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Victoria M GE, Rujano A AJ, Zilipo GM. Laser-sclerosing foam hybrid treatment, a non-tumescent technique for insufficient great saphenous vein ablation. Phlebology 2024; 39:267-272. [PMID: 38182555 DOI: 10.1177/02683555231226264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2024]
Abstract
OBJECTIVE We aim to report on the Laser-Sclerosing Foam Hybrid Treatment (LSFHT) and its outcomes when used on patients with great saphenous vein (GSV) insufficiency. METHODS This was a single center retrospective cohort study on patients with GSV insufficiency that were treated with the LSFHT technique, a surgical procedure that comprises the use of both sclerosing foam and endovenous ablation and avoids the use of tumescent anesthesia. Occlusion rates and complications were reported. RESULTS 139 legs from 106 patients were operated, achieving a 100% occlusion rate, while only a small burn and 2 popliteal vein thrombosis cases occurred. CONCLUSION The study suggests that the LSFHT is a feasible fast procedure that proved both effective and safe for the treatment of GSV insufficiency.
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Alongi G, Bissacco D, Cervi E. Three-year follow-up analysis of automated microfoam preparation system for great saphenous vein incompetence and varicose veins sclerotherapy treatment. Phlebology 2024:2683555241250226. [PMID: 38670934 DOI: 10.1177/02683555241250226] [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: 04/28/2024]
Abstract
BACKGROUND To describe the treatment of patients with great saphenous vein (GSV) incompetence and varicose veins (VVs), utilizing an Automated Microfoam Preparation System (AMPS, Varixio®, VB Devices, Barcelona, Spain). METHODS Adults between January and June 2021 were included. The AMPS system was used for foam preparation. Sclerotherapy treatment followed international recommendations. The primary endpoint was GSV closure rate after 36 months. RESULTS 164 patients were enrolled. During the 7-day follow-up period, all GSVs showed complete closure, which was maintained at the 1-year mark. No major complications were reported. A cumulative complete GSV recanalization rate of 6.1% and a partial recanalization rate of 26.8% after 36 months were noted. Some patients (9.7%) required additional treatment. A higher BMI was associated with complete recanalization. CONCLUSION The AMPS offers an easy-to-use and standardized procedure, potentially enhancing treatment outcomes if compared with manual preparation. Caution is advised when treating obese patients.
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Affiliation(s)
| | - Daniele Bissacco
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Salerno M, Bissacco D, Chi YW, Narayanan S, Addis A, Dellavia C, Canciani E, Righini PC, Nano G, Gianesini S. Empty vein ablation (EVA) technique: an in-vivo animal model to assess the effects of sclerosing agent concentration and wall contact time on intima and media tunicae structure. INT ANGIOL 2024; 43:223-228. [PMID: 38512703 DOI: 10.23736/s0392-9590.24.05147-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
BACKGROUND Sclerotherapy is a cornerstone of the treatment of chronic venous disease, despite some technical aspects (e.g., sclerosant liquid agent concentration [SLAC] and contact time between sclerosant agent and vein wall [ctSA/VW]) to maximize outcomes remain an unsolved problem and a source of debate. An innovative three-balloon catheter has been developed to allow sclerotherapy in empty vein conditions (Empty Vein Ablation technique, EVA), revolutionizing the definition of SLAC and ctSA/VW. Aim of this experimental study is to analyze EVA effects on intima and media vessel tunicae using different SLAC and ctSA/VW in an in-vivo animal model. METHODS Two adult sheep were treated by EVA using jugular and common iliac vein axes (eight vein segments). Different SLAC (polidocanol 0.5% or 1%) and different ctSA/VW (3 or 5 minutes) were combined for testing residual circumferential intima percentage and media thickness after EVA. RESULTS Intact circumferential residual intima after the treatment was 21.3±4.9%, 18.2±7.4%, 15.7±2.4% and 8.9±2.0% using 0.5% (3 min), 0.5% (5 min), 1% (3 min) and 1% (5 min), respectively (R2=0.945; control sample: 97.6%). Media thickness after the treatment was 121.6±35.3 µm, 110.9±7.8 µm, 96.1±30.4 µm and 79.1±34.1 µm using 0.5% (3 min), 0.5% (5 min), 1% (3 min) and 1% (5 min), respectively (R2=0.990; control sample 125.7 µm). No significant modifications were detected analyzing the adventitia in all samples. CONCLUSIONS EVA proved to be effective in venous wall destruction even with a very low SLAC and ctSA/VW (0.5% in 3 minutes), in quite large caliber veins. Direct comparisons with foam/liquid sclerotherapy should be done to confirm therapeutic effectiveness of these results, despite EVA has provided a maximized and controlled SA/VW contact time and ratio.
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Affiliation(s)
- Mario Salerno
- Unit of Angiology, Department of Medicine and Cardiopulmonary Rehabilitation, Istituti Clinici Scientifici Maugeri IRCCS, Institute of Tradate, Varese, Italy
- I-VASC S.r.l, Milan, Italy
| | - Daniele Bissacco
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy -
| | - Yung-Wei Chi
- Vascular Center, University of California, Sacramento, CA, USA
| | | | - Alessandro Addis
- CRABCC, Biotechnology Research Center for Cardiothoracic Applications, Rivolta D'Adda, Cremona, Italy
| | - Claudia Dellavia
- Department of Biomedical Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Elena Canciani
- Department of Health Sciences "Amedeo Avogadro", University of Eastern Piedmont, Vercelli, Italy
| | - Paolo C Righini
- Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Giovanni Nano
- Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy
| | - Sergio Gianesini
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Tan M, Moreno HB, Bechter-Hugl B, Gianesini S, Connor D, Parsi K, Davies AH. Sclerotherapy: Indications and safety volumes. Phlebology 2024; 39:135-138. [PMID: 37899570 PMCID: PMC10877989 DOI: 10.1177/02683555231211092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Affiliation(s)
- Matthew Tan
- Department of Surgery and Cancer, Imperial College London, London, UK
| | | | - Beate Bechter-Hugl
- Department of Vascular Surgery, Centre for Lymphedema, UZ Leuven - University Hospitals Leuven, Leuven, Belgium
| | - Sergio Gianesini
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - David Connor
- Department of Dermatology, St Vincent’s Hospital Sydney, Sydney, Australia
| | - Kurosh Parsi
- Department of Dermatology, St Vincent’s Hospital Sydney, Sydney, Australia
| | - Alun H Davies
- Department of Surgery and Cancer, Imperial College London, London, UK
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Salerno M, Bissacco D, Chi YW, Narayanan S, Addis A, Dellavia C, Canciani E, Gard M, Gianesini S. Empty vein ablation innovative technique for chronic venous disease treatment: proof of concept and ex-vivo analysis. INT ANGIOL 2023; 42:420-426. [PMID: 37377397 DOI: 10.23736/s0392-9590.23.05055-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
BACKGROUND Sclerotherapy is among the mainstays of chronic venous disease treatment, yet its occlusion rate remains suboptimal compared to thermal tumescent techniques. An innovative three-balloons catheter has been developed to allow sclerotherapy in empty vein conditions (empty vein ablation technique, EVA). Aim of this investigation was to describe the EVA technical aspects and related ex-vivo effects on vein wall. METHODS Two samples from jugular veins of an adult sheep were treated by EVA or foam sclerotherapy (FS, Tessari method). Primary outcome was the percentage of circumferential intima treated by EVA or FS; secondary outcomes were intima and media thickness modifications after treatment. RESULTS Intact circumferential residual intima were 6.07±2.94% and 16.55±0.70% after EVA and FS, respectively (P=0.020). Despite the average intima and media thickness did not differ between treatments, EVA demonstrated a homogenous damage throughout the vein segment, while FS effect was less destructive distally to the injection site, because moving away from the injection site and floating, it has a less contact with internal surface of the vein. CONCLUSIONS EVA seems to overcome chemical ablation limits as flushing effect and the increases vein wall/sclerosant agent contact effect compared to FS. Ex-vivo encouraging results need in-vivo validation to evaluate other points like deactivation of sclerosing agent by blood protein and the contact time control between SA and the vein wall. If we have further confirmations in vivo we might think we have a potential higher occlusion rate compared to FS, paving the way for future clinical trials.
