLAf started from the SFJ level, and in group 2 EVLAs started two cm below the SFJ. The primary endpoint was reflux in the GSV stump after 900 days. Secondary endpoints were reflux in the anterior accessory saphenous vein (AASV), proximal clinically recurrent varicose veins related to reflux in the stump and/or the AASV. Results: At day 900, 27 patients were lost to follow-up. Reflux in the stump was detected in 3.6% in group 1 and in 22.2% in group 2 (p<0.05). Reflux in the AASV was present in 7.1% in group 1 and in 17.46% in group 2 (p=0.09). Proximal clinically recurrent varicose veins were observed in 8.9% in group 1 and in 19.1% in group 2 (p=0.12). The greatest diameter of the stump was significantly larger in group 2 (group 1: 0.41 cm, group 2: 0.6 cm, p<0.001). Conclusions: EVLAf is associated with a significantly lower incidence of reflux in the GSV stump, with a trend to a lower incidence of reflux in the AASV and with a lower incidence of proximal recurrent varicose veins after 900 days follow-up compared to EVLAs. EVLAf may improve the clinical recurrence rate after EVLA of the GSV.
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Affiliation(s)
| | | | - Eberhard Rabe
- Private Practice Dermatology & Phlebology, Bonn, Germany
| | | | | | | | | | - Felicitas Pannier
- Private Practice Dermatology & Phlebology, Bonn, Germany
- Department of Dermatology, University of Cologne, Germany
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Endovenous Laser Ablation for Varicose Vein Treatment: A Systematic Review and Meta-Analysis. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03441-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Pannier F, Noppeney T, Alm J, Breu FX, Bruning G, Flessenkämper I, Gerlach H, Hartmann K, Kahle B, Kluess H, Mendoza E, Mühlberger D, Mumme A, Nüllen H, Rass K, Reich-Schupke S, Stenger D, Stücker M, Schmedt CG, Schwarz T, Tesmann J, Teßarek J, Werth S, Valesky E. S2k guidelines: diagnosis and treatment of varicose veins. DER HAUTARZT 2022; 73:1-44. [PMID: 35438355 PMCID: PMC9358954 DOI: 10.1007/s00105-022-04977-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/23/2022] [Indexed: 11/29/2022]
Affiliation(s)
- F Pannier
- Praxis für Dermatologie und Phlebologie, Helmholtzstr. 4-6, 53123, Bonn, Germany.
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Shimizu T, Kasuga Y, Shimizu T. Cranial Tributary Ablation of the Saphenofemoral Junction during Laser Crossectomy of the Great Saphenous Vein. Ann Vasc Dis 2021; 14:355-361. [PMID: 35082940 PMCID: PMC8752922 DOI: 10.3400/avd.oa.21-00066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 10/21/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: Anterior accessory saphenous vein (AASV) insufficiency is one of the most common causes of recurrent varicose veins after endovenous thermal ablation (EVTA) for great saphenous vein (GSV) insufficiency. The purpose of this study was to evaluate the efficacy and safety of cranial tributary ablation (CTA) during laser crossectomy (LC) of the GSV. Methods: We reviewed 182 limbs in 171 patients undergoing EVTA aiming for LC with a 1470-nm diode laser. In the CTA group, either the superficial circumflex iliac vein or the superficial epigastric vein was directly ablated during LC. The result was compared between the CTA (n=63) and control (n=119) groups using follow-up duplex ultrasound performed for 6 months after EVTA. Results: Initial success rate of CTA was 69%. The AASV occlusion rate (90% vs. 63%, p<0.001) and the flush GSV occlusion rate (68% vs. 30%, p<0.001) at 6 months were better in the CTA group. No major adverse events were observed. Conclusion: CTA during LC of the GSV is a safe and effective approach to achieve better flush or AASV occlusion rates after EVTA. It is occasionally technically demanding but can be a feasible option. Further investigation is needed to confirm our results.
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Affiliation(s)
- Tsuyoshi Shimizu
- Department of Cardiovascular Surgery, Nagano Matsushiro General Hospital, Nagano, Nagano, Japan.,Cosmos Nagano Clinic, Nagano, Nagano, Japan
| | - Yoshio Kasuga
- Department of Surgery, Nagano Matsushiro General Hospital, Nagano, Nagano, Japan
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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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12
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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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13
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Abud B, Kunt AG. Midterm varicose vein recurrence rates after endovenous laser ablation: comparison of radial fibre and bare fibre tips. Interact Cardiovasc Thorac Surg 2021; 32:77-82. [PMID: 33212479 DOI: 10.1093/icvts/ivaa219] [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: 03/25/2020] [Revised: 08/09/2020] [Accepted: 08/17/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES We evaluated and compared midterm recurrence results of our patients with great saphenous vein insufficiency who were treated with a 1470-nm diode laser using 2 different types of fibre catheter kits. METHODS A total of 61 consecutive patients were treated between 2013 and 2014 with a bare fibre (BF) tip (BF group) and 60 consecutive patients were treated with a radial fibre (RF) tip (RF group) from 2014 to 2016. First-year venous clinical severity scores (VCSSs) were compared with VCSS before endovenous laser ablation and at the first-month follow-up. Patients were examined for recurrence and classified according to the system developed by Stonebridge. RESULTS There was no significant difference between the 2 groups in terms of VCSS. Examination with Doppler ultrasonography showed no recurrence in the RF group, whereas recurrences were detected in 6 patients in the BF group, which was statistically significant (P = 0.028). All of the recurrences were type 1b (incompetent tributaries) varicose vein recurrences. The VCSS of the patients with recurrence were the same as the scores of patients without recurrence (0.5 ± 0.55). CONCLUSIONS Varicose vein recurrence was more often seen in the BF group than in the RF group. Recanalization-induced and neovascularization-induced recurrences were not found in either group. Saphenofemoral side branch-induced recurrence was more significant in the group treated with the BF tip.
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Affiliation(s)
- Burcin Abud
- Department of Cardiovascular Surgery, University of Health Sciences, İzmir Tepecik Research and Education Hospital, Izmir, Turkey
| | - Ayse Gul Kunt
- Department of Cardiovascular Surgery, University of Health Sciences, İzmir Tepecik Research and Education Hospital, Izmir, Turkey
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14
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Faccini FP, Sathler-Melo CC. Elimination of saphenous reflux after tributary sclerotherapy: report of two cases. J Vasc Bras 2021; 20:e20200064. [PMID: 34188666 PMCID: PMC8210543 DOI: 10.1590/1677-5449.200064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Most patients with chronic venous disease (CVD) and reflux in the saphenous vein are treated with saphenous stripping or ablation. The venous hemodynamics approach offers the possibility of treating saphenous reflux without eliminating the saphenous vein. We present 2 cases in which venous reflux was eliminated while preserving the great saphenous vein, after treatment with hemodynamic sclerotherapy using a protocol of synergic use of Dextrose and long pulse Nd YAG 1064 laser. These cases show that treating the tributaries responsible for saphenous reflux can correct hemodynamic imbalances and restore normal flow in the great saphenous vein with improvements in symptoms and esthetics. Long-term results are still uncertain.
