Endovenous Saphenous Ablation Corrects the Hemodynamic Abnormality in Patients with CEAP Clinical Class 3–6 CVI Due to Superficial Reflux

Iliac vein stenting is a safe and effective treatment for iliac vein compression syndrome: A systematic review of Chinese data

OBJECTIVES

This study was a systematic review of available data from China, and our aim was to evaluate the safety and efficacy of stenting in iliac vein compression syndrome.

METHODS

We searched the PubMed, National Knowledge Infrastructure, Chongqing Weipu Information Company, and Cochrane Central Register for Controlled Trials databases, and key references.

RESULTS

Twelve studies were included (nine retrospective analyses, two retrospective case series studies, and one prospective cohort study) involving 2292 patients and 1897 stented limbs. The overall primary patency rates ranged from 81.8% to 100%. Studies showed significant improvements in patients' symptoms, and ulcer healing rates ranged from 71.4% to 100% in stented limbs. The incidence of severe complications ranged from 0 to 16.8%.

CONCLUSIONS

For Chinese patients with iliac vein compression syndrome, stenting provided significant efficacy regarding favorable patency rates, symptom relief, and complications. However, the quality of evidence to support the use of iliac vein stenting to treat iliac vein compression syndrome is currently weak, especially for Chinese patients.

Treatment of superficial and perforator reflux and deep venous stenosis improves healing of chronic venous leg ulcers

OBJECTIVE

To evaluate the impact of three treatment modalities, superficial truncal vein ablation, perforator vein ablation, and deep venous stenting on venous leg ulcer (VLU) healing, as well as their cumulative effect on ulcer healing, in an attempt to establish the best algorithm for the treatment of chronic and recalcitrant VLUs.

METHODS

Multicenter retrospective cohort study using a standardized database to evaluate patients with chronic venous ulcers treated between January 2013 and December 2017.

RESULTS

Eight-hundred thirty-two consecutive patients with VLU were identified at 11 centers in the United States. All patients were initially managed with wound care and compression for at least 2 months. Compression and wound care management alone, used in 187 patients, led to ulcer healing in 75% of patients by 36 months. Ulcer recurrence in patients managed without surgery at 6, 12, and 24 months was 3%, 5% and 15%, respectively. Five hundred twenty-eight patients underwent ablation of incompetent superficial veins, and 344 of those also underwent incompetent perforator ablation. Patients who underwent truncal vein ablation alone had an ulcer healing rate of 51% at 36 months. Patients who received both superficial and perforator ablation were significantly younger, and had a 17% improvement in healing at 36 months (68% vs 51%, respectively), but there was no impact of combined superficial and perforator ablations on ulcer recurrence rates. One hundred thirty-four patients had stenosis of one of more lower extremity deep veins and 95 (71%) underwent endovenous stenting. Ulcer healing and recurrence rates for those who underwent stent placement alone was 77% and 27%, respectively, at 36 months. Patients who underwent deep venous stenting and ablation of both incompetent truncal and perforator veins had an ulcer healing rate of 87% at 36 months and ulcer recurrence of 26% at 24 months.

CONCLUSIONS

This study demonstrates that correction of superficial truncal vein reflux, as well as deep vein stenosis, both contribute to healing of VLU. Patients who fail to heal their VLU after superficial and perforator ablation should have the iliocaval system imaged to identify hemodynamically significant stenoses or occlusions amenable to stenting, which facilitates venous ulcer healing even in patients with large ulcers.

Incidence of venous leg ulcer healing and recurrence after treatment with endovenous laser ablation

BACKGROUND

The Effect of Surgery and Compression on Healing and Recurrence (ESCHAR) trial previously reported that patients with venous leg ulcers treated with saphenous stripping experienced a significantly reduced incidence of ulcer recurrence compared with patients treated with compression therapy. Most patients with leg ulcers and saphenous insufficiency are currently treated with endovenous thermal ablation (EVTA), but little information is available on the long-term results after EVTA in Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) clinical class 5 (C5) and class 6 (C6) patients.