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Affiliation(s)
- Mario Salerno
- Unit of Angiology, Department of Medicine and Cardiopulmonary Rehabilitation, IRCCS Maugeri Institute, Tradate, Varese, Italy
- I-VASC S.r.l, Milan, Italy
| | - Daniele Bissacco
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy -
| | - Yung-Wei Chi
- University of California, Davis Vascular Center, Sacramento, CA, USA
| | - Sriram Narayanan
- The Harley Street Heart and Vascular Center, Singapore, Singapore
| | - Alessandro Addis
- CRABCC, Biotechnology Research Center for Cardiothoracic Applications, Rivolta D'Adda, Cremona, Italy
| | - Claudia Dellavia
- Department of Biomedical Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Elena Canciani
- Center for Translational Research on Autoimmune & Allergic Disease-CAAD, Department of Health Sciences, University of Eastern Piedmont, Novara, Italy
| | | | - Sergio Gianesini
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Wolosker N, Louzada ACS, Portela FSO, da Silva MFA, Schettino GDPP, Corrêa LH, Juniordata EA, Teivelis MP. Proposed public policies to improve outcomes in vascular surgery: an experts' forum. EINSTEIN-SAO PAULO 2023; 21:eAE0241. [PMID: 37585883 PMCID: PMC10421605 DOI: 10.31744/einstein_journal/2023ae0241] [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: 07/13/2022] [Accepted: 12/18/2022] [Indexed: 08/18/2023] Open
Abstract
OBJECTIVE To evaluate outcomes of vascular surgeries and identify strategies to improve public vascular care. METHODS This was a descriptive, qualitative, and cross-sectional survey involving 30 specialists of the Hospital Israelita Albert Einstein via Zoom. The outcomes of vascular procedures performed in the Public Health System extracted through Big Data analysis were discussed, and 53 potential strategies to improve public vascular care to improve public vascular care. RESULTS There was a consensus on mandatory reporting of some key complications after complex arterial surgeries, such as stroke after carotid revascularization and amputations after lower limb revascularization. Participants agreed on the recommendation of screening for diabetic feet and infrarenal abdominal aortic aneurysms. The use of Telemedicine as a tool for patient follow-up, auditing of centers for major arterial surgeries, and the concentration of complex arterial surgeries in reference centers were also points of consensus, as well as the need to reduce the values of endovascular materials. Regarding venous surgery, it was suggested that there should be incentives for simultaneous treatment of both limbs in cases of varicose veins of the lower limbs, in addition to the promotion of ultrasound-guided foam sclerotherapy in the public system. CONCLUSION After discussing the data from the Brazilian Public System, proposals were defined for standardizing measures in population health care in the area of vascular surgery. Notification of complications of arterial surgeries is essential in identifying strategies to improve surgical outcomes. Screening of prevalent and/or morbid diseases allows early intervention and prevention of complications. Use of telemedicine in vascular follow-up allows optimizing the use of resources and reducing the burden on health services. Concentrating complex cases in reference hospitals leads to improved surgical outcomes.
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Affiliation(s)
- Nelson Wolosker
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
- Faculdade Israelita de Ciências da Saúde Albert EinsteinHospital Israelita Albert EinsteinSão PauloSPBrazil Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | | | | | | | | | - Lucas Hernandes Corrêa
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Edson Amaro Juniordata
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Marcelo Passos Teivelis
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
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Keohane CR, Westby D, Twyford M, Ahern T, Tawfick W, Walsh SR. Axial ablation versus terminal interruption of the reflux source (AAVTIRS): a randomised controlled trial. Trials 2022; 23:483. [PMID: 35689289 PMCID: PMC9188187 DOI: 10.1186/s13063-022-06440-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 05/31/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Treatment of superficial venous reflux has been shown to improve ulcer healing time and reduce the risk of ulcer recurrence. Terminal ablation of the reflux source (TIRS) is an alternative to formal endovenous ablation or surgery which can be performed by injecting sclerosant foam into the peri-ulcer plexus of the veins. TIRS has been shown to be successful and in our experience is the option preferred by many patients, when offered as an alternative to axial ablation (AA). AIM To determine if the proportion of ulcers healed within 6 months of endovenous treatment differs between patients undergoing AA of varicose veins or TIRS by peri-ulcer foam sclerotherapy. METHODS AAVTIRS is an assessor-blinded randomised controlled trial. Patients will be recruited from a dedicated ulcer clinic in Roscommon University Hospital and from the vascular surgical clinics in University Hospital Galway. All patients attending the ulcer clinic will be screened for eligibility. RANDOMISATION Random computer-generated sequence is stratified by ulcer size. Allocation will be concealed using sealed opaque envelopes. BLINDING Assessors reviewing wounds at follow -p visits will be blinded to patient allocation. PRIMARY ENDPOINT The proportion of ulcers healed within 6 months of enrolment. DISCUSSION This will be the first time that TIRS has been evaluated with a properly powered randomised trial in the setting of venous ulcer management. Streamlining the management of venous ulcers has broad health economic benefits. If it is found that TIRS is superior or non-inferior to AA, then a less expensive, less invasive injection can be offered as an alternative to AA in an attempt to encourage the healing of venous ulcers. If AA is found to be superior to TIRS, then this would suggest that all patients undergoing ablation in the management of venous ulcers should have their superficial reflux fully treated, building on the evidence of the EVRA trial. TRIAL REGISTRATION ClinicalTrials.gov NCT04484168. Registered on 23 July 2020.
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Affiliation(s)
- C R Keohane
- University Hospital Galway, Galway, Ireland. .,National University of Ireland Galway, Galway, Ireland.
