A practical approach to tumescent local anaesthesia in ambulatory endovenous thermal ablation

Endovenous thermal ablation in the treatment of large great saphenous veins of diameters > 12 mm: A systematic review meta-analysis and meta-regression

BACKGROUND

We sought to assess the safety and efficacy of endovenous thermal ablation (EVTA) in treating large great saphenous veins (GSV) > 12 mm in diameter.

METHODS

We performed a systematic review according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 for comparative and noncomparative studies depicting EVTA in the treatment of GSV > 12 mm. Primary endpoints included GSV occlusion, technical success, deep vein thrombosis (DVT), and endovenous heat-induced thrombosis (EHIT). We conducted a comparative analysis between GSV > 12 mm and < 12 mm and a meta-regression analysis for two sets of studies, one including the whole dataset, containing treatment arms of comparative studies with GSV < 12 mm and one exclusively for GSV > 12 mm.

RESULTS

Seven studies, including 2564 GSV, depicting radiofrequency (RFA) and endovenous laser ablation (EVLA) were included. GSV > 12 mm occlusion, technical success, DVT, and EHIT estimates were 95.9% (95% CI: 93.6-97.8), 99.9% (95% CI: 98.9-100.0), 0.04% (95% CI: 0.0-3.4), and 1.6% (95% CI: 0.3-3.5). Meta-regression revealed a negative association between GSV diameter and occlusion for both the whole dataset (p < 0.01) and the > 12 mm groups (p = 0.04), GSV diameter and technical success for both groups (p < 0.01), (p = 0.016), and GSV diameter and EHIT only for the whole dataset (p = 0.02). The comparative analysis between GSV < 12 mm and GSV > 12 mm displayed an occlusion estimate of OR 1.79 (95% CI: 1.25-2.56) favoring small GSV.

CONCLUSION

Whereas we have displayed excellent occlusion and technical success results for the EVTA of GSV > 12 mm, our analysis has illustrated the unfavorable impact of GSV diameter on occlusion, technical success, and EHIT outcomes regardless of the 12 mm threshold. Potential parameter or device adjustments in a diameter-oriented fashion could further enhance outcomes.

Risk analysis of systemic side effects of tumescent local anaesthesia in the surgical treatment of geriatric and multimorbid patients with skin cancer

BACKGROUND

Due to demographic change and increased UV exposure, the number of dermatosurgical procedures in the elderly is increasing. Data on the occurrence of systemic side effects during and after treatment with tumescent local anaesthesia are limited and do not refer to details such as volume and composition of local anaesthetics or epinephrine additive.

OBJECTIVES

The aim of this study was to investigate the risk of systemic side effects in elderly patients undergoing skin tumour surgery with tumescent local anaesthesia.

METHODS

Investigation of systemic complications in patients (≥75 years) who underwent head and neck skin tumour surgery under tumescent local anaesthesia at the Department of Dermatology, University Medical Centre Tübingen, between October 2018 and March 2020.

RESULTS

In total 782 patients (479 males, 303 females) with a mean age of 83.3 years (range: 75.1-102.2 years) could be included. A total of 2940 procedures were performed. Patients were assigned to two groups. The old-old group (≥75-84 years) included 491 patients and the oldest-old group (≥85 years) included 291 patients. The total inpatient stay and thus mean follow-up period was 4.9 days (range 1-28 days). 92.0% (719/782) suffered from pre-existing comorbidities. Systemic complications occurred in 10.2% (80/782; old-olds: 8.6%, oldest-olds: 13.1%). Hypertensive crisis (>180/120 mmHg) requiring intervention (6.7%) that occurred intraoperatively or during the inpatient stay was the most frequent systemic complication. Cardiac arrhythmias occurred postoperatively in 0.8% of cases. No life-threatening complications directly related to tumescent local anaesthesia were found.

CONCLUSIONS

Skin tumour surgery in tumescent local anaesthesia for the elderly is safe, and complications caused by general anaesthesia can be avoided. Systemic complications can occur, but are usually mild, are caused by pre-existing diseases and perioperative excitement, and can be rapidly detected and well treated by monitoring. There is no direct correlation of complications to high-tumescent concentrations or volume quantities.