METHODS

We retrospectively reviewed all CEAP C5 or C6 patients treated with EVTA to define the incidence of ulcer healing and recurrence. Patients with active ulcers were managed weekly in a comprehensive wound center until healed. After healing, patients were treated with compression stockings and returned at 6-month intervals for follow-up. Time to healing and time to ulcer recurrence were determined by Kaplan-Meier survival analysis. Risk factors were assessed to determine their association with ulcer recurrence.

RESULTS

EVTA of the great saphenous vein (n = 146), small saphenous vein (n = 20), or both (n = 7) was performed on 173 limbs with active (n = 72) or healed (n = 101) ulcers. Deep venous insufficiency was present in 54 cases (31.2%). Concomitant phlebectomy was performed in 59 limbs (34%). Median follow-up time was 25.2 months after EVTA. Venous ulcers healed after EVTA in 57% of cases at 3 months, 74% at 6 months, and 78% at 12 months. Ulcers recurred in 9% of patients at 1 year after EVTA, 20% at 2 years, and 29% at 3 years of follow-up. Ulcers recurred significantly more often in patients with deep venous insufficiency and in patients who did not undergo phlebectomy of associated varicose veins at the time of EVTA.

CONCLUSIONS

Ulcers recurred in a minority of CEAP clinical C5 and C6 patients after EVTA of the saphenous veins. Ulcer recurrence was less frequent in patients without concomitant deep venous reflux and in those treated with phlebectomy of varicose veins at the time of EVTA. We suggest consideration of phlebectomy at the time of EVTA for patients with C5 and C6 venous insufficiency, particularly in those with isolated superficial venous insufficiency.

Validation of Venous Clinical Severity Score (VCSS) with other venous severity assessment tools from the American Venous Forum, National Venous Screening Program

BACKGROUND

Several standard venous assessment tools have been used as independent determinants of venous disease severity, but correlation between these instruments as a global venous screening tool has not been tested. The scope of this study is to assess the validity of Venous Clinical Severity Scoring (VCSS) and its integration with other venous assessment tools as a global venous screening instrument.

METHODS

The American Venous Forum (AVF), National Venous Screening Program (NVSP) data registry from 2007 to 2009 was queried for participants with complete datasets, including CEAP clinical staging, VCSS, modified Chronic Venous Insufficiency Quality of Life (CIVIQ) assessment, and venous ultrasound results. Statistical correlation trends were analyzed using Spearman's rank coefficient as related to VCSS.

RESULTS

Five thousand eight hundred fourteen limbs in 2,907 participants were screened and included CEAP clinical stage C0: 26%; C1: 33%; C2: 24%; C3: 9%; C4: 7%; C5: 0.5%; C6: 0.2% (mean, 1.41 ± 1.22). VCSS mean score distribution (range, 0-3) for the entire cohort included: pain 1.01 ± 0.80, varicose veins 0.61 ± 0.84, edema 0.61 ± 0.81, pigmentation 0.15 ± 0.47, inflammation 0.07 ± 0.33, induration 0.04 ± 0.27, ulcer number 0.004 ± 0.081, ulcer size 0.007 ± 0.112, ulcer duration 0.007 ± 0.134, and compression 0.30 ± 0.81. Overall correlation between CEAP and VCSS was moderately strong (r(s) = 0.49; P < .0001), with highest correlation for attributes reflecting more advanced disease, including varicose vein (r(s) = 0.51; P < .0001), pigmentation (r(s) = 0.39; P < .0001), inflammation (r(s) = 0.28; P < .0001), induration (r(s) = 0.22; P < .0001), and edema (r(s) = 0.21; P < .0001). Based on the modified CIVIQ assessment, overall mean score for each general category included: Quality of Life (QoL)-Pain 6.04 ± 3.12 (range, 3-15), QoL-Functional 9.90 ± 5.32 (range, 5-25), and QoL-Social 5.41 ± 3.09 (range, 3-15). Overall correlation between CIVIQ and VCSS was moderately strong (r(s) = 0.43; P < .0001), with the highest correlation noted for pain (r(s) = 0.55; P < .0001) and edema (r(s) = 0.30; P < .0001). Based on screening venous ultrasound results, 38.1% of limbs had reflux and 1.5% obstruction in the femoral, saphenous, or popliteal vein segments. Correlation between overall venous ultrasound findings (reflux + obstruction) and VCSS was slightly positive (r(s) = 0.23; P < .0001) but was highest for varicose vein (r(s) = 0.32; P < .0001) and showed no correlation to swelling (r(s) = 0.06; P < .0001) and pain (r(s) = 0.003; P = .7947).