| | - D Westby
- Roscommon University Hospital, Roscommon, Ireland.,National University of Ireland Galway, Galway, Ireland
| | - M Twyford
- University Hospital Galway, Galway, Ireland.,National University of Ireland Galway, Galway, Ireland
| | - T Ahern
- University Hospital Galway, Galway, Ireland.,National University of Ireland Galway, Galway, Ireland
| | - W Tawfick
- University Hospital Galway, Galway, Ireland.,National University of Ireland Galway, Galway, Ireland
| | - S R Walsh
- University Hospital Galway, Galway, Ireland.,Lambe Institute for Translational Research, National University of Ireland Galway, Newcastle Rd, Galway, Ireland
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Whiteley MS. Current Best Practice in the Management of Varicose Veins. Clin Cosmet Investig Dermatol 2022; 15:567-583. [PMID: 35418769 PMCID: PMC8995160 DOI: 10.2147/ccid.s294990] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 03/27/2022] [Indexed: 12/01/2022]
Abstract
This article outlines the current best practice in the management of varicose veins. “Varicose veins” traditionally means bulging veins, usually seen on the legs, when standing. It is now a general term used to describe these bulging veins, and also underlying incompetent veins that reflux and cause the surface varicose veins. Importantly, “varicose veins” is often used for superficial venous reflux even in the absence of visible bulging veins. These can be simply called “hidden varicose veins”. Varicose veins usually deteriorate, progressing to discomfort, swollen ankles, skin damage, leg ulcers, superficial venous thrombosis and venous bleeds. Patients with varicose veins and symptoms or signs have a significant advantage in having treatment over conservative treatment with compression stockings or venotropic drugs. Small varicose veins or telangiectasia without symptoms or signs can be treated for cosmetic reasons. However, most have underlying venous reflux from saphenous, perforator or local “feeding veins” and so investigation with venous duplex should be mandatory before treatment. Best practice for investigating leg varicose veins is venous duplex ultrasound in the erect position, performed by a specialist trained in ultrasonography optimally not the doctor who performs the treatment. Pelvic vein reflux is best investigated with transvaginal duplex ultrasound (TVS), performed using the Holdstock-Harrison protocol. In men or women unable to have TVS, venography or cross-sectional imaging is needed. Best practice for treating truncal vein incompetence is endovenous thermal ablation. Increasing evidence suggests that significant incompetent perforating veins should be found and treated by thermal ablation using the transluminal occlusion of perforator (TRLOP) approach, and that incompetent pelvic veins refluxing into symptomatic varicose veins in the genital region or leg should be treated by coil embolisation. Bulging varicosities should be treated by phlebectomy at the time of truncal vein ablation. Monitoring and reporting outcomes is essential for doctors and patients; hence, participation in a venous registry should probably be mandatory.
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Rabe E, Breu FX, Flessenkämper I, Gerlach H, Guggenbichler S, Kahle B, Murena R, Reich-Schupke S, Schwarz T, Stücker M, Valesky E, Werth S, Pannier F. Sclerotherapy in the treatment of varicose veins : S2k guideline of the Deutsche Gesellschaft für Phlebologie (DGP) in cooperation with the following societies: DDG, DGA, DGG, BVP. DER HAUTARZT 2021; 72:23-36. [PMID: 33252705 PMCID: PMC8692296 DOI: 10.1007/s00105-020-04705-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- E Rabe
- Emeritus Klinik und Poliklinik für Dermatologie und Allergologie, Universitätsklinikum Bonn (AöR), Venusberg-Campus 1, 53127, Bonn, Germany.
| | | | | | | | | | - B Kahle
- Klinik für Dermatologie, Allergologie und Venerologie, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - R Murena
- Phlebologische Praxis, Köln, Germany
| | - S Reich-Schupke
- Privatpraxis für Haut- und Gefäßmedizin, Wundtherapie, Recklinghausen, Germany
| | - T Schwarz
- Praxis für Gefäßmedizin, Freiburg, Germany
| | - M Stücker
- Klinik für Dermatologie, Venerologie und Allergologie, Ruhr-Universität Bochum, St. Josef Hospital, Bochum, Germany
| | - E Valesky
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinik Frankfurt, Frankfurt, Germany
| | - S Werth
- Universitäts-Gefäßzentrum, Innere Medizin III, Universitätsklinikum Carl Gustav Carus, Dresden, Germany
| | - F Pannier
- Praxis Dermatologie & Phlebologie Bonn und Dermatologische Universitätsklinik Köln, Bonn, Germany
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Cartee TV, Wirth P, Greene A, Straight C, Friedmann DP, Pittman C, Daugherty SF, Blebea J, Meissner M, Schul MW, Mishra V. Ultrasound-guided foam sclerotherapy is safe and effective in the management of superficial venous insufficiency of the lower extremity. J Vasc Surg Venous Lymphat Disord 2021; 9:1031-1040. [PMID: 34144767 DOI: 10.1016/j.jvsv.2021.03.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 03/31/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Superficial venous disease of the lower extremity has a significant impact on quality of life. Both truncal and tributary vein reflux contribute to this disease process. Endovenous foam sclerotherapy is a widely used technique throughout the world for the management of superficial venous reflux and ultrasound guidance improves its safety and efficacy. METHODS A PubMed search for ultrasound-guided foam sclerotherapy (UGFS) was conducted and all abstracts were reviewed to identify clinical trials and systematic reviews for a full-text analysis. Additional articles were also identified through searching the references of the selected studies. RESULTS The production of foam for sclerotherapy in a 1:3 or 1:4 ratio of air to sclerosant is optimal in a low silicone, low-volume syringe system. Physiologic gas may decrease any side effects, with the trade-off of decreased foam stability. Proper technique with appropriate sterility and cleansing protocols are paramount for safe and effective treatment. The technical success of UGFS for great saphenous vein disease is inferior to endothermal and surgical modalities and retreatment is more common. However, the clinical improvement in patient-reported quality of life is similar between these three modalities. When used for tributary veins in combination with endothermal approaches of the truncal veins, UGFS has high rates of success with excellent patient satisfaction. UGFS has demonstrated an excellent safety profile comparable with or superior to other modalities. CONCLUSIONS With proper technique, UGFS is safe and effective for the management of superficial venous disease.
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Affiliation(s)
- Todd V Cartee
- Department of Dermatology, Penn State Health, Hershey, Pa.
| | - Paul Wirth
- Department of Dermatology, Penn State Health, Hershey, Pa
| | - Amrit Greene
- Department of Dermatology, Penn State Health, Hershey, Pa
| | | | | | - Chris Pittman
- Department of Radiology, University of South Florida Morsani College of Medicine, Tampa, Fla; Vein911 Vein Treatment Centers, Tampa, Fla
| | | | - John Blebea
- Department of Surgical Disciplines, Central Michigan University College of Medicine, Mount Pleasant, Mich
| | - Mark Meissner
- Department of Surgery, University of Washington School of Medicine, Seattle, Wash
| | - Marlin W Schul
- Indiana University School of Medicine, West Lafayette campus, Lafayette, Ind; Indiana Vascular Associates, LLC, Lafayette, Ind
| | - Vineet Mishra
- Division of Mohs Surgery, Dermatology & Vascular Surgery, Scripps Clinic, San Diego, Calif
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12
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Pappas PJ, Lakhanpal S, Nguyen KQ, Fernandez E, Sufian S. Extended Center for Vein Restoration study assessing comparative outcomes for the treatment of chronic venous insufficiency in Medicare- and non-Medicare-eligible patients. J Vasc Surg Venous Lymphat Disord 2021; 9:1426-1436.e2. [PMID: 33965612 DOI: 10.1016/j.jvsv.2021.04.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 04/20/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND We previously reported that chronic venous insufficiency treatment of Medicare-eligible patients achieved outcomes similar to those for non-Medicare-eligible patients. The goal of the present investigation was to assess the long-term treatment outcomes and the effect of race in a larger patient cohort. METHODS From January 2015 to December 2019, we retrospectively reviewed the data from 131,268 patients who had presented for a lower extremity venous evaluation. We divided the patients into two groups by age: group A was aged ≥65 years and group B, <65 years. The treatments analyzed in each group were axial thermal ablation (TA), axial Varithena ablation (VA), TA plus phlebectomy, VA plus phlebectomy, and TA or VA with phlebectomy and ultrasound-guided foam sclerotherapy (UGFS). The treatment outcomes were assessed using the revised venous clinical severity score (rVCSS) and Chronic Venous Insufficiency Quality of Life 20-item questionnaire (CIVIQ-20) scores at the initial consultation and 1, 6, and 12 months after completion of the treatment plan. RESULTS Of the 131,268 patients, 40,020 were in group A and 91,248 in group B, with an average age of 74.4 ± 6.6 and 49.9 ± 10.6 years, respectively. Of the 40,020 patients in group A, 15,697 (n = 25,234 limbs) had undergone TA and 1910 (n = 3222 limbs) had undergone VA. Of the 91,248 patients in group B, 35,220 (n = 53,717 limbs) had undergone TA and 2178 (n = 3672 limbs) had undergone VA. For the TA subgroups, all rVCSSs had significantly improved after treatment at each evaluation point (P ≤ .001). For the TA and VA plus phlebectomy with or without UGFS subgroup, the older patients (group A) required 6 months to develop the same degree of improvement as the younger patients (group B) at 1 month. When subdivided by race, all initial and 6-month rVCSSs and CIVIQ-20 scores within a race had improved and were better in group B, except for Asian and Hispanic patients (P ≤ .001). After TA or VA plus phlebectomy, with or without UGFS, the CIVIQ-20 outcomes had improved by 1 month in both groups, although the rVCSS lagged by 6 months in group A. No differences in the rVCSSs or CIVIQ-20 scores were observed between the groups treated with TA or VA. CONCLUSIONS Medicare-eligible beneficiaries demonstrated improved outcomes similar to those of non-Medicare-eligible beneficiaries after ablation. When TA or VA plus phlebectomy with or without UGFS were examined, group A required 6 months to demonstrate rVCSSs equivalent to those of group B at 1 month. The CIVIQ-20 scores had improved by 1 month in both groups, regardless of the treatment modality. The difference in rVCSSs appeared to be driven by African American and white patients because Hispanic and Asian patients demonstrated equivalent results regardless of age. Patients treated with TA or VA demonstrated equivalent results.