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Affiliation(s)
- Felipe Puricelli Faccini
- Hospital Moinhos de Vento - HMV, Cirurgia Vascular, Porto Alegre, RS, Brasil.,Instituto de Cardiologia, Porto Alegre, RS, Brasil
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15
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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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Hartmann K. Endovenous (minimally invasive) procedures for treatment of varicose veins : The gentle and effective alternative to high ligation and stripping operations. Hautarzt 2020; 71:67-73. [PMID: 32123975 PMCID: PMC7744384 DOI: 10.1007/s00105-019-04532-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Thermal ablation of saphenous vein varicosis has developed into a standard procedure for treatment of varicose veins. The clinical success of the endovenous thermal procedure is comparable to high ligation and stripping operations and a significant difference between these groups could not be detected in long-term analyses. The only difference is in the genesis of saphenofemoral recurrence detected by duplex ultrasound: neoangiogenesis occurs after high ligation and stripping operation and after endovenous ablation of the great saphenous vein a recurrence occurs predominantly via a residual anterior accessory saphenous vein (AASV). Reduction of costs by an increase in endovenous procedures carried out in an outpatient setting in comparison to stripping operations, which are still frequently carried out in Germany (in comparison to other countries) as an inpatient procedure, have meanwhile been confirmed. An endovenous crossectomy (i.e., high ligation) should be strived for. Nonthermal endoluminal catheter procedures are predominantly reserved for treatment of the short saphenous vein.
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Affiliation(s)
- Karsten Hartmann
- Venenzentrum Freiburg, Zähringer Str. 14, 79108, Freiburg, Germany.
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17
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Fink C. Endovenöse Radiofrequenzablation. PHLEBOLOGIE 2020. [DOI: 10.1055/a-1264-4207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
ZusammenfassungDie Radiofrequenzablation (RFA) ist seit 1998 in Deutschland zugelassen und hat sich als schonende, minimalinvasive Methode zur Behandlung der Stammvarikose etabliert. Im Rahmen der RFA wird ein Behandlungskatheter in die betroffene Vene eingebracht und thermisch verschlossen. In diesem Artikel wird der Behandlungsablauf mittels einer detaillierten Schritt-für-Schritt-Anleitung mit Bebilderung der endovenösen thermalen Ablation dargestellt.
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Affiliation(s)
- Christine Fink
- Universitätshautklinik Heidelberg, Heidelberg, Deutschland
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18
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Guo Z, Li X, Wang T, Liu J, Chen B, Fan L. Reply. J Vasc Surg Venous Lymphat Disord 2020; 8:905-906. [PMID: 32800262 DOI: 10.1016/j.jvsv.2020.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 03/04/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Zhenyu Guo
- Department of Vascular Surgery of Zhongshan Hospital Affiliated to Fudan University, Shanghai, China
| | - Xu Li
- Department of Vascular Surgery of Qingpu Branch of Zhongshan Hospital Affiliated to Fudan University, Shanghai, China
| | - Tao Wang
- Department of Vascular Surgery of Qingpu Branch of Zhongshan Hospital Affiliated to Fudan University, Shanghai, China
| | - Jianjun Liu
- Department of Vascular Surgery of Qingpu Branch of Zhongshan Hospital Affiliated to Fudan University, Shanghai, China
| | - Bin Chen
- Department of Vascular Surgery of Zhongshan Hospital Affiliated to Fudan University, Shanghai, China
| | - Longhua Fan
- Department of Vascular Surgery of Zhongshan Hospital Affiliated to Fudan University, Shanghai, China; Department of Vascular Surgery of Qingpu Branch of Zhongshan Hospital Affiliated to Fudan University, Shanghai, China
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19
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Vähäaho S, Halmesmäki K, Mahmoud O, Albäck A, Noronen K, Venermo M. Three-year results of a randomized controlled trial comparing mechanochemical and thermal ablation in the treatment of insufficient great saphenous veins. J Vasc Surg Venous Lymphat Disord 2020; 9:652-659. [PMID: 32795619 DOI: 10.1016/j.jvsv.2020.08.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 08/02/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Mechanochemical ablation (MOCA) is a nonthermal nontumescent method of treating saphenous vein insufficiency. The feasibility and short-term results of MOCA are good, but its long-term results are unknown. A randomized study was performed to compare MOCA with endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) in the setting of unilateral great saphenous vein (GSV) insufficiency. METHODS Venous outpatient clinic patients with varicose veins (CEAP class C2-C4) caused by GSV insufficiency were invited to participate in the study; in total, 132 patients met the inclusion criteria and were willing to participate. Patients were randomized to treatment (2:1:1 for MOCA, EVLA, and RFA, respectively). The state of the GSV with duplex Doppler ultrasound examination and the disease-specific quality of life were assessed at 1 month, 1 year, and 3 years after the treatment. RESULTS Some patients declined to continue in the study after randomization; in total, 117 patients underwent treatment. At 3 years, the occlusion rate was significantly lower with MOCA than with either EVLA or RFA (82% vs 100%; P = .005). Quality of life was similar between the groups. In the MOCA group, GSVs that were larger than 7 mm in diameter preoperatively were more likely to recanalize during the follow-up period. The partial recanalizations of proximal GSV observed at 1 year progressed during the follow-up. CONCLUSIONS MOCA is a feasible treatment option in an outpatient setting, but its technical success rates are inferior compared with endovenous thermal ablation. Its use in large-caliber veins should be considered carefully.
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Affiliation(s)
- Sari Vähäaho
- Department of Vascular Surgery, Helsinki University Hospital, Helsinki University, Helsinki, Finland.