CONCLUSIONS

While there is correlation between VCSS, CEAP, modified CIVIQ, and venous ultrasound findings, subgroup analysis indicates that this correlation is driven by different components of VCSS compared with the other venous assessment tools. This observation may reflect that VCSS has more global application in determining overall severity of venous disease, while at the same time highlighting the strengths of the other venous assessment tools.

Endovenous laser ablation and foam sclerotherapy for varicose veins: does the presence of perforating vein insufficiency affect the treatment outcome?

BACKGROUND

Superficial venous insufficiency is a common problem associated with varicose veins. Endovenous laser ablation (EVLA) and concomitant ultrasound (US)-guided foam sclerotherapy are recent treatment methods alternative to surgery in the treatment of superficial venous insufficiency.

PURPOSE

To compare the effectiveness of EVLA and concomitant US-guided foam sclerotherapy prospectively in two different subgroups of the disease (isolated truncal vs. truncal with perforating vein insufficiency).

MATERIAL AND METHODS

The study was approved by the institutional review board. Fifty-five patients with symptomatic saphenous vein insufficiency and varicose veins were included in the study. Seventy-three EVLA and concomitant foam sclerotherapy were performed for 60 lower extremities. To determine the severity of the venous disease, Venous Clinical Severity Score (VCSS) and Visual Analogue Scale (VAS) were carried out before and 6 months after the treatment. Patients were followed up clinically and with Doppler ultrasonography for 6 months after the procedures.

RESULTS

At the sixth month of the follow-up; the total occlusion rate for the saphenous veins was 98.64% (72/73), and re-canalization rate was 1.36% (1/73). The total occlusion rate for the perforating veins was 75% (18/24), re-canalization rate was 25% (6/24). There was no notable major complication. VCSS and VAS scores were decreased significantly following the treatment (p < 0.05). The patients who had isolated saphenous vein insufficiency (Group I: 36/60) and those who had saphenous and perforating vein reflux (Group II: 24/60) were compared. VAS scores were more prominently decreased after the treatment in the isolated saphenous vein insufficiency group (p < 0.05). VCSS were also decreased more prominently in Group I when compared to Group II.

CONCLUSION

EVLA and concomitant US-guided foam sclerotherapy are effective, safe, and minimally invasive treatment options, yielding good cosmetic and clinical results in both isolated truncal and truncal with perforating vein insufficiency groups. However, clinical results and satisfaction of the patients were remarkably superior in cases with isolated truncal vein insufficiency compared to truncal and perforating vein insufficiency.

Surgical management of varicose veins: meta-analysis

Open surgery remains the gold standard by which endovascular treatment of superficial chronic venous insufficiency is measured. This meta-analysis of randomized controlled trials reviews the current evidence base, comparing open and endovascular treatment of varicose veins. Systematic review of studies reporting duplex scan follow-up after open surgical, laser (endovenous laser therapy [EVLT]), or radiofrequency (VNUS Closure device, VNUS Medical Technologies, San Jose, CA) treatment of refluxing great saphenous veins was completed. Primary outcome measures were occlusion and complication rates and time taken to resume work. No significant difference in recurrence rates at 3 months between open surgery and EVLT (RR 2.19, 95% CI 0.99-4.85, p = .05) or VNUS device (RR 7.57; 95% CI 0.42-136.02) were found. Return to work is significantly faster following VNUS (by 8.24 days; 95% CI 10.50-5.97) or EVLT (by 5.02 days; 95% CI 6.52-3.52). Endovascular treatment of varicose veins is safe and effective and offers the significant advantage of rapid recovery.

