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

OBJECTIVE

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

DATA SOURCES

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

REVIEW METHODS

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

RESULTS

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

CONCLUSION

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

Evaluation of the efficacy of foam sclerosant after addition of glycerine on human great saphenous vein: histological and immunohistochemical study

INTRODUCTION

Several treatment modalities have been postulated to improve the efficacy of varicose vein treatment. Addition of glycerine to the sclerosing material has been documented to increase its viscosity and subsequently prolong the duration of stability, in addition to the direct sclerosing effect of glycerine. This histological and immunohistochemical study investigated the efficacy of addition of glycerine 72% to sclerotherapy on the human varicose vein.

METHODS

After surgical stripping of great saphenous veins, three equal segments were resected between two clamps. Specimen 1 was injected with saline only, specimen 2 was exposed to foam sclerosant 2%, and specimen 3 was exposed to a mixture of foam sclerosant 2% and glycerine 72%. All segments were left for 5min. Vein segments were then processed for histological and immunohistochemical study.

RESULTS

Microscopically, haematoxylin and eosin-stained specimen 1 showed endothelial swelling, cytoplasmic eosinophilia and pyknotic nuclei. The media showed sarcoplasm vacuolisation and necrosis. Specimen 3 showed hypereosinophilic sarcoplasm of the smooth muscle fibres. Oedema was less evident, with a relative decrease in the thickness of the wall compared with specimen 2. Immunohistochemically, the expression of smooth muscle actin was weak in specimen 3 compared with specimens 1 and 2. Expression of CD31 antibody was much reduced in specimen 2 which showed conserved islands of endothelial cells. By contrast, there was a complete loss of endothelial cells in specimen 3.

CONCLUSION

Addition of glycerine 72% to foam sclerosant has a more damaging effect on human vein wall.

The effect of the calibre and length of needle on the stability of sclerosing foam

OBJECTIVES

Little is known how calibre and length of needles affect the stability of sclerosing foam.

METHODS

Foams were made of 0.5%, 1%, 2% and 3% polidocanol, and 0.2%, 0.5%, 1% and 3% sodium tetradecyl sulfate (STS), which were mixed with air in the proportion of 4:1. These foams were ejected through needles with the length of: 4 mm, 6 mm and 13 mm, and diameter of: 0.26 mm, 0.3 mm and 0.4 mm.

RESULTS

Foams made of more concentrated polidocanol were more stable. Regarding STS an opposite relationship was revealed. Foams made of polidocanol were more stable if ejected through a longer needle, while the length of needle did not significantly affect stability of STS foams. Foams ejected through 0.26 mm diameter needles were very unstable. In the case of 0.5% polidocanol, 0.3x6mm needle provided atypically stable foam.

CONCLUSION

In order to inject maximally stable foam, calibre and length of needle should be taken into account.

Short Term Outcome of Adjunct Foam Sclerotherapy for Varicose Veins in Patients Subjected to RFA at Dhulikhel Hospital, Nepal

Background

Varicose veins are dilated, tortuous, superficial veins usually seen on lower limbs. Various surgical modalities are available for varicose veins including open surgery (Trendelenburg operation), Endovenous Laser Ablation (EVLA), Radiofrequency Ablation (RFA) and Sclerotherapy. The aim of this study is to look for the outcome of adjunct sclerotherapy for varicose veins done as an adjunct with Radio Frequency Ablation.

Objective

To know the possible outcome regarding benefits and complications of adjunct sclerotherapy with Radio Frequency Ablation.

Methodology

We combined Radio Frequency Ablation of varicose veins with necessary phlebectomy and perforator ligation and performed adjunct sclerotherapy for residual significant varicosities with polidocanol (2%) mixed with 2 ml NS and 2 cc of air (Tessari method) to patients undergoing varicose vein surgery in between 2016 and 2017. Records on complications were enquired immediately following surgery and on 1^st follow up done within 3-5 days of the procedure.

Results

Among 256 limbs subjected to varicose veins surgery 51 limbs were given adjunct sclerotherapy. Among them, five limbs had perivenous spillage with some localized swelling while there was allergic reaction in one patient as immediate postprocedural complication. Nine limbs had painful thrombosed veins during early follow-up.

Conclusions

Adjunct sclerotherapy showed complication rate of roughly one tenth and one fifth of the treated cases in immediate and early postoperative follow-up.