| | - Karolina Halmesmäki
- Department of Vascular Surgery, Helsinki University Hospital, Helsinki University, Helsinki, Finland
| | - Osman Mahmoud
- Department of Vascular Surgery, Helsinki University Hospital, Helsinki University, Helsinki, Finland
| | - Anders Albäck
- Department of Vascular Surgery, Helsinki University Hospital, Helsinki University, Helsinki, Finland
| | - Katarina Noronen
- Department of Vascular Surgery, Helsinki University Hospital, Helsinki University, Helsinki, Finland
| | - Maarit Venermo
- Department of Vascular Surgery, Helsinki University Hospital, Helsinki University, Helsinki, Finland
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20
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Rodriguez Santos F, Loson V, Coria A, Marquez Fosser C, Dotta M, Katsini R, Pared C, Bauzá Moreno H, Martínez H. Secondary Ablation of Recanalized Saphenous Vein after Endovenous Thermal Ablation. Ann Vasc Surg 2020; 68:172-178. [PMID: 32339689 DOI: 10.1016/j.avsg.2020.04.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 04/01/2020] [Accepted: 04/16/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND To describe the occlusion rate and clinical response of a redo ablative procedure in symptomatic patients with recanalization of saphenous vein after endovascular thermal ablation. METHODS A retrospective cohort study was performed in a prospectively collected data of symptomatic patients with recanalization of the great saphenous vein (GSV) or small saphenous vein (SSV) after endovascular thermal ablation who underwent a secondary ablation (SA) from June 2015 to May 2018. RESULTS Ten patients (15 limbs) with recanalization of the GSV or SSV were treated with SA. The median age was 67 years and 60% were men. The median time from the first ablation was 7.3 years (interquartile range [IQR] 6.5-9.6). For SA, radiofrequency ablation was performed in 12 limbs (80%) and ultrasound-guided foam sclerotherapy in 3 cases (20%). The GSV was the treated vessel in 14 cases (93.3%). No complications were reported. Median follow-up was 13 months. Preoperative and 1-year follow-up Venous Clinical Severity Score was 9 (IQR 5-10) and 4 (IQR 2-8), respectively. Duplex ultrasound evaluation after 1 year showed an occlusion rate of 93.3% evidencing a partially recanalized vein in 1 treated limb. CONCLUSIONS In this study, the occlusion rate was 93.3% at 1 year after SA; clinical improvement and no complications were reported. SA appears to be a valid option for the treatment of symptomatic patients with recanalized GSV or SSV.
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Affiliation(s)
- Fanny Rodriguez Santos
- Phlebolymphology Unit, General Surgery Department, Hospital Italiano de Buenos Aires, Argentina.
| | - Victoria Loson
- Phlebolymphology Unit, General Surgery Department, Hospital Italiano de Buenos Aires, Argentina
| | - Agustín Coria
- Phlebolymphology Unit, General Surgery Department, Hospital Italiano de Buenos Aires, Argentina
| | - Carolina Marquez Fosser
- Phlebolymphology Unit, General Surgery Department, Hospital Italiano de Buenos Aires, Argentina
| | - Mariana Dotta
- Phlebolymphology Unit, General Surgery Department, Hospital Italiano de Buenos Aires, Argentina
| | - Roxana Katsini
- Phlebolymphology Unit, General Surgery Department, Hospital Italiano de Buenos Aires, Argentina
| | - Carlos Pared
- Phlebolymphology Unit, General Surgery Department, Hospital Italiano de Buenos Aires, Argentina
| | - Hernan Bauzá Moreno
- Phlebolymphology Unit, General Surgery Department, Hospital Italiano de Buenos Aires, Argentina
| | - Hugo Martínez
- Phlebolymphology Unit, General Surgery Department, Hospital Italiano de Buenos Aires, Argentina
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21
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Mendoza E. Does the suture material influence the outcome after high ligation of great saphenous vein? VASA 2020; 49:153-155. [PMID: 32091977 DOI: 10.1024/0301-1526/a000833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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22
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Kolluri R, Chung J, Kim S, Nath N, Bhalla BB, Jain T, Zygmunt J, Davies A. Network meta-analysis to compare VenaSeal with other superficial venous therapies for chronic venous insufficiency. J Vasc Surg Venous Lymphat Disord 2020; 8:472-481.e3. [PMID: 32063522 DOI: 10.1016/j.jvsv.2019.12.061] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 12/07/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Several randomized controlled trials (RCTs) have compared different interventions for chronic venous insufficiency (CVI) management, but mixed comparison of these interventions is lacking. The aim of this network meta-analysis was to compare VenaSeal closure system (Medtronic, Minneapolis, Minn) with endovenous laser ablation (EVLA), radiofrequency ablation (RFA), mechanochemical ablation, sclerotherapy, and surgery for management of CVI to achieve anatomic success (complete closure of treated vein within 6 months after intervention) as the primary outcome and health-related quality of life (HRQoL; EuroQol-5 Dimension, Aberdeen Varicose Vein Questionnaire), Venous Clinical Severity Score (VCSS), pain scores, and adverse events as secondary outcomes. METHODS A systematic review of journal databases was undertaken, and RCTs between January 1996 and September 2018 comparing different treatment options were included. Risk of bias and quality of publications were assessed using the Cochrane bias tool; Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used for study selection and reporting. Twenty RCTs comprising 4570 patients were analyzed. Data for anatomic success, VCSS, HRQoL, pain score, and adverse events were extracted and analyzed using mixed treatment comparison in a network meta-analysis. A Bayesian fixed or random effects model was selected for analysis. Rank probability graphs were generated for various treatments and corresponding ranks obtained to estimate their probability of being best. Relative treatment effects were calculated in terms of log odds ratios for anatomic success and adverse events. Mean difference was calculated for VCSS, HRQoL, and pain score. RESULTS For the primary outcome measure (anatomic success), VenaSeal system had the highest probability of being ranked first (P = .980); RFA was ranked second (P = .365), EVLA third (P = .397), surgery fourth (P = .290), mechanochemical ablation fifth (P = .695), and sclerotherapy sixth (P = .982). For secondary outcome measures, VenaSeal system ranked third for VCSS (P = .332), fifth for EuroQol-5 Dimension (P = .420), and third for Aberdeen Varicose Vein Questionnaire (P = .300). Although, VenaSeal system was slightly inferior to some of the other interventions for HRQoL, the 95% credible interval of log odds ratio indicated insufficient evidence for any concrete conclusion to be drawn. VenaSeal system ranked first in reduction of postoperative pain score from baseline (P = .690) and was lowest in occurrence of adverse events (P = .650). Odds of occurrence of adverse events was 3.3 times in the sclerotherapy arm, 2.7 times in the EVLA arm, 1.6 times with surgery, and 1.1 times with RFA vs VenaSeal system arm. CONCLUSIONS VenaSeal system is a promising therapeutic option for anatomic success at 6 months, with fewer occurrences of adverse events (wound and groin infection, pulmonary embolism) in CVI patients compared with other interventions in this study. Additional economic analysis including cost-effectiveness analysis would provide interesting perspectives on real-world insights to patients, payers, and providers.