Combined endovascular laser plus ambulatory phlebectomy for the treatment of superficial venous incompetence: A 4‐year perspective

BACKGROUND

Combination endovascular laser obliteration of the greater saphenous vein in conjunction with ambulatory phlebectomy has become the treatment of choice for superficial venous incompetence.

OBJECTIVES

The present study examines the treatment of saphenofemoral junction (SFJ) incompetence with simultaneous treatment of associated truncal varicosities by ambulatory phlebectomy.

METHODS

Four-year follow-up data for recurrence rate and complication profile was ascertained for 90 patients (mean age 40 years) with SFJ reflux associated with greater saphenous vein (GSV) incompetence (4-12 mm; mean 7.8 mm) and enlargement of branch varicosities as documented by Duplex ultrasound, which were treated with a combined approach of endovascular laser obliteration of the GSV (810 nm, Diomed S30) followed by hook avulsion (ambulatory phlebectomy) of the remaining truncal varicosities. Follow-up by Duplex ultrasound to ensure closure was carried out at week 1 and months 1, 3, 6, 12, 24, 36 and 48.

RESULTS

A total recurrence rate (r = 94 limbs) of 4.3 was found in the patient cohort. All recurrences occurred within 12 months, with the majority documented at month 6.

CONCLUSIONS

Combination endovascular laser treatment (EVLT) with ambulatory phlebectomy is an effective treatment modality for superficial venous incompetence in the outpatient ambulatory setting. Low recurrence rates are noted with this approach. In the present patient series, all recurrences were noted within 12 months of the aforementioned procedure. These results are comparable with other endovenous and radiofrequency technologies.

Venous Clinical Severity Score and quality-of-life assessment tools: application to vein practice

The time is ripe for universal understanding and acceptance of outcome assessment in venous disease. Outcome studies promote understanding of the diseases we treat and the results of treatment. The choice of a valid and reliable assessment tool is crucial. Patient-generated quality-of-life tools include generic instruments and disease-specific instruments. Generic instruments evaluate overall well-being and provide subjective measurements of treatment outcomes in various disease states. The 36-Item Short Form Health Survey and the Nottingham Health Profile are widely used generic surveys. Disease-specific instruments relate to a particular disease state. They are popular in venous disease reporting and have high sensitivity. The Chronic Venous Insufficiency Questionnaire, the Venous Insufficiency Epidemiological and Economic Study, the Aberdeen Varicose Vein Questionnaire and the Charing Cross Venous Ulceration Questionnaire are such devices. Physician-generated measurement tools are used to evaluate and classify the consequences of venous disease. The clinical, aetiology, anatomy, pathophysiology classification (CEAP) is a popular descriptive platform for chronic venous disease. The Venous Severity Scoring (VSS) system was derived from the CEAP classification to provide evaluative capabilities. The three elements of the VSS are the venous disability score, the venous segmental disease score and the venous clinical severity score (VCSS). The VCSS facilitates the follow-up of features of venous disease that change with treatment. Each of these outcomes tools has been validated, and each has strengths and weaknesses. Maintaining the dynamic nature of assessment with periodic review and revision is the way forward to generating universal applicability. Although the choice of instrument is debatable, the most important factor in improving treatment outcomes is the decision to examine results and to share them in a meaningful way.

Evaluation and treatment of leg ulcers associated with chronic venous insufficiency

The successful management of patients who have leg ulcers related to chronic venous disease requires optimal management of the wound bed, elimination of edema with compression, and correction of venous hypertension whenever possible. Healing of the wound itself requires compression, debridement, bacterial control, and stimulation of the wound bed. Prevention of ulcer recurrence is most effective if the patient is amenable to correction of the venous insufficiency. This is most successful when the superficial or perforator veins are the primary source. Quality diagnostic studies are critical in determining the anatomy and hemodynamic importance of various venous abnormalities and can guide appropriate interventional treatment. Venous corrective procedures usually can be performed using minimally invasive endovenous methods, which are associated with fewer complications and more rapid recovery than are major surgical techniques.