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13
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Diken Aİ, Alemdaroğlu U, Özyalçın S, Hafez İ, Tünel HA, Yalçınkaya A, Ecevit AN. Adjuvant radiofrequency thermocoagulation improves the outcome of liquid sclerotherapy in the treatment of spider veins of the leg: A pilot study. Phlebology 2021; 36:620-626. [PMID: 33813962 DOI: 10.1177/02683555211006534] [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: 11/16/2022]
Abstract
OBJECTIVE This study evaluated the effect of low-energy radiofrequency thermocoagulation added to standard liquid sclerotherapy on clinical outcomes of patients with venous insufficiency. PATIENTS AND METHOD We included 111 patients with spider veins CEAP/C1 stage. The patients were randomized into sclerotherapy (Group 1) and sclerotherapy + sclerotherapy immediately followed by low energy percutaneous RF thermocoagulation (Group 2) groups and followed up with same protocols prospectively. RESULTS The study groups did not differ in terms of the mean age, body mass index, the number of spider veins and pre-interventional venous clinical severity scores (VCSS). Patients' self-assessed satisfaction ratings of cosmetic outcomes were found to be higher compared to the baseline (p = 0.001). While both techniques caused a significant decline in VCSS at postprocedural third month, it was observed that the type of applied intervention did not affect the VCSS (p = 0.43 and p = 0.93, respectively). There was a significant difference in hyperpigmentation and trapped blood between the two groups after the procedure (p = 0.009 and p = 0.02, respectively), there was no statistically significant difference in terms of skin necrosis (p = 0.52). A significant difference in the self-assessed cosmetic outcomes was observed in patients treated with sclerotherapy followed by low energy percutaneous RF thermocoagulation compared with patients whom sclerotherapy performed alone (p = 0.001). DISCUSSION This study suggests that radiofrequency thermocoagulation added to the sclerotherapy provides better cosmetic outcomes with less treatment sessions and no additional complication rates.
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Affiliation(s)
- Adem İlkay Diken
- Cardiovascular Surgery, Faculty of Medicine, Baskent University, Adana, Turkey
| | - Utku Alemdaroğlu
- Cardiovascular Surgery, Faculty of Medicine, Baskent University, Adana, Turkey
| | - Sertan Özyalçın
- Cardiovascular Surgery, Faculty of Medicine, Hitit University, Çorum, Turkey
| | - İzzet Hafez
- Cardiovascular Surgery, Faculty of Medicine, Baskent University, Adana, Turkey
| | - Hüseyin A Tünel
- Cardiovascular Surgery, Faculty of Medicine, Baskent University, Adana, Turkey
| | - Adnan Yalçınkaya
- Cardiovascular Surgery, Faculty of Medicine, Hitit University, Çorum, Turkey
| | - Ata N Ecevit
- Cardiovascular Surgery, Ministry of Health Ankara City Hospital, Ankara, Turkey
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[Guidelines for sclerotherapy of varicose veins : S2k guideline of the German Society of Phlebology (DGP) in cooperation with the following professional associations: DDG, DGA, DDG, BVP. German Version]. DER HAUTARZT 2021; 72:50-64. [PMID: 33151348 DOI: 10.1007/s00105-020-04707-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Cavezzi A. Medicine and Phlebolymphology: Time to Change? J Clin Med 2020; 9:E4091. [PMID: 33353052 PMCID: PMC7766771 DOI: 10.3390/jcm9124091] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 12/10/2020] [Accepted: 12/15/2020] [Indexed: 02/07/2023] Open
Abstract
Biomedical science is undergoing a reappraisal of its scientific advancement process and of the related healthcare management. Progress in medicine should combine improvements of knowledge, efficacy, and safety of diagnostic/therapeutic procedures, with adequate cost-effectiveness profiles. This narrative review is aimed at assessing in medicine, more specifically in phlebology and lymphology: (a) scientific literature possible biases, (b) the level of evidence, comprehensiveness, and cost-effectiveness of the main therapeutic options, and (c) the possible contribution of integrative and translational medicine. Current medical research may have cognitive biases, or industry-tied influences, which impacts clinical practice. Some reductionism, with an increasing use of drugs and technology, often neglecting the understanding and care of the root causative pathways of the diseases, is affecting biomedical science as well. Aging brings a relevant burden of chronic degenerative diseases and disabilities, with relevant socio-economic repercussions; thus, a major attention to cost-effectiveness and appropriateness of healthcare is warranted. In this scenario, costly and innovative but relatively validated therapies may tend to be adopted in venous and lymphatic diseases, such as varicose veins, leg venous ulcer, post-thrombotic syndrome, pelvic congestion syndrome, and lymphedema. Conversely, a more comprehensive approach to the basic pathophysiology of chronic venous and lymphatic insufficiency and the inclusion of pharmacoeconomics analyses would benefit overall patients' management. Erroneous lifestyle and nutrition, together with chronic stress-induced syndromes, significantly influence chronic degenerative phlebo-lymphatic diseases. The main active epigenetic socio-biologic factors are obesity, dysfunctions of musculo-respiratory-vascular pumps, pro-inflammatory nutrition, hyperactivation of stress axis, and sedentarism. An overall critical view of the scientific evidence and innovations in phebolymphology could be of help to improve efficacy, safety, and sustainability of current practice. Translational and integrative medicine may contribute to a patient-centered approach. Conversely, reductionism, eminence/reimbursement-based decisional processes, patients' lack of education, industry-influenced science, and physician's improvable awareness, may compromise efficacy, safety, appropriateness, and cost-effectiveness of future diagnostic and therapeutic patterns of phlebology and lymphology.