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Affiliation(s)
- Raghu Kolluri
- Department of Cardiovascular Medicine, Ohio Health & Riverside Methodist Hospital, Columbus, Ohio.
| | | | - Sue Kim
- Medtronic, Minneapolis, Minn
| | | | | | | | | | - Alun Davies
- Department of Surgery, Imperial College London, London, United Kingdom
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Hartmann K. [Endovenous (minimally invasive) procedures for treatment of varicose veins : The gentle and effective alternative to high ligation and stripping operations]. Hautarzt 2020; 71:12-19. [PMID: 31863127 DOI: 10.1007/s00105-019-04520-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Thermal ablation of saphenous vein varicosis has developed into a standard procedure for treatment of varicose veins. The clinical success of the endovenous thermal procedure is comparable to high ligation and stripping operations and a significant difference between these groups could not be detected in long-term analyses. The only difference is in the genesis of saphenofemoral recurrence detected by duplex ultrasound: neoangiogenesis occurs after high ligation and stripping operation and after endovenous ablation of the great saphenous vein a recurrence occurs predominantly via a residual anterior accessory saphenous vein (AASV). Reduction of costs by an increase in endovenous procedures carried out in an outpatient setting in comparison to stripping operations, which are still frequently carried out in Germany (in comparison to other countries) as an inpatient procedure, have meanwhile been confirmed. An endovenous crossectomy (i.e. high ligation) should be strived for. Nonthermal endoluminal catheter procedures are predominantly reserved for treatment of the short saphenous vein.
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Affiliation(s)
- Karsten Hartmann
- Venenzentrum Freiburg, Zähringer Str. 14, 79108, Freiburg, Deutschland.
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Lim SY, Tan JX, D'Cruz RT, Syn N, Chong TT, Tang TY. Catheter-directed foam sclerotherapy, an alternative to ultrasound-guided foam sclerotherapy for varicose vein treatment: A systematic review and meta-analysis. Phlebology 2020; 35:369-383. [PMID: 31918640 DOI: 10.1177/0268355519898309] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE Catheter-directed foam sclerotherapy is a new addition to the treatment modalities available for varicose veins. As a modification of ultrasound-guided foam sclerotherapy, catheter-directed foam sclerotherapy has been purported to offer higher complete ablation rates and an improved safety profile. The aim of this study is to appraise the current literature on the outcomes of catheter-directed foam sclerotherapy compared to ultrasound-guided foam sclerotherapy in chronic venous insufficiency. METHODS The review of the literature was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data from studies that reported the outcomes of catheter-directed foam sclerotherapy and ultrasound-guided foam sclerotherapy were extracted, to determine the pooled proportion of complete ablation rates, using a random effect meta-analysis model. RESULTS A total of 62 studies, involving 3689 patients, were included in the systematic review. Higher rates of complete ablation were reported in catheter-directed foam sclerotherapy compared to ultrasound-guided foam sclerotherapy during the short- and medium-term follow-ups (Relative Risk = 1.06, Relative Risk = 1.15, Relative Risk = 1.19, p < 0.05). Fewer major and minor complications were also reported in patients who underwent catheter-directed foam sclerotherapy (Relative Risk = 0.23, Relative Risk= 0.43-0.76, p < 0.05). CONCLUSION Catheter-directed foam sclerotherapy has been demonstrated to have many advantages over ultrasound-guided foam sclerotherapy, offering superior complete ablation rates in the short-, medium- and long-term follow-ups. It also has a better safety profile, conferring a lower risk of major and minor complications. The conclusions should however be viewed in the context of significant limitations imposed by limited study data.
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Affiliation(s)
- Sheng Y Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Joshua Xd Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Reuban T D'Cruz
- Department of General Surgery, National University Hospital, Singapore, Singapore
| | - Nicholas Syn
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Tze T Chong
- Department of Vascular Surgery, Singapore General Hospital, Singapore, Singapore
| | - Tjun Y Tang
- Department of Vascular Surgery, Singapore General Hospital, Singapore, Singapore
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Guo Z, Li X, Wang T, Liu J, Chen B, Fan L. Effectiveness of iliac vein stenting combined with high ligation/endovenous laser treatment of the great saphenous veins in patients with Clinical, Etiology, Anatomy, Pathophysiology class 4 to 6 chronic venous disease. J Vasc Surg Venous Lymphat Disord 2020; 8:74-83. [DOI: 10.1016/j.jvsv.2019.08.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 08/06/2019] [Indexed: 12/17/2022]
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Cao G, Gu HC, Wang JT, Huang Q, Cao JC. Comparison of endovenous laser treatment and high ligation in treatment of limb varicosity: A meta-analysis. Int Wound J 2019; 16:696-702. [PMID: 30767406 DOI: 10.1111/iwj.13083] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 01/03/2019] [Accepted: 01/08/2019] [Indexed: 02/06/2023] Open
Abstract
To assess the efficacy and safety of endovenous laser treatment (EVLT) and high ligation (HL) for limb varicosity using meta-analysis. Multiple databases including PubMed, Springer, Excerpta Medica Database, Ovid Technologies, and China Journal Full-text database were searched for relevant studies in English or Chinese, and full-text articles were used to compare EVLT and HL for limb varicosity. Review Manager 5.0 was used to estimate the effects of the results among eligible articles. Forest plots, sensitivity analysis, and bias analysis of the included articles were also conducted. Initial screening yielded 1031 studies, 11 randomised controlled trials involving 1145 limb varicosity patients met the inclusion criteria in this study. The results of the heterogeneity test suggested that intraoperative blood loss mean difference (MD) = -6.31[-9.03, -3.60], P < 0.00001), operative time (MD) = -39.76[-42.27, -37.24], P < 0.00001), rate of complications (odds ratio [OR] = 0.37[0.22, 0.61], P < 0.0001), and recurrence (OR = 0.28[0.16, 0.49], P < 0.0001) were significantly different. Although both EVLT and HL have their own merits and demerits, EVLT is a more effective and safe method to treat limb varicosity.
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Affiliation(s)
- Gang Cao
- Department of the Fourth Surgery, Dong-Fang Hospital of Beijing University of Chinese Medicine, Beijing, China
| | - Han-Cheng Gu
- Department of the Fourth Surgery, Dong-Fang Hospital of Beijing University of Chinese Medicine, Beijing, China
| | - Ji-Ting Wang
- Department of the Fourth Surgery, Dong-Fang Hospital of Beijing University of Chinese Medicine, Beijing, China
| | - Qiang Huang
- Department of the Fourth Surgery, Dong-Fang Hospital of Beijing University of Chinese Medicine, Beijing, China
| | - Jian-Chun Cao
- Department of the Fourth Surgery, Dong-Fang Hospital of Beijing University of Chinese Medicine, Beijing, China
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Aherne TM, Medani M, Sahebally S, Kheirelseid E, Mulkern E, McDonnell C, Walsh SR, O'Donohoe MK. The use of high venous ligation as an adjunct to endovenous therapy in the management of great saphenous vein incompetence: A systematic review and meta-analysis of randomized controlled trials. Phlebology 2019; 34:433-444. [PMID: 30621523 DOI: 10.1177/0268355518821805] [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: 11/17/2022]
Abstract
Background In recent years, endovenous intervention has emerged as a minimally invasive alternative to open venous surgery. However, endovenous intervention does not formally disconnect the deep and superficial venous systems and it is hypothesized that recurrence may be greater in the absence of high venous ligation. This study aims to compare the efficacy of a hybrid endovenous approach with adjuvant high venous ligation and standard operative intervention in the management of great saphenous incompetence. Methods In March 2018, Medline and Embase were systematically searched for relevant randomized controlled trials. All randomized controlled trials comparing a hybrid approach with standard operative intervention were included. Studies were required to include at least one pre-defined outcome. Data were extracted and assessed by two independent reviewers. Pooled risk ratios were calculated using a random effects model. Additional subgroup analyses were performed. Results Eight randomized controlled trials including 1244 patients were analysed. Pooled standardized data revealed no difference in overall recurrence (pooled RR = 1.00 [95% CI = 0.57, 1.77]), major operative morbidity (RR = 0.43 [95% CI = 0.06, 2.89]), or re-interventions (RR = 0.94 [95% CI = 0.12, 7.24]) for the hybrid group compared with standard operative intervention alone. Subgroup analysis revealed comparable short-, medium- and long-term recurrence rates between both cohorts. Furthermore, no difference in recurrence was identified when the hybrid approach was compared to open surgery alone (RR = 1.01 [95% CI = 0.63, 1.61]) or endovenous monotherapy (RR = 0.67 [95% CI = 0.04, 12.24]). Conclusion The use of a hybrid approach in the management of great saphenous incompetence appears to offer no recurrence, re-intervention or morbidity benefit when compared to standard operative intervention.