Role of endovenous laser treatment in the management of chronic venous insufficiency

Endovenous laser therapy (EVLT) is a recognized option in the treatment of uncomplicated varicose veins. This uncontrolled case series evaluates its effectiveness in the management of chronic venous insufficiency. Patients with a history of active or healed ulcers were selected for EVLT. The procedure was carried out in an outpatient setting over a period of 12 months. Assessment was carried out for evidence of ulcer healing and recurrence, long saphenous vein occlusion, and patient satisfaction at 3, 12, and 22 months. Results are expressed as means with range. EVLT was used to treat 23 limbs in 20 patients with a median age of 59 years (range 32-76) including 12 females and eight males. All patients had evidence of chronic venous insufficiency, graded at C5 or greater on the CEAP classification (C5 16, C6 7). Patients with long saphenous vein insufficiency were included, whereas those with either deep or combined deep and superficial venous incompetence were excluded. The cumulative 3-, 12-, and 22-month healing rates were 87% (20/23), 100% (23/23), and 95% (21/22), respectively. The only patient having a recurrence of ulcers at 22 months' follow-up (CEAP 6) had mid-calf perforator incompetence with recanalized long saphenous vein. Duplex scan demonstrated long saphenous vein occlusion in 100% (23/23), 96% (22/23), and 91% (20/22) at 3, 12, and 22 months, respectively. In all, 84% (16/19) of patients were satisfied with the results of treatment without any major procedure-related complication. These results demonstrate that EVLT, carried out in an outpatient setting, is effective in the treatment and prevention of chronic venous ulcers, with good patient satisfaction and no major complication.

Technical review of endovenous laser therapy for varicose veins

BACKGROUND

In the last decade, several new treatments of truncal varicose veins have been introduced. Of these new therapies, endovenous laser therapy (EVLT) is one of the most widely accepted and used treatment options for incompetent greater and lesser saphenous veins.

OBJECTIVE

The objective of this report is to inform clinicians about the EVLT procedure and to review its efficacy and safety in treatment of truncal varicose veins. Also, we discuss some of the underlying theoretical principles and laser parameters that affect EVLT.

METHODS

We carried out a literature review of EVLT;s efficacy and safety. We included reports that included 100 or more limbs with a follow-up of at least 3 months. The principals and procedure of EVLT are described. Of the laser parameters, mode of administration, wavelength, fluence, wattage and pullback speed are discussed.

CONCLUSION

EVLT appears to be a very effective and safe option in the treatment of varicose veins but large randomized comparative studies are needed.

[Primary varicosis]

The classic varicose vein operation still represents the "gold standard" in the operative therapy of varicose veins. The results of this procedure in view of perioperative complications are very good, with the incidence of perioperative deep venous thrombosis varying between 0.05% and 0.1%. Recurrence rates between 6% and 60% are published. However, the true recurrence rate is unknown since an exact definition of recurrent varicosis is still lacking. In recurrent varices it is essential to distinguish between disease progression, including neorevascularisation, and technical errors. Endovascular procedures for elimination of the superficial venous system - radiofrequency obliteration and endovenous laser therapy - meanwhile have established themselves as alternative, minimally invasive procedures. The perioperative complication rate of endovenous procedures is very low and comparable to that of the classic operation. Good results, with occlusion rates of the treated vein around 87% to 93% up to 2 years postoperatively, have been published for both endovenous laser therapy and radiofrequency obliteration. For the latter, 5-year results were published, with occlusion of the treated vein in 87%. Results in the literature for radiofrequency are better documented than for endovenous laser treatment because there are now five prospective randomised trials for the former and most publications for endovenous laser treatment are single-center experiences. The advantage of endovenous procedures, especially radiofrequency obliteration, over the classic operation is the lower rate of perioperative pain and better quality of life. The spectrum of operative treatment methods of the superficial venous system has increased tremendously due to new technical developments. For the surgeon this implies the necessity of informing patients conscientiously about the pros and cons and available results of each procedure, and carefully weighing which methods are at the time best for the patient.