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Mann MW. Sclerotherapy – How to Achieve a Spectacular Outcome. PHLEBOLOGIE 2020. [DOI: 10.1055/a-1195-4262] [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
AbstractWhen performed correctly, sclerotherapy results in fibrous occlusion that is not amenable to recanalization. Paramount to success is adequate contact time of a sclerosant to the endothelial cells to cause sufficient damage to the vein while minimizing side effects. To optimize sclerotherapy results, one needs to choose the right patient and the right vein and then use the proper sclerosing agent and injection techniques. This paper will review current literature on sclerotherapy, as well as tips and tricks to optimize outcome and minimize complications.
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Affiliation(s)
- Margaret W. Mann
- Department of Dermatology at Case Western Reserve University, Cleveland, OH. Innova Dermatology, Hendersonville, TN
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Reitz KM, Salem K, Mohapatra A, Liang NL, Avgerinos ED, Singh MJ, Hager E. Complete Venous Ulceration Healing after Perforator Ablation Does Not Depend on Treatment Modality. Ann Vasc Surg 2020; 70:109-115. [PMID: 32603845 DOI: 10.1016/j.avsg.2020.06.051] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/06/2020] [Accepted: 06/24/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Venous leg ulceration (VLU) represents the most advanced form of chronic venous insufficiency (CVI). Persistent VLU that fails to respond to noninvasive treatment requires a minimally invasive endovascular treatment, which may include chemical (ultrasound-guided foam sclerotherapy [UGFS]) and thermal ablation (endovenous laser therapy [EVLT] or radiofrequency ablation [RFA]) targeting incompetent veins. Current guidelines suggest ablation of incompetent perforating veins (IPVs) juxtaposed to active or healed VLU; however, the ideal treatment modality is unknown. We hypothesize that similar to incompetent superficial vein treatment options therapies, VLU healing will be equivalent across minimally invasive IPV treatment options. METHODS Using the Vascular Low Frequency Disease Consortium, adults with VLU across 11 medical centers were retrospectively reviewed (2013-2017). We included those who underwent IPV therapies. The primary outcome was complete ulcer healing over time compared with cumulative hazard curves, log-rank testing, and multivariable Cox proportional hazard regression. Secondary outcomes included number of subsequent procedures, which were compared using negative binomial regression. RESULTS Of the 832 adults with VLU, 158 (19%) were exclusively treated conservatively, and 232 (28%) underwent index treatment for IPV and constitute the full and final cohort. The mean age was 60 ± 14 years, 57% were men, and the mean ulcer area was 3.0 cm2 (interquartile range, 1-6 cm2). Ninety-one (39%) were treated with EVLT, 127 (55%) RFA, and 14 (6%) UGFS. Patients treated with RFA were older (RFA 62 ± 14 years; EVLT 59 ± 14 years; UGFS 52 ± 9 years; P = 0.01), more likely to be men (RFA 68%, n = 86; EVLT 41%, n = 37; UGFS 64%, n = 9; P < 0.001), with a higher frequency of anticoagulation (RFA 36%, n = 46; EVLT 18%, n = 16; UGFS 14%, n = 2; P = 0.005). VLU did not significantly differ in size between groups (RFA 6.2 ± 8; EVLT 4.2 ± 5.4; UGFS 6.1 ± 8; P < 0.001). There were no differences in 1-year ulcer healing rates between groups (P = 0.18). The number of subsequent procedures did not differ by treatment modality (P = 0.47). CONCLUSIONS This multi-institutional retrospective study does not demonstrate any association of IPV treatment modality with differing rates of VLU healing or number of subsequent procedures.
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Affiliation(s)
| | - Karim Salem
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | - Nathan L Liang
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | - Michael J Singh
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Eric Hager
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
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Liu X, Zheng G, Ye B, Chen W, Xie H, Zhang T, Lin J. A retrospective cohort study comparing two treatments for active venous leg ulcers. Medicine (Baltimore) 2020; 99:e19317. [PMID: 32080149 PMCID: PMC7034671 DOI: 10.1097/md.0000000000019317] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Endovenous laser ablation (EVLA) and ultrasound-guided foam sclerotherapy (UGFS) have largely replaced traditional surgery for treatment of varicose veins (VVs) with active venous leg ulcers (VLUs), and multiple combined modes have emerged. A retrospective cohort study was performed to compare the effect of traditional surgery (high ligation and stripping followed with compression [compression plus HL-S]) to high ligation-endovenous laser ablation-foam sclerotherapy followed with compression (compression plus HL-EVLA-FS) on the treatment of active VLUs.Data of active VLUs treated in our center from 2008 to 2017 and followed up for 1 year were analyzed. The intervention measures in the first 5 years were compression plus HL-S, and in the following 5 years were compression plus HL-EVLA-FS. The primary outcome was ulcer healing time. The secondary outcomes were the VVs occlusion and clinical success as assessed by a change in venous clinical severity score (VCSS) and complications.The study included 120 patients and 200 patients treated with HL-S and HL-EVLA-FS, respectively, during 2008 to 2017. The average ulcer healing time were 2.3 ± 2.4 and 1.7 ± 1.7 months, respectively. Significant difference was found in the cumulative ulcers healing rate between the two groups (Hazard ratio [HR] and 95% confidence interval [CI] was respectively 1.458 and 1.140-1.865, P = .0002), but no difference was found in the VVs occlusion (HR and 95% CI was respectively 1.005 and 0.774-1.3071, P = .967). Significant difference occurred in 6 months and 12 months post-operatively in the VCSS change and in the procedure data and some complications between the 2 groups.In conclusion, the treatment of HL-EVLA-FS can accelerate the healing of VLUs, improve the VCSS and present superior procedure data. However, no advantage could be found in the VVs occlusion compared with control group.
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Hassanin A, Aherne TM, Greene G, Boyle E, Egan B, Tierney S, Walsh SR, McHugh S, Aly S. A systematic review and meta-analysis of comparative studies comparing nonthermal versus thermal endovenous ablation in superficial venous incompetence. J Vasc Surg Venous Lymphat Disord 2019; 7:902-913.e3. [DOI: 10.1016/j.jvsv.2019.06.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 06/18/2019] [Indexed: 12/29/2022]
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Gianesini S, Obi A, Onida S, Baccellieri D, Bissacco D, Borsuk D, Campisi C, Campisi CC, Cavezzi A, Chi YW, Chunga J, Corda D, Crippa A, Davies A, De Maeseneer M, Diaz J, Ferreira J, Gasparis A, Intriago E, Jawien A, Jindal R, Kabnick L, Latorre A, Lee BB, Liew NC, Lurie F, Meissner M, Menegatti E, Molteni M, Morrison N, Mosti G, Narayanan S, Pannier F, Parsi K, Partsch H, Rabe E, Raffetto J, Raymond-Martimbeau P, Rockson S, Rosukhovski D, Santiago FR, Schul A, Schul M, Shaydakov E, Sibilla MG, Tessari L, Tomaselli F, Urbanek T, van Rijn MJ, Wakefield T, Wittens C, Zamboni P, Bottini O. Global guidelines trends and controversies in lower limb venous and lymphatic disease: Narrative literature revision and experts' opinions following the vWINter international meeting in Phlebology, Lymphology & Aesthetics, 23-25 January 2019. Phlebology 2019; 34:4-66. [PMID: 31495256 DOI: 10.1177/0268355519870690] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Guidelines are fundamental in addressing everyday clinical indications and in reporting the current evidence-based data of related scientific investigations. At the same time, a spatial and temporal issue can limit their value. Indeed, variability in the recommendations can be found both among the same nation different scientific societies and among different nations/continents. On the other side, Garcia already published in 2014 data showing how, after three years in average, one out of five recommendations gets outdated (Martinez Garcia LM, Sanabria AJ, Garcia Alvarez E, et al. The validity of recommendations from clinical guidelines: a survival analysis. CMAJ 2014;186(16):1211–1219). The present document reports a narrative literature revision on the major international recommendations in lower limb venous and lymphatic disease management, focusing on the different countries’ guidelines, trends and controversies from all the continents, while identifying new evidence-based data potentially influencing future guidelines. World renowned experts’ opinions are also provided. The document has been written following the recorded round tables scientific discussions held at the vWINter international meeting (22–26 January 2019; Cortina d’Ampezzo, Italy) and the pre- and post-meeting literature search performed by the leading experts.