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Affiliation(s)
- Thomas M Aherne
- 1 Department of Vascular Surgery, Mater Misericordiae Hospital, Dublin, Ireland.,2 Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland
| | - Mekki Medani
- 1 Department of Vascular Surgery, Mater Misericordiae Hospital, Dublin, Ireland
| | - Shaheel Sahebally
- 2 Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland
| | | | - Edward Mulkern
- 1 Department of Vascular Surgery, Mater Misericordiae Hospital, Dublin, Ireland
| | - Ciaran McDonnell
- 1 Department of Vascular Surgery, Mater Misericordiae Hospital, Dublin, Ireland
| | - Stewart R Walsh
- 2 Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland
| | - Martin K O'Donohoe
- 1 Department of Vascular Surgery, Mater Misericordiae Hospital, Dublin, Ireland
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Endovenous Photocoagulation Using a Diode Laser for Complicated Varicose Veins Related to Stasis Ulcers. Ann Plast Surg 2018; 82:S103-S107. [PMID: 30461460 DOI: 10.1097/sap.0000000000001726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The objective of this study was to assess the efficacy and safety of endovenous laser photocoagulation (EVLP) at a wavelength of 810 nm for treating complicated venous insufficiency associated with venous ulcers. MATERIALS AND METHODS A retrospective review of 110 patients with 180 legs having chronic venous insufficiencies associated with varicose veins treated over an 8-year period was conducted. Patients ranged from 16 to 80 years of age and included 85 women and 25 men. Of the 110 patients, 32 (29.10%) patients with 40 legs having varicose veins were defined as having complicated varicose veins associated with venous ulcers. All 32 patients received EVLP treatment using a diode laser. Complications were evaluated at 3 weeks (early), 6 weeks (late), and 6 months (final) after EVLP treatment. The primary efficacy and final outcome measurement were determined through quantitative assessment using Hach's and clinical, etiological, anatomical, and pathophysiological classification. Safety was evaluated for each treatment group by monitoring adverse effects. RESULTS Early complications were swelling, local paresthesia, pigmentation, minor superficial thermal injury, superficial phlebitis, and localized hematomas. All complications and ulcerations resolved completely within 2 weeks. No recurrence occurred after the study's 6-month follow-up period. Based on paired t test analysis, clinically significant differences in severity scores were discovered, which were based on Hach's classification before and after EVLP treatment at a wavelength of 810 nm. All patients achieved improvement from clinical, etiological, anatomical, and pathophysiological class C6 to C5. Permanent adverse effects were not observed. CONCLUSIONS Endovenous laser photocoagulation at the wavelength of 810 nm permitted the use of appropriate light doses for treating complicated varicose veins associated with venous ulcers and resulted in significant improvement in lesions.
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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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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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Anwar MA, Idrees M, Aswini M, Theivacumar NS. Fate of the tributaries of sapheno femoral junction following endovenous thermal ablation of incompetent axial vein – A review article. Phlebology 2018; 34:151-155. [PMID: 29945471 DOI: 10.1177/0268355518783635] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Sapheno femoral junctional tributaries are usually left untreated at the time of endovenous ablation of axial vein. The long-term clinical significance of these untreated tributaries remains elusive and there is very little research done into this area. This article reviews the fate of untreated tributaries at sapheno femoral junction following ablation of incompetent axial vein. A literature search and analysis of evidence reveal that the junctional tributaries are one of the commonest (ranges between 8% and 31%) cause for recurrence following endovenous ablation of the axial veins. Follow up of this subset of patients after their axial vein treatment should be considered to identify neoreflux in side branches at sapheno femoral junction and plan treatment.
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Affiliation(s)
- Muzaffar A Anwar
- West London Vascular and Interventional Centre, Northwick Park Hospital and The Hillingdon Hospital, Watford Road, Harrow, London
| | - Madeeha Idrees
- West London Vascular and Interventional Centre, Northwick Park Hospital and The Hillingdon Hospital, Watford Road, Harrow, London
| | - Misro Aswini
- Department of Vascular Surgery, Kings College Hospital, London
| | - Nadarajah S Theivacumar
- West London Vascular and Interventional Centre, Northwick Park Hospital and The Hillingdon Hospital, Watford Road, Harrow, London
- Department of Vascular Surgery, Kings College Hospital, London
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Aurshina A, Zhang Y, Wang F, Cardella J, Orion K, Sumpio B, Sarac T, Ochoa Chaar CI. The effect of increasing catheter distance from the deep junction on the outcomes of radiofrequency vein ablation. J Vasc Surg Venous Lymphat Disord 2018; 6:614-620. [PMID: 29784594 DOI: 10.1016/j.jvsv.2018.04.006] [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: 01/02/2018] [Accepted: 04/08/2018] [Indexed: 10/16/2022]
Abstract
OBJECTIVE Thermal vein ablation (VA) is the recommended treatment modality for superficial venous reflux, with a recommended positioning of the catheter at 2 to 3 cm from the junction of the deep venous system. In contrast, novel sealing technology for saphenous VA involves treatment starting at 3 to 5 cm distal to the deep junction. This study examines the effect of increasing catheter distance from the junction on the outcomes of VA using radiofrequency. METHODS A retrospective single-center review of patients treated with VA was performed. Demographics, symptoms, clinical class (Clinical, Etiology, Anatomy, and Pathophysiology classification), and ultrasound data were reviewed. The treatment groups were divided on the basis of the position of the catheter <3 cm (group A) or ≥3 cm (group B) from the deep junction. Clinical success, technical success, complications, and recurrence were compared between the two groups. Long-term follow-up was collected by telephone survey inquiring about intensity of symptoms on a numeric rating scale of 0 to 10 before and after treatment. A multivariable analysis was performed to identify predictors of recurrence. RESULTS There were 362 patients with 529 veins treated. The mean age was 59.2 ± 14.4 years (63% women). There was a significantly higher proportion of patients with past medical history of hypertension (P = .02) and deep venous thrombosis (P = .02) in group B compared with group A. Group B also had significantly larger vein diameter on ultrasound (P = .04). The clinical success, technical success, and complication rates were 80%, 95.6%, and 11.5%. There were no significant differences between the two groups in outcomes. After a mean follow-up of 27.5 months, recurrence rate was 22.2%. There was a trend toward higher recurrence in group B that did not, however, reach statistical significance (P = .1). On multivariable analysis, there was no clinical or technical factor that could predict recurrence. CONCLUSIONS The experience with radiofrequency ablation does not support difference in outcomes when treatment starts at ≥3 cm from the junction. However, there is a trend toward increased long-term recurrence that warrants further investigation with newer technology.