Reducing tumescent anesthetic injection pain by topical anesthesia pretreatment among patients undergoing endovenous radiofrequency ablation of varicose veins: Adouble-blind randomized controlled trial

OBJECTIVES

Tumescent anesthesia frequently causes the intraoperative and postoperative pain during radiofrequency ablation (RFA) of varicose veins. We have to find a way to reduce pain caused by these injections. This randomized controlled trial investigated the effectiveness of topical anesthesia pretreatment (TAP) on relieving needle puncture pain during administration of tumescent anesthesia among patients undergoing RFA of varicose veins.

METHODS

Eligible patients treated with RFA were recruited and randomized to either application of TAP with lidocaine-prilocaine cream (EMLA) or water-based cream (placebo). The primary outcome was patient described pain scores on the visual analogue scale (VAS) at different time points during the procedure. Secondary outcomes were technical success rate, complications, satisfaction level, expense, and extra analgesia use.

RESULTS

Sixty-two patients were randomized: 32 to EMLA and 30 to placebo. Both groups had comparable baseline demographics, CEAP classification, and Venous Clinical Severity Score (VCSS). Less tumescent anesthetic needle puncture pain was found in the EMLA group (22 ± 7 vs 42 ± 8, p < .01). Pain scores of other time points were equivalent. There was less pain in EMLA pretreated area compared to non-pretreated area in the same patient during needle puncture (22 ± 7 vs 45 ± 7, p < .01), and similar phenomena did not appear in the placebo group. There was no statistical difference in complications, satisfaction level, expense, and technical success between the two groups. And no extra analgesia was used in all patients.

CONCLUSION

We recommend the routine use of TAP to reduce the needle puncture pain during tumescent anesthesia in RFA of lower extremity varicose veins.

How effective is cyanoacrylate closure in small saphenous vein insufficiency? A single center experience

OBJECTIVES

The present study was aimed to evaluate the efficacy and early outcomes of n-butyl cyanoacrylate (NBCA) ablation in small saphenous vein (SSV) insufficiency.

METHODS

In this single-center, retrospective, single-arm study, NBCA ablation was performed in 80 patients with SSV insufficiency between September 2018 and May 2020. Primary outcomes (anatomic success rate and occlusion rate) and secondary outcomes (VCSS and AVVQ scores) of the patients were analyzed.

RESULTS

No technical failure and device-related complications were encountered. Anatomic success rate was 100% after procedures. Each treated SSV was occluded on colored Doppler ultrasonography immediately after the procedure, and all veins remained occluded at 2 weeks after the procedure. Partial recanalization was observed in five patients at 12-month follow-up. Kaplan-Meier analysis revealed an occlusion rates at 6 months and 12 months follow-up were 97.5% and 93.75%, respectively. The mean pretreatment VCSS (4.72 ± 2.04) decreased to 1.61 ± 0.93, 0.87 ± 0.58, and 0.73 ± 0.52 at 2 weeks, 6 months, and 12 months after treatment, respectively (p < .001). The mean pretreatment AVVQ score (11.92 ± 2.23) decreased to 8.2 ± 1.89, 4.2 ± 1.16, and 3.32 ± 1.19 at 2 weeks, 6 months, and 12 months after treatment, respectively (p < .001). The Clinical, Etiologic, Anatomic, and Pathophysiology clinical classification at 12 months demonstrated a significant reduction in disease severity compared with preoperative values (p < .001). There was no mortality and major adverse events including anaphylaxis and pulmonary thromboembolism (PTE) related to procedure after follow-ups. Moreover, there were no symptoms or signs of any sural nerve injury and no cases of skin necrosis, infection, or hyperpigmentation. In addition, no hematoma, deep venous thrombosis, and hypersensitivity reactions were observed. Phlebitis-like abnormal reaction was observed in three patients (3.8%).

CONCLUSIONS

In conclusion, in patients with SSV insufficiency, NBCA ablation with VenaBlock® system appears to be an effective and reliable treatment method. At the 12-month follow-up, the NBCA of SSVs showed a low recanalization rate and had a satisfactory improvement on the VCSS and AVVQ scores.