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Affiliation(s)
| | - Andrea Obi
- 2 University of Michigan, Ann Arbor, MI, USA
| | | | | | | | - Denis Borsuk
- 6 Clinic of Phlebology and Laser Surgery, 'Vasculab' Ltd, Chelyabinsk, Russia
| | | | | | - Attilio Cavezzi
- 9 Eurocenter Venalinfa, San Benedetto del Tronto (AP), Italy
| | - Yung-Wei Chi
- 10 University of California, Davis Vascular Center, Sacramento, CA, USA
| | | | | | | | | | | | - Josè Diaz
- 15 Vanderbilt University Medical Center, Nashville, TN, USA
| | - Julio Ferreira
- 16 Instituto Brasilerio de Flebologia, Sao Paulo, Brazil
| | | | | | - Arkadiusz Jawien
- 19 Collegium Medicum, University of Nicolaus Copernicus, Bydgoszcz, Poland
| | | | | | | | | | - N C Liew
- 24 Putra University, Serdang, Malaysia
| | - Fedor Lurie
- 25 Jobst Vascular Institute, Toledo, OH, USA
| | | | | | | | | | | | | | | | - Kurosh Parsi
- 32 St. Vincent's Hospital, University of NSW, Sydney, Australia
| | | | | | | | | | - Stanley Rockson
- 37 Stanford University School of Medicine, Stanford, CA, USA
| | | | | | | | | | | | | | | | | | | | | | | | - Cees Wittens
- 44 Maastricht University Medical Center, Maastricht, Netherlands.,45 Uniklinik Aachen, Aachen, Germany
| | | | - Oscar Bottini
- 46 Universidad de Buenos Aires, Buenos Aires, Argentina
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Abstract
GENERAL PURPOSE To provide information about the use of ultrasound for diagnostic and therapeutic treatment of venous and arterial ulcers. TARGET AUDIENCE This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES After completing this continuing education activity, you should be able to: ABSTRACT: To review the diagnostic and therapeutic use of ultrasound on venous and arterial ulcers. METHODS PubMed was searched for peer-reviewed articles using the search terms "ultrasound for venous ulcers" and "ultrasound for arterial ulcers." The search yielded 282 articles on ultrasound for venous ulcers and 455 articles for ultrasound on arterial ulcers. Data from 36 articles were selected and included after abstract review. RESULTS Ultrasound is an established diagnostic modality for venous and arterial disease and is indicated for wound debridement. Recent evidence continues to support its superiority over standard of care in healing venous ulcers, but findings conflict in terms of the effectiveness of low-frequency ultrasound over high-frequency ultrasound. There are currently no standardized treatment protocols for ultrasound. CONCLUSIONS Diagnostic ultrasound is used to assess venous and arterial disease and guide appropriate treatment for ulcers. Therapeutic low-frequency ultrasound is used to debride the wound bed, as an adjunctive topical wound treatment with standard of care, and to guide the application of other advanced therapies to chronic wounds. Better trial designs and consistent data are needed to support the effectiveness of ultrasound therapy on venous and arterial ulcers.
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Toniolo J, Chiang N, Munteanu D, Russell A, Hao H, Chuen J. Vein diameter is a predictive factor for recanalization in treatment with ultrasound-guided foam sclerotherapy. J Vasc Surg Venous Lymphat Disord 2018; 6:707-716. [PMID: 30108030 DOI: 10.1016/j.jvsv.2018.05.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 05/31/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Ultrasound-guided foam sclerotherapy (UGFS) is a low-cost and minimally invasive treatment option for varicose veins. There is a relative paucity of outcome reports. METHODS UGFS procedures at a tertiary public hospital between 2010 and 2017 were studied. Either the great saphenous vein (GSV) or small saphenous vein (SSV) was treated. Pretreatment, in-treatment, 6-week, and 1-year post-treatment ultrasound reports were analyzed. The primary outcome was to determine whether vein diameter predicts obliteration failure. RESULTS There were 457 treatments completed in 290 patients. The GSV was targeted in 372 (81%). Mean vein diameters of the GSV were not different from those of the SSV (GSV, 5.7 mm; SSV, 6.2 mm; P = .18); 109 (24%) had a Clinical, Etiology, Anatomy, and Pathophysiology score of at least 4. Of the 457 UGFS procedures, 360 (78.8%) were for primary veins. Baseline information, including vein diameter, was not different between primary and recurrent veins. At 6 weeks, complete obliteration, partial recanalization, and complete recanalization rates were 54.9%, 29.1%, and 16%, respectively. Of those with complete obliteration at 6 weeks, the recanalization rate at 1 year was 25%. Increasing vein diameter was associated with recanalization at 1 year (obliteration, 4.9 mm; recanalization, 5.7 mm; P = .03), especially for primary veins (4.8 vs 5.8 mm; P = .009). Multivariate analysis showed similar outcome. Vein diameter of >6 mm had good specificity (88%) but poor sensitivity (43%) for predicting obliteration failure. There were 15 (3%) new-onset deep venous thromboses reported on follow-up, all of which were from treatment of primary veins (P = .049). CONCLUSIONS Only 44% of UGFS procedures were observed to have complete obliteration at 1 year after a single intervention. Significant recanalization developed at 1 year. Increased vein diameter was associated with recanalization. The impact on clinical recurrence is unknown.
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Affiliation(s)
- Jason Toniolo
- Department of Vascular Surgery, Austin Health, Melbourne, Victoria, Australia.
| | - Nathaniel Chiang
- Department of Vascular Surgery, Austin Health, Melbourne, Victoria, Australia
| | - Diana Munteanu
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - Amelia Russell
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - Huming Hao
- Department of Vascular Surgery, Austin Health, Melbourne, Victoria, Australia
| | - Jason Chuen
- Department of Vascular Surgery, Austin Health, Melbourne, Victoria, Australia; Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
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Khilnani NM, Meissner MH, Vedanatham S, Piazza G, Wasen SM, Lyden S, Schul M, Beckman JA. The evidence supporting treatment of reflux and obstruction in chronic venous disease. J Vasc Surg Venous Lymphat Disord 2018; 5:399-412. [PMID: 28411707 DOI: 10.1016/j.jvsv.2017.02.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 02/06/2017] [Indexed: 10/19/2022]
Abstract
On July 20, 2016, a Medicare Evidence Development and Coverage Advisory Committee panel convened to assess the evidence supporting treatment of chronic venous disease. Several societies addressed the questions posed to the panel. A multidisciplinary coalition, representing nine societies of venous specialists, reviewed the literature and presented a consensus opinion regarding the panel questions. The purpose of this paper is to present our coalition's consensus review of the literature and recommendations for chronic venous disease.