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Affiliation(s)
- Afsha Aurshina
- Section of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
| | - Yawei Zhang
- Department of Surgery, Yale School of Medicine, New Haven, Conn
| | - Fang Wang
- Department of Surgery, Yale School of Medicine, New Haven, Conn
| | - Jonathan Cardella
- Section of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
| | - Kristine Orion
- Section of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
| | - Bauer Sumpio
- Section of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
| | - Timur Sarac
- Section of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
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Abstract
SummaryIntroduction: Since it’s description the CHIVA strategy was performed with surgical techniques. After the introduction of endoluminal heat techniques these might be applied also in the CHIVA context.Method: 104 patients were investigated before and 3–6 months after the treatment of the great saphenous vein (GSV) with CHIVA strategy using enoluminal heat techniques to close the groin segment (VNUS Closure-Fast™ or LASER [1470 nm, Intros radial]). General data (age, sex, BMI) and phlebological data (QoL as reflected in VCSS, clinics as C[CEAP], refilling time after muscle pump measured with light reflection rheography, diameters of GSV at the groin and proximal thigh, as well as diameters of the common femoral vein) were measured and compared.Results: Significant reduction of diameters of GSV at proximal thigh from 6.5 ± 1.6 to 3.7 ± 1.1 and VFC from 15.2 ± 2.3 to 14.8 ± 2.2 were recorded, as well as reduction of clinical scores (VCSS from 5.6 ± 3.1 to 2.2 ± 2 and C[CEAP] from 3.2 ± 1 to 2.1 ± 1.1). Refilling time improved from 20.3 ± 11 to 28.8 ± 10.2. Results are comparable to those achieved after surgical crossectomy and published in other series.Conclusion: The disconnection of the insufficiency point at the saphenofemoral junction seems to be possible in the context of CHIVA Strategy applying endoluminal heat technique. No difference could be found between both techniques, Laser or VNUS Closure-Fast™.
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Abstract
SummaryEndovenous treatment of incompetent great and small saphenous veins has become firmly established as an alternative to cross-ectomy and stripping operations. Among other thermal and non-thermal procedures, endovenous laser ablation (EVLA) is one of the most frequently used methods. Development of the procedure has continued since its introduction in 1998: the low wavelengths used at first (810 nm) resulted in a high rate of complications (ecchymosis, pain), and over the years systems using longer wavelengths have been developed with increasingly fewer side effects. The effectiveness of the wavelength most frequently used today (1470 nm) has been reported in numerous studies. The most frequent side effects include endovenous heat-induced thrombosis (EHIT), nerve damage and ecchymosis; major complications like lung embolism are reported very rarely.
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Kheirelseid EAH, Crowe G, Sehgal R, Liakopoulos D, Bela H, Mulkern E, McDonnell C, O'Donohoe M. Systematic review and meta-analysis of randomized controlled trials evaluating long-term outcomes of endovenous management of lower extremity varicose veins. J Vasc Surg Venous Lymphat Disord 2017; 6:256-270. [PMID: 29292115 DOI: 10.1016/j.jvsv.2017.10.012] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 10/26/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Early studies have demonstrated that endovenous therapy for varicose veins is associated with a faster recovery and lower complication rates compared with conventional therapy. More than one million procedures have been performed worldwide. The objective of this study was to determine long-term efficacy of currently available endovenous therapy methods for varicose veins compared with conventional surgery (saphenofemoral ligation and stripping of great saphenous vein [GSV] with or without multiple avulsions) in management of GSV-related varicose veins. METHODS In July 2017, we searched MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Embase, Scopus, Cochrane Library, and Web of Science without date or language restriction for relevant randomized controlled trials (RCTs). Bibliographies of included studies were also searched for additional studies. RCTs comparing conventional surgery and endovenous therapy for treating lower extremity varicose veins with 5 years or more of follow-up were selected. Data extraction and quality assessment were performed independently by two review authors, and any disagreements were resolved by consensus or by arbitration of a third author. Cochrane RevMan 5 was used for analysis. RESULTS At time of data extraction, long-term follow-up was available for endovenous laser therapy (EVLT), radiofrequency ablation (RFA), and ultrasound-guided foam sclerotherapy. Included in the review were nine RCTs. The RCTs included 2185 legs; however, only 1352 legs were followed up for 5 years (61.9%). There was no statically significant difference in recurrence rate in comparing EVLT with conventional surgery in treating GSV incompetence (36.6% vs 33.3%, respectively; pooled risk ratio, 1.35; 95% confidence interval, 0.76-2.37; P = .3). Also, no significant difference was determined for recurrence rate in comparing RFA with surgery or EVLT. CONCLUSIONS Although the analysis showed that EVLT and RFA are as effective as conventional surgery in treating saphenous venous insufficiency, the number of patients available for analysis was too small for definitive conclusions to be drawn.