Cyanoacrylate Closure of Small Saphenous Vein Insufficiency

BACKGROUND

As minimally invasive techniques were issued, endovenous thermal ablations have emerged. However, the thermal-associated complication has been reported in the treatment of small saphenous vein (SSV) insufficiency, such as sural nerve injury. Recently introduced cyanoacrylate closure (CAC) is a nonthermal modality, so this thermal-associated complication can be avoided.

OBJECTIVE

This retrospective study analyzed the feasibility, safety, and 2-year results of CAC for treating SSV insufficiency, particularly the incidence of sural nerve injury.

MATERIALS AND METHODS

One hundred sixty-three SSV insufficiencies in 128 patients were treated with CAC were reviewed. Pain, venous severity, and quality of life (QoL) scores were evaluated. Postoperative duplex scanning also evaluated anatomical and clinical success rates.

RESULTS

The mean patient age was 56.8 years. The initial technical success rate was 100%. The occlusion rate after 2 years was 96.3%. Pain, venous severity, and QoL scores were improved significantly from 2.4 to 0.0, 4.39 to 0.47, and 11.95 to 2.69, respectively, before and 2 years after CAC. No major complications were observed, such as sural nerve injury.

CONCLUSION

Cyanoacrylate closure for the ablation of SSV insufficiency could be a great alternative to endothermal ablation with an excellent success rate and shorter procedure time.

Strategy to prevent nerve injury and deep vein thrombosis in radiofrequency segmental thermal ablation of the saphenous veins using a new objective pain scale

Objective

We evaluated the benefit of local anesthesia including tumescent anesthesia and active walking soon after surgery in preventing nerve injury and deep vein thrombosis caused during endovenous ablation.

Methods

Endovenous ablation was performed in 1334 consecutive patients. Varicectomy was performed using the stab avulsion technique. After surgery, patients were encouraged to walk 100–200 m inside the ward for 3–5 times/h. The pain was evaluated objectively using the Okamura pain scale and subjectively using the numerical rating scale.

Results

Stab avulsion was performed at 11.8 ± 8.0 sites and the mean operative time was 33.9 ± 15.2 min. The mean Okamura pain scale and numerical rating scale scores were 1.6 ± 1.3 and 3.0 ± 2.0, respectively. Deep vein thrombosis and pulmonary embolism were absent. The incidence of nerve injury was 0.3%.

Conclusions

Endovenous ablation should be performed with the patients under local anesthesia to prevent nerve injury and deep vein thrombosis.

Ablation of the great saphenous vein with F-care versus Closurefast endovenous radiofrequency therapy: Double-blinded prospective study

Objectives

F-care (endovenous radiofrequency, F Care Systems, Antwerp, Belgium) is a relatively new radiofrequency ablation technique for the treatment of venous insufficiency. There is a lack of published data about F-care in literature. This study aimed to prospectively compare the F-care method with conventional endovenous radiofrequency ablation Closurefast method for the management of incompetent great saphenous veins.

Methods

Between June 2015 and December 2018, 114 patients with incompetent varicose veins were treated either with the F-care or Closurefast. The pre-, intra-, postprocedural, and follow-up data of the patients were collected and prospectively compared.

Results

The average ablated vein length was 23.1 ± 4 cm in the F-care group and 26.6 ± 4 cm in the Closurefast group ( P =  0.01). The average procedure time was 17.4 ± 4 min (range: 10–30 min) in the F-care group, and 17.1 ± 3 min (range: 11–27 min) in the Closurefast group ( P =  0.77). The one-month total occlusion rates in the F-care and Closurefast groups were 96.2% and 98.1%, respectively ( P =  0.5). The one-year full occlusion rates in the F-care and Closurefast groups were 71.7% and 90.6%, respectively ( P =  0.013). In both the F-care and Closurefast groups, the venous clinical severity scores declined significantly with no difference between groups. There was no significant difference between adverse events following F-care treatment compared with Closurefast treatment ( P ≤  0.05).

Conclusions

The F-care system was as safe and fast, but the one-year closure rate was significantly lower when compared to the other method. There was no significant difference between the adverse effects of both approaches. Further large-scale, multi-center prospective studies with long-term outcomes are required to identify the effectiveness of F-care treatment modality for patients with saphenous vein insufficiency.