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Affiliation(s)
- Neil M Khilnani
- Division of Interventional Radiology, Weill Cornell Medicine Vein Treatment Center, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, NY.
| | - Mark H Meissner
- Department of Surgery, University of Washington School of Medicine, Seattle, Wash
| | - Suresh Vedanatham
- Division of Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Mo
| | - Gregory Piazza
- Vascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Suman M Wasen
- Division of Vascular Medicine, Cardiovascular Section, University of Oklahoma College of Medicine, Oklahoma City, Okla
| | - Sean Lyden
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Joshua A Beckman
- Vascular Medicine, Cardiovascular Division, Vanderbilt University Medical Center, Vanderbilt School of Medicine, Nashville, Tenn
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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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Tiwari A, Chong TT, Walsh SR, Davies AH, Tang TY. Reporting outcomes of new and old endovenous technologies using a standardized dataset – Now is the time for change. Phlebology 2018. [DOI: 10.1177/0268355518764988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Alok Tiwari
- Department of Vascular Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - Tze T Chong
- Department of Vascular Surgery, Singapore General Hospital, Singapore, Singapore
| | - Stewart R Walsh
- Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland
| | - Alun H Davies
- Academic Department of Vascular Surgery, Charing Cross Hospital, London, UK
| | - Tjun Y Tang
- Department of Vascular Surgery, Singapore General Hospital, Singapore, Singapore
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Prospective Comparison of Effect of Ligation and Foam Sclerotherapy with Foam Sclerotherapy Alone for Varicose Veins. Ann Vasc Surg 2018; 49:75-79. [PMID: 29428536 DOI: 10.1016/j.avsg.2018.01.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 09/29/2017] [Accepted: 01/29/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND To compare the efficacy of ligation after foam sclerotherapy (FSL) with foam sclerotherapy (FS) alone for patients with varicose veins prospectively. METHODS Ninety-four patients with varicose veins underwent foam sclerothrapy alone and 88 patients with varicose veins received FSL. Patients were followed up at 1, 3, 6, and 12 months after treatment. The postoperative complications were documented prospectively. RESULTS In comparison with patients who underwent FSL, patients treated with FS only had higher incidence of phlebitis within 4 weeks (14.9% vs. 1.1%, P = 0.002) and at 6 months (10.6% vs. 0, P = 0.002) after treatment and had higher incidence of tenderness or discomfort (9.8% vs. 0, P = 0.003) and recanalization rate (8.5% vs. 1.1%, P = 0.007) at 6 months after treatment. All patients in both groups had no deep vein thrombosis and pulmonary embolism. CONCLUSIONS Patients treated with FSL have less postoperative complications than those with foam sclerotheray alone. FSL is an alternative procedure for management of patients with varicose veins. Also, a randomized prospective study is required to observe the long-term outcomes of the FSL.
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Campbell B, Chinai N, Hollering P, Wright H, McCarthy R. Factors influencing the choice of treatment modality for individual patients with varicose veins. Ann R Coll Surg Engl 2017; 99:624-630. [PMID: 28682127 PMCID: PMC5696925 DOI: 10.1308/rcsann.2017.0122] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2017] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION There is evidence of effectiveness for a range of different treatment modalities for varicose veins but limited information about factors that influence treatment choice for individual patients. METHODS A postal survey was sent to 438 UK members of the Vascular Society of Great Britain and Ireland. RESULTS Overall, 251 responses were received (response rate 57%). A total of 222 respondents treated varicose veins using conventional surgery (84%), endothermal ablation (82%) and foam sclerotherapy (68%). The clinical pattern of veins appeared to have the greatest influence on treatment choice. This was followed by guidance from the National Institute for Health and Care Excellence, patient expectations, facilities, cost and whether treatment was carried out in the public or private sector. Respondents were asked to indicate whether each of 13 clinical 'scenarios' (eg very extensive varicose veins in both legs) would influence them towards or against using specified treatment modalities. 'Consensus' was defined as ≥80% of responses either towards or against any treatment modality; and disagreement as 41-59% both towards and against any modality (i.e. ∼50:50 split). There was consensus towards using endothermal ablation for truncal reflux, towards UGFS for localised varicose veins and towards conventional surgery for large, extensive, bilateral veins. There was consensus against UGFS for large truncal veins, and against surgery for obese patients and those with a history of venous thromboembolism. There were important disagreements about the influence of large or extensive veins, about whether patients were obese or slim and about a prior history of venous thromboembolism. CONCLUSIONS Conventional surgery is still widely available in the UK. Disagreements about treatment choice in different clinical scenarios suggest substantial variation in the treatments patients are offered. Attention to identifying subgroups in trials would help to guide treatment choice for individual patients.
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Affiliation(s)
- B Campbell
- South Devon and Exeter Vascular Service, Royal Devon and Exeter Hospital, UK
| | - N Chinai
- South Devon and Exeter Vascular Service, Royal Devon and Exeter Hospital, UK
| | - P Hollering
- South Devon and Exeter Vascular Service, Royal Devon and Exeter Hospital, UK
| | - H Wright
- South Devon and Exeter Vascular Service, Royal Devon and Exeter Hospital, UK
| | - R McCarthy
- South Devon and Exeter Vascular Service, Royal Devon and Exeter Hospital, UK
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Ali H, Elbadawy A, Saleh M, Mahmoud O. Mid-term Results of Catheter Directed Foam Sclerotherapy Combined with Tumescent Local Anaesthesia for Treatment of Great Saphenous Vein Incompetence. Eur J Vasc Endovasc Surg 2017; 54:363-368. [DOI: 10.1016/j.ejvs.2017.05.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 05/26/2017] [Indexed: 11/29/2022]
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Vos CG, Ünlü Ç, Bosma J, van Vlijmen CJ, de Nie AJ, Schreve MA. A systematic review and meta-analysis of two novel techniques of nonthermal endovenous ablation of the great saphenous vein. J Vasc Surg Venous Lymphat Disord 2017; 5:880-896. [PMID: 29037363 DOI: 10.1016/j.jvsv.2017.05.022] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Accepted: 05/28/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Endothermal treatment of the great saphenous vein (GSV) has become the first-line treatment for superficial venous reflux. Nonthermal ablation has potential benefits for acceptability by patients and decreased risk of nerve injury. We performed a systematic review and meta-analysis to evaluate the efficacy of mechanochemical endovenous ablation (MOCA) and cyanoacrylate vein ablation (CAVA) for GSV incompetence. METHODS MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases were searched for papers published between January 1966 and December 2016. Eligible articles were prospective studies that included patients treated for GSV incompetence and described the primary outcome. Exclusion criteria were full text not available, case reports, retrospective studies, small series (n < 10), reviews, abstracts, animal studies, studies of small saphenous vein incompetence, and recurrent GSV incompetence. Primary outcome was anatomic success. Secondary outcomes were initial technical success, Venous Clinical Severity Score, Aberdeen Varicose Vein Questionnaire score, and complications. RESULTS Fifteen articles met the inclusion criteria. Pooled anatomic success for MOCA and CAVA was 94.7% and 94.8% at 6 months and 94.1% and 89.0% at 1 year, respectively. Venous Clinical Severity Score and Aberdeen Varicose Vein Questionnaire score significantly improved after treatment with MOCA and CAVA. CONCLUSIONS These results are promising for these novel techniques that could serve as alternatives for thermal ablation techniques. However, to determine their exact role in clinical practice, high-quality randomized controlled trials comparing these novel modalities with well-established techniques are required.