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Affiliation(s)
| | - Gillian Crowe
- Department of Vascular Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Rishabh Sehgal
- Department of Vascular Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Dimitrios Liakopoulos
- Department of Vascular Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Hafiz Bela
- Department of Vascular Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Edward Mulkern
- Department of Vascular Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Ciaran McDonnell
- Department of Vascular Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Martin O'Donohoe
- Department of Vascular Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
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Abstract
SummaryBackground Endovenous laser ablation (EVLA) is globally counted among the most frequently administered methods to treat saphenous vein incompetence. Technical development proceeded in three particular steps: EVLA #1 – Diode lasers linearly emitting wavelengths from 810 to 980 nm through optical bare fibres; EVLA #2 – Diode or Nd:YAG lasers emitting wavelengths from 1064 to 1500 nm; EVLA #3 – Modified optical fibres warranting an optimised emission geometry by centralisation of the fibre tip (Tulip-fibre, Jacket-tip) or radial emission of the laser beam. Due to the number of different EVLA techniques their value compared with standard surgery (high ligation and stripping, HLS) and other endovascular approaches has to be questioned.Methods Selective literature analysis based on a systematic PubMed search focussed on randomised controlled trials (RCT) comparing EVLA with HLS and other thermal or nonthermal ablation techniques – radiofrequency ablation (RFA), ultrasound guided foam sclerotherapy (UGFS), endothermal steam ablation (EStA).Results The search terms “endovenous”, “laser”, “varicose vein” resulted in 509 publications, hereof 57 RCTs, hereof 24 randomised studies comparing EVLA with other treatment approaches: 15 studies comprise comparisons with standard surgery and further 9 studies with other endovenous techniques. 6 RCTs contain long-term followup data on EVLA #1 vs. HLS suggesting superiority of HLS in terms of same site clinical and duplex detected recurrence from the groin. 15 RCTs are reporting short-term results clearly demonstrating inferiority of EVLA #1 against EVLA #2, EVLA #3, and RFA with respect to postoperative complaints and patients’ quality of life.Conclusions The first generation endovenous laser systems are disadvantageous or even harmful as compared with more advanced EVLA techniques and RFA in terms of patients’ complaints and side effects. Furthermore, evidence is rising that EVLA #1 is inferior to standard surgery regarding long-term treatment efficacy. Therefore, the application of EVLA #1 in the treatment of saphenous vein incompetence cannot be recommended any longer. In view of the more recently published RCTs reporting long-term superiority of standard surgery, HLS should still be implemented as control group in studies investigating endovenous treatment approaches.
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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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Abstract
Open and endovenous surgery of varicose veins provides an excellent way to treat varicose veins. However, there are great differences in the how the techniques are performed. No matter which procedure is carried out, there are standards that should be observed. The state of the art of open venous surgery with radical crossectomy is well-known, but unfortunately is still not always performed correctly nowadays. The state of the art of endovenous surgery has unfortunately not yet been sufficiently documented, but should be based on open-surgical techniques. How the standard of both methods today is (or should be) is described in detail in this work. A recurrence definition which applies to both techniques, is set up.
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Balint R, Farics A, Parti K, Vizsy L, Batorfi J, Menyhei G, Balint IB. Which endovenous ablation method does offer a better long-term technical success in the treatment of the incompetent great saphenous vein? Review. Vascular 2016; 24:649-657. [DOI: 10.1177/1708538116648035] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective The aim of this review article was to evaluate the long-term technical success rates of the known endovenous ablation procedures in the treatment of the incompetence of the great saphenous vein. Methods A literature search was conducted in the PubMed-database until the 5 January 2016. All publications with four to five years follow-up were eligible. Meta-analysis was performed by the IVhet-model. Results Eight hundred and sixty-two unique publications were found; 17 of them were appropriate for meta-analysis. Overall, 1420 limbs were included in the trial, 939 for endovenous laser ablation, 353 for radiofrequency ablation and 128 for ultrasound guided foam sclerotherapy. Overall, technical success rates were 84.8% for endovenous laser ablation, 88.7% for radiofrequency ablation and 32.8% for ultrasound guided foam sclerotherapy. There were no significant differences between endovenous laser ablation, radiofrequency ablation and ultrasound guided foam sclerotherapy regarding the great saphenous vein reopening ( p = 0.66; OR: 0.22; 95% of CI: 0.08–0.62 for radiofrequency ablation vs. endovenous laser ablation; p = 0.96; OR: 0.11; 95% of CI: 0.06–0.20 for endovenous laser ablation vs. ultrasound guided foam sclerotherapy; p = 0.93; OR: 3.20; 95% of CI: 0.54–18.90 for ultrasound guided foam sclerotherapy vs. radiofrequency ablation). Conclusion Both endovenous laser ablation and radiofrequency ablation are efficient in great saphenous vein occlusion on the long term. Lacking long-conducted large trials, the efficacy and reliability of ultrasound guided foam sclerotherapy to treat great saphenous vein-reflux is not affirmed.
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Affiliation(s)
- Renata Balint
- Faculty of Business and Economics, University of Pannonia, Nagykanizsa, Hungary
| | - Akos Farics
- Department of Surgery, Kanizsai Dorottya Hospital, Nagykanizsa, Hungary
| | - Krisztina Parti
- Department of Surgery, Kanizsai Dorottya Hospital, Nagykanizsa, Hungary
| | - Laszlo Vizsy
- Department of Surgery, Kanizsai Dorottya Hospital, Nagykanizsa, Hungary
| | - Jozsef Batorfi
- Department of Surgery, Kanizsai Dorottya Hospital, Nagykanizsa, Hungary
| | - Gabor Menyhei
- Department of Vascular Surgery, University of Pecs, Pecs, Hungary
| | - Istvan B Balint
- Department of Surgery, Kanizsai Dorottya Hospital, Nagykanizsa, Hungary
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Kabnick LS, Sadek M. Fiber type as compared to wavelength may contribute more to improving postoperative recovery following endovenous laser ablation. J Vasc Surg Venous Lymphat Disord 2016; 4:286-92. [DOI: 10.1016/j.jvsv.2015.12.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 12/30/2015] [Indexed: 10/22/2022]
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Nelzén O. Reconsidering the endovenous revolution. Br J Surg 2016; 103:939-40. [PMID: 27168120 DOI: 10.1002/bjs.10192] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 03/09/2016] [Indexed: 12/22/2022]
Abstract
Not as cost-effective as you might think
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Affiliation(s)
- O Nelzén
- Vascular Surgery Unit, Skaraborg Hospital, 54185 Skövde, Sweden.
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42
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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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Huang Y, Gloviczki P. Relationships between duplex findings and quality of life in long-term follow-up of patients treated for chronic venous disease. Phlebology 2016; 31:88-98. [PMID: 26916775 DOI: 10.1177/0268355516630868] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Relationships between duplex findings and data on health-related quality of life (QoL) to assess long-term results of treatment of varicose veins and chronic venous insufficiency (CVI) are not well known. The goal of this review was to correlate duplex findings and QoL assessments in clinical studies with long-term follow-up. METHODS A review of the English language literature on PUBMED revealed 17 clinical studies, including 9 randomized controlled trials (RCTs), 6 prospective, and 2 retrospective studies that included patients with at least 5-year follow-up after endovenous laser ablation (EVLA), radiofrequency ablation (RFA), ultrasound-guided foam sclerotherapy (UGFS), and traditional superficial venous surgery. RESULTS At 5 years, great saphenous vein (GSV) occlusion rate on duplex ultrasound ranged from 66% to 82% for EVLA, from 62% to 92% for RFA, from 41% to 58% for UGFS and from 54% to 85% for surgery. Freedom from GSV reflux rates were 82% and 84%, respectively for EVLA and surgery, and ranged between 84% and 95% for RFA. Significant improvements were observed in several domains of generic QoL and in most domains of venous disease-specific QoL, irrespective of the treatment. In at least one RCT, CIVIQ scores correlated well with abnormal duplex findings in patients who underwent treatment with UGFS. In another RCT, long-term AVVQ was significantly better after surgery as compared with UGFS similar to results of duplex findings. CONCLUSIONS Analysis of the available literature confirmed that all four techniques were effective in the abolishment of reflux or obliteration of the GSV. Moreover, well-designed RCTs with large sample size are needed to produce robust long-term data on clinical outcome after treatment of varicose veins and CVI and to better understand the relationships between duplex-derived data and QoL assessments.