Periulcer Foam Sclerotherapy Injection in Chronic Venous Leg Ulcers Using Near-Infrared Laser for Vein Visualization

High recurrence and high costs of treatment are the main problems with venous ulcer management. Therefore, it is of utmost importance to target the exact pathological cause. The role of cutaneous microvalves reflux in the pathogenesis of these ulcers has been confirmed. In this study, 20 chronic venous leg ulcers were prospectively subjected to foam sclerotherapy injection into periulcer veins using direct visualization by AccuVein AV400. Patients having infected ulcers, acute deep vein thrombosis, hypercoagulability, Ankle-Brachial Index <0.9, pregnancy, and/or allergy to the sclerosant were excluded. Endpoints included rates of ulcer size reduction, complete healing, ulcer recurrence, and procedure-related complications. Aethoxysklerol 1% was used in all cases to produce foam employing the double-syringe system. The mean reduction in ulcer surface area, postinjection, was 75% after 8 weeks and 91% after 12 weeks. Nineteen ulcers (95%) healed in a median time of 8 weeks, range 3 to 17 weeks. At 1 year of follow-up, 18 patients (90%) were still ulcer-free, while 1 patient's ulcer (5%) recurred 19 weeks postinjection. No major complications were encountered. Periulcer foam sclerotherapy injection, guided by vein visualization technology, should be one of the main lines of treatment of venous leg ulcers. It offers good results with regard to rapid ulcer healing and low recurrence rate without major risk. Randomized controlled trials are needed to establish these conclusions.

Venous intervention in chronic venous ulcer treatment and recurrence avoidance

In this brief overview I will progress from superficial venous intervention for venous leg ulcers (VLU) to perforator intervention and finally to deep venous intervention. But first there are a number of concepts that must be accepted. We know that 70 % of patients with leg ulcers have a venous component (1), and in at least 40 % of those patients, ulcers will be caused by superficial venous insufficiency alone or in combination with perforator incompetence (2). Such patients will likely benefit from treatment of their superficial venous disease.

One of the most important but often overlooked factors in venous ulcers is calf pump failure. Simka has reported that 45 % of patients with venous ulcers have calf pump failure (3).

Thorough duplex evaluation of the venous leg ulcer patient is paramount for accurate diagnosis, the differentiation between arterial and venous components (purely arterial, venous, or mixed etiology), and the obstructive and/or incompetent nature and location of venous lesions. In obstructive venous lesions the degree of obstruction as well as how proximal the lesion extends must be known. For venous insufficiency the location (deep and/or superficial venous system) and the extent (segmental or axial) will help determine how much the incompetence contributes to the overall ulcer condition, and what lesions can be safely treated.

Catheter-directed foam sclerotherapy for chronic venous leg ulcers

Objectives

This study presents the results of catheter-directed foam sclerotherapy (CDS) for chronic venous ulcer refractory to compression treatment, four weeks and one year after treatment.

Methods

In sum, 31 patients (32 limbs) with refractory chronic venous ulcer and duplex-verified superficial insufficiency were offered CDS. CDS was conducted with 10 ml of sclerosant foam of 3% polidocanol. Four weeks and one year after treatment, the patients were evaluated regarding ulcer healing and ultrasound appearance of the saphenous trunk.

Results

CDS was successfully performed in all patients. After one year, 65% of the ulcers were healed. Only two (6%) recurred. 86% of the treated saphenous trunk were completely occluded, 3% was partly occluded and 10% were recanalised. No serious side effects occurred.

Conclusions

CDS is one alternative of eliminating superficial venous reflux when treating refractory venous leg ulcers. This study suggests that the treatment is safe and induce a quick ulcer healing.

A novel biomimetic analysis system for quantitative characterisation of sclerosing foams used for the treatment of varicose veins

A novel analysis system for the quantification of sclerosing foam properties under clinically relevant conditions was developed with the purpose of establishing a robust methodology for comparative characterisation of different foam formulations and production strategies. The developed biomimetic-inspired model comprised of 4 or 10 mm inner diameter polytetrafluoroethylene tubing, filled with a blood substitute and fixed to a platform with an adjustable inclination angle. Sclerosing foams were produced by mixing polidocanol with either atmospheric air or 100 % CO₂, using a double-syringe system method. Individual foams were injected into the tube, while videos were captured simultaneously. Videos were then transferred to an in-house computational foam analysis system (CFAS) which performed a sequence of semi-automated operations, allowing quantitative characterisation of sclerosing foam dynamic behaviour. Using CFAS, degradation rates of different foams were measured and the effect of gas composition, liquid sclerosant concentration and time delay between foam production and injection were evaluated.