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Affiliation(s)
- Cornelis G Vos
- Department of Surgery, Northwest Clinics, Alkmaar, The Netherlands.
| | - Çağdaş Ünlü
- Department of Surgery, Northwest Clinics, Alkmaar, The Netherlands
| | - Jan Bosma
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
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Abstract
Stasis dermatitis commonly occurs in older age. It is caused by venous hypertension resulting from retrograde flow due to incompetent venous valves, valve destruction, or obstruction of the venous system. Further tissue changes arise from an inflammatory process mediated by metalloproteinases, which are up-regulated by ferric ion from extravasated red blood cells. Stasis dermatitis presents initially as poorly demarcated erythematous plaques of the lower legs bilaterally, classically involving the medial malleolus. It is one of the spectrum of cutaneous findings that may result from chronic venous insufficiency. Its mimics include cellulitis, contact dermatitis, and pigmented purpuric dermatoses. Duplex ultrasound is useful in demonstrating venous reflux when the clinical diagnosis of stasis dermatitis is inadequate. Conservative treatment involves the use of compression therapy directed at improving ambulatory venous pressure. Interventional therapy currently includes minimally invasive techniques such as endovenous thermal ablation and ultrasound-guided foam sclerotherapy, which have supplanted the use of open surgical techniques.
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Kugler NW, Brown KR. An update on the currently available nonthermal ablative options in the management of superficial venous disease. J Vasc Surg Venous Lymphat Disord 2017; 5:422-429. [DOI: 10.1016/j.jvsv.2017.01.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 01/28/2017] [Indexed: 11/25/2022]
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Sun Y, Li X, Chen Z, Li X, Ren S. Feasibility and safety of foam sclerotherapy followed by a multiple subcutaneously interrupt ligation under local anaesthesia for outpatients with varicose veins. Int J Surg 2017; 42:49-53. [PMID: 28419883 DOI: 10.1016/j.ijsu.2017.04.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 04/04/2017] [Accepted: 04/12/2017] [Indexed: 02/05/2023]
Abstract
PURPOSE To prospectively evaluate the feasibility and safety of foam sclerotherapy and ligation (FSL) for outpatients with varicose veins under local anaesthesia. METHODS 136 outpatients with varicose veins who were unwilling to be hospitalized underwent FSL. FSL is a technique in which the dilated varicose veins were ligated subcutaneously after foam sclerotherapy with an absorbable suture. Patients were reviewed at 1, 3, 6 and 12 months after FSL. Pain scores were recorded after FSL. The revised venous clinical severity scorer (rVCSS) and clinical, etiological, anatomical, and pathological classification (CEAP) were used to evaluate the improvement at 3 months after treatment. RESULTS 146 limbs in 136 outpatients with varicose veins were managed with FSL. The pain scores decreased following FSL, CEAP classification score, the rVCSS values improved 3 months postintervention. No significant postoperative complications were observed on follow-up. CONCLUSION FSL is feasible, safe and easily to perform under local anaesthesia for outpatients with varicose veins.
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Affiliation(s)
- Yan Sun
- Department of Vascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China; Department of Vascular Surgery, Provincial Hospital Affiliated to Shandong University, Jinan, 250021, China
| | - Xin Li
- Department of Neurology, First Affiliated Hospital of Jiamusi University, Helongjiang, 154002, China
| | - Zhong Chen
- Department of Vascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China.
| | - Xianlun Li
- Cardiovascular Center, China-Japan Friendship Hospital, Beijing, 100019, China.
| | - Shiyan Ren
- Vascular Surgery, Aviation General Hospital, Beiijng, 100023, China.
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Estado actual de las técnicas endoablativas en el tratamiento de la insuficiencia venosa superficial. ANGIOLOGIA 2017. [DOI: 10.1016/j.angio.2016.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
OPINION STATEMENT Minimally invasive endothermal treatments have replaced surgical ligation and stripping in the management of chronic venous insufficiency (CVI) and are now considered the standard of care. Newer techniques have emerged in the last few years in an attempt to further minimize the procedural discomfort associated with endothermal procedures. These new techniques are designed to avoid tumescent anesthesia (TA). These new non-thermal, tumescentless techniques are well tolerated and are shown to result in equivalent outcomes when compared to the thermal ablations. Since there is no data to support the argument that one of these therapies is truly superior to another, selection of a particular thermal or non-thermal technique is dependent on patient and physician preferences. Adoption of a particular non-thermal procedure is also dependent on other factors such as the learning curve, initial setup costs, overall cost-effectiveness and reimbursement. Once the reimbursement issues are resolved and durability is confirmed, these techniques have the potential to become the new standard of care for the management of CVI.
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Affiliation(s)
- Raghu Kolluri
- System Medical Director - Vascular Medicine, OhioHealth Heart and Vascular/ Riverside Methodist Hospital, 3705 Olentangy River Road, Columbus, OH, 43017, USA.
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Davies HO, Popplewell M, Bate G, Kelly L, Darvall K, Bradbury AW. The impact of 2013 UK NICE guidelines on the management of varicose veins at the Heart of England NHS Foundation Trust, Birmingham, UK. Phlebology 2015; 31:612-6. [PMID: 26452636 DOI: 10.1177/0268355515610236] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Although varicose veins are a common cause of morbidity, the UK National Health Service and private medical insurers have previously sought to ration their treatment in a non-evidence based manner in order to limit health-care expenditure and reimbursement. In July 2013, the UK National Institute for Health and Care Excellence published new national Clinical Guidelines (CG168) to promote evidence-based commissioning and management of varicose veins. The aim of this study was to evaluate the impact of CG168 on the referral and management of varicose veins at the Heart of England NHS Foundation Trust, Birmingham, UK. METHODS Interrogation of a prospectively gathered database, provided by the Heart of England NHS Foundation Trust Performance Unit, of patients undergoing interventions for varicose veins since 1 January 2012. Patients treated before (group 1) and after (group 2) publication of CG168 were compared. RESULTS There were 253 patients, 286 legs (48% male, mean (range) age 54 (20-91) years) treated in group 1, and 417 patients, 452 legs, (46% male, mean (range) age 54 (14-90) years) treated in group 2, an increase of 65%. CG168 was associated with a significant reduction in the use of surgery (131 patients (52%) group 1 vs. 127 patients (30%) group 2, p = 0.0003, χ(2)), no change in endothermal ablation (30 patients (12%) group 1 vs. 45 patients (11%) group 2), a significant increase in ultrasound-guided foam sclerotherapy (92 patients (36%) group 1 and 245 patients (59%) group 2, p = 0.0001, χ(2)) and an increase in treatment for C2/3 disease (53% group 1 and 65.2% group 2, p = 0.0022, χ(2)). CONCLUSIONS Publication of National Institute for Health and Care Excellence CG168 has been associated with a significant increase (65%) in the number of patients treated, referral at an earlier (CEAP C) stage and increased use of endovenous treatment. CG 168 has been highly effective in improving access to, and quality of care, for varicose veins at Heart of England NHS Foundation Trust.
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Affiliation(s)
- Huw Ob Davies
- Department of Vascular Surgery, University of Birmingham, Solihull Hospital, Birmingham, UK
| | - Matthew Popplewell
- Department of Vascular Surgery, University of Birmingham, Solihull Hospital, Birmingham, UK
| | - Gareth Bate
- Department of Vascular Surgery, University of Birmingham, Solihull Hospital, Birmingham, UK
| | - Lisa Kelly
- Department of Vascular Surgery, University of Birmingham, Solihull Hospital, Birmingham, UK
| | - Katy Darvall
- North Devon District Hospital, Barnstaple, Devon, UK
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Solihull Hospital, Birmingham, UK
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