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Affiliation(s)
- Ying Huang
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
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Eschrich J, Meyer R, Kuk H, Wagner AH, Noppeney T, Debus S, Hecker M, Korff T. Varicose Remodeling of Veins Is Suppressed by 3-Hydroxy-3-Methylglutaryl Coenzyme A Reductase Inhibitors. J Am Heart Assoc 2016; 5:e002405. [PMID: 26908399 PMCID: PMC4802467 DOI: 10.1161/jaha.115.002405] [Citation(s) in RCA: 13] [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] [Received: 11/25/2015] [Accepted: 01/07/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite the high prevalence of chronic venous insufficiency and varicose veins in the Western world, suitable pharmaceutical therapies for these venous diseases have not been explored to date. In this context, we recently reported that a chronic increase in venous wall stress or biomechanical stretch is sufficient to cause development of varicose veins through the activation of the transcription factor activator protein 1. METHODS AND RESULTS We investigated whether deleterious venous remodeling is suppressed by the pleiotropic effects of statins. In vitro, activator protein 1 activity was inhibited by two 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, rosuvastatin and atorvastatin, in stretch-stimulated human venous smooth muscle cells. Correspondingly, both statins inhibited venous smooth muscle cell proliferation as well as mRNA expression of the activator protein 1 target gene monocyte chemotactic protein 1 (MCP1). In isolated mouse veins exposed to an increased level of intraluminal pressure, statin treatment diminished proliferation of venous smooth muscle cells and protein abundance of MCP1 while suppressing the development of varicose veins in a corresponding animal model by almost 80%. Further analyses of human varicose vein samples from patients chronically treated with statins indicated a decrease in venous smooth muscle cell proliferation and MCP1 abundance compared with samples from untreated patients. CONCLUSIONS Our findings imply that both atorvastatin and rosuvastatin effectively inhibit the development of varicose veins, at least partially, by interfering with wall stress-mediated activator protein 1 activity in venous smooth muscle cells. For the first time, this study reveals a potential pharmacological treatment option that may be suitable to prevent growth of varicose veins and to limit formation of recurrence after varicose vein surgery.
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MESH Headings
- Animals
- Atorvastatin/pharmacology
- Case-Control Studies
- Cell Proliferation/drug effects
- Cells, Cultured
- Chemokine CCL2/metabolism
- Disease Models, Animal
- Dose-Response Relationship, Drug
- Female
- Humans
- Hydroxymethylglutaryl-CoA Reductase Inhibitors/pharmacology
- Male
- Mice
- Middle Aged
- Muscle, Smooth, Vascular/drug effects
- Muscle, Smooth, Vascular/metabolism
- Muscle, Smooth, Vascular/pathology
- Myocytes, Smooth Muscle/drug effects
- Myocytes, Smooth Muscle/metabolism
- Myocytes, Smooth Muscle/pathology
- Rosuvastatin Calcium/pharmacology
- Signal Transduction/drug effects
- Time Factors
- Transcription Factor AP-1/genetics
- Transcription Factor AP-1/metabolism
- Varicose Veins/metabolism
- Varicose Veins/pathology
- Varicose Veins/prevention & control
- Vascular Remodeling/drug effects
- Veins/drug effects
- Veins/metabolism
- Veins/pathology
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Affiliation(s)
- Johannes Eschrich
- Division of Cardiovascular Physiology, Institute of Physiology and Pathophysiology, Heidelberg University, Heidelberg, Germany
| | - Ralph Meyer
- Division of Cardiovascular Physiology, Institute of Physiology and Pathophysiology, Heidelberg University, Heidelberg, Germany
| | - Hanna Kuk
- Division of Cardiovascular Physiology, Institute of Physiology and Pathophysiology, Heidelberg University, Heidelberg, Germany
| | - Andreas H Wagner
- Division of Cardiovascular Physiology, Institute of Physiology and Pathophysiology, Heidelberg University, Heidelberg, Germany
| | | | - Sebastian Debus
- Department of Vascular Medicine, German Aortic Center, Hamburg, Germany
| | - Markus Hecker
- Division of Cardiovascular Physiology, Institute of Physiology and Pathophysiology, Heidelberg University, Heidelberg, Germany
| | - Thomas Korff
- Division of Cardiovascular Physiology, Institute of Physiology and Pathophysiology, Heidelberg University, Heidelberg, Germany
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External Application of Traditional Chinese Medicine for Venous Ulcers: A Systematic Review and Meta-Analysis. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2015; 2015:831474. [PMID: 26435725 PMCID: PMC4576005 DOI: 10.1155/2015/831474] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 08/14/2015] [Accepted: 08/23/2015] [Indexed: 01/22/2023]
Abstract
Objective. To evaluate the effectiveness of external application of traditional Chinese medicine (EA-TCM) on venous ulcers. Methods. Seven databases were searched until April 2015 for randomized controlled trials (RCTs) of EA-TCM for venous ulcers. Risk of bias was assessed using Cochrane Handbook guidelines. Study outcomes were presented as risk ratios (RRs) for dichotomous data or mean differences (MDs) for continuous data. Results. Sixteen of 193 potentially relevant trials met the inclusion criteria; however, their methodological qualities were low. Comparison of the same intervention strategies revealed significant differences in total effectiveness rates between EA-TCM and conventional therapy groups (RR = 1.22, 95% confidence interval [CI] = 1.16–1.29, and P < 0.00001). Compared to conventional therapy, EA-TCM combined with conventional therapy had a superior total effectiveness rate (RR = 1.11, 95% CI = 1.04–1.19, and P = 0.003). There were no significant differences in recurrence rates during followup and final pain measurements between the experimental and those in the control groups (RR = 0.86, 95% CI = 0.31–2.39, and P = 0.85; MD −0.75, 95% CI = −2.15–0.65, and P = 0.29). Conclusion. The evidence that EA-TCM is an effective treatment for venous ulcers is encouraging, but not conclusive due to the low methodological quality of the RCTs. Therefore, more high-quality RCTs with larger sample sizes are required.
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