Effect of saphenous vein diameter on closure rate with ClosureFAST radiofrequency catheter

Comparison of Radiofrequency Ablation and Cyanoacrylate Closure for Large-Diameter Great Saphenous Vein Insufficiency

BACKGROUND

To compare radiofrequency ablation (RFA) and cyanoacrylate closure (CAC) for large-diameter great saphenous vein (GSV) insufficiency between diameters of 12 and 16 mm.

METHODS

This study is a single-center retrospective study. Subjects who underwent endovenous treatment with RFA (Group A) or CAC (Group B) for GSV insufficiency between June 2015 and June 2021 who were followed up for at least 2 years were included in the study. Subjects who had a 12-mm to 16-mm target vessel diameter and subjects with grade 3 and grade 4 reflux were included. Subjects' demographic data (age, sex), body mass indices, clinical, etiological, anatomic, pathophysiologic classification, GSV diameter, reflux grade, target vessel length, preoperative venous clinical severity score (VCSS), procedural time, postoperative first-day pain scores, postoperative 14th-day patient satisfaction scale, and postoperative complications were noted. In follow-up, subjects were evaluated with duplex ultrasonography and VCSS at 1, 6, 12, and 24 months.

RESULTS

In total, 142 subjects were included (n = 71 for both groups). The mean GSV diameter was 13.21 ± 1.00 for Group A and 13.51 ± 0.97 for Group B. The groups did not differ in terms of age, sex, body mass index, clinical, etiological, anatomic, pathophysiologic classification, GSV diameter, reflux grade, target GSV length, preoperative VCSS, complications, postoperative 24-hr pain status or postoperative 14-day patient satisfaction scale (P > 0.05 for all comparisons). The procedure time was significantly shorter in Group B (34.68 ± 4.22 min for Group A vs. 22.59 ± 4.5 min for Group B, P = 0.001). In the 1-month and 6-month Duplex ultrasonography of the subjects, partial closure and patency rates in Group B were significantly higher than those in Group A (P = 0.003 and P = 0.025, respectively). At the 12-month and 24-month evaluation, closure rates did not show a statistically significant difference between the groups (P = 0.056 and P = 0.090, respectively). Preoperative and 1-month VCSS measurements did not show a statistically significant difference between groups (P > 0.05 for all comparisons). The 6-month, 12-month, and 24-month VCSS measurements of Group A were significantly higher than those in Group B. (P = 0.043, P = 0.009 and P = 0.002, respectively).

CONCLUSIONS

Both RFA and CAC were found to be effective in the treatment of large-diameter GSV incompetency. The complication rates were similar between the 2 techniques. CAC had a shorter procedure time. Although the closure rates in the early postoperative period were better in the RFA group, long-term follow-up demonstrated similar patency rates. The functional results in the long-term follow-up were better in the RFA group.

A systematic review on ablation techniques for larger saphenous veins in patients with symptomatic superficial venous disease

OBJECTIVE

The aim of this study was to summarize the existing evidence for the treatment of saphenous veins >10 mm in diameter, to determine whether there were vein size limits for treatment modalities, and to determine if there are specific technical considerations for treatment of large veins.

METHODS

We searched the literature for reports of treatment methods and outcomes for patients with large-diameter saphenous veins treated with various ablation methods between 1993 and 2023. These studies were evaluated for the size of the vein determined as "large diameter," type of ablation method, study type, outcomes, adverse events, and any technical considerations noted. A systematic review was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. The COVIDENCE software was used for full-text screening and data extraction. Three reviewers reviewed the data, and the content expert served as the tiebreaker.

RESULTS

Seventy-one records were identified, of which 24 studies were deemed appropriate for extraction. Most of the studies identified reported outcomes of endovenous thermal ablation modalities. There were fewer studies on non-thermal, non-tumescent techniques, and these studies reported an overall lower occlusion rate compared with endovenous thermal ablation techniques.

CONCLUSIONS

Large head-to-head trials or randomized controlled that compare all the modalities over a long follow-up duration are yet to be performed. In the existing literature, there is considerable heterogeneity in terms of the study size, design, definition of large veins, site of vein measurement, and follow-up periods, making it challenging to make fair comparisons and draw firm conclusions. Currently available evidence supports the use of endothermal ablation techniques for the treatment of veins >10 mm in diameter as they have a more favorable efficacy and safety profile and have a larger body of evidence available compared with non-thermal, non-tumescent techniques or surgery.

The 2023 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part II: Endorsed by the Society of Interventional Radiology and the Society for Vascular Medicine

The Society for Vascular Surgery, the American Venous Forum, and the American Vein and Lymphatic Society recently published Part I of the 2022 clinical practice guidelines on varicose veins. Recommendations were based on the latest scientific evidence researched following an independent systematic review and meta-analysis of five critical issues affecting the management of patients with lower extremity varicose veins, using the patients, interventions, comparators, and outcome system to answer critical questions. Part I discussed the role of duplex ultrasound scanning in the evaluation of varicose veins and treatment of superficial truncal reflux. Part II focuses on evidence supporting the prevention and management of varicose vein patients with compression, on treatment with drugs and nutritional supplements, on evaluation and treatment of varicose tributaries, on superficial venous aneurysms, and on the management of complications of varicose veins and their treatment. All guidelines were based on systematic reviews, and they were graded according to the level of evidence and the strength of recommendations, using the GRADE method. All ungraded Consensus Statements were supported by an extensive literature review and the unanimous agreement of an expert, multidisciplinary panel. Ungraded Good Practice Statements are recommendations that are supported only by indirect evidence. The topic, however, is usually noncontroversial and agreed upon by most stakeholders. The Implementation Remarks contain technical information that supports the implementation of specific recommendations. This comprehensive document includes a list of all recommendations (Parts I-II), ungraded consensus statements, implementation remarks, and best practice statements to aid practitioners with appropriate, up-to-date management of patients with lower extremity varicose veins.

Radiofrequency Ablation and Concomitant Sclerotherapy for the Treatment of Varicose Veins (VV): Perspectives from a Developing Country

Objectives/Background: With decreased patient downtime and reduction in health expenditures, endovascular treatments have become popular for the treatment of venous insufficiency. In this study, we assessed the outcomes of using radiofrequency ablation (RFA) and sclerotherapy for refluxing veins and incompetent perforators in a developing country.

Materials and Methods: Subjects were selected from an ongoing registry from October 15, 2015 to April 5, 2018. Patients were followed up until 6 months. Pre- and post-procedural Clinical, Etiologic, Anatomic, and Pathophysiologic (CEAP) scores were compared, and complications were documented and treated accordingly.

Results: In total, 102 limbs (n=97) with 76 great saphenous veins (GSVs) and 26 small saphenous veins (SSVs) underwent RFA, with 79% undergoing concomitant sclerotherapy. Mean follow-up time was 188 days (±33.16). Moreover, 59% were males and 41% females. At the end of follow-up, 99% of the legs had complete occlusion. Pre- and post-procedural CEAP scores were 4.21±1.5 and 3.36±1.7, respectively (p-value <0.001). Endovenous heat-induced thrombosis (EHIT) types 1, 2, 3, and 4 were found in 8.8%, 3.9%, 1.9%, and 0% of the legs, respectively. Most common complications were pain and tenderness (51%), bruising (18%), and paresthesia (7%).

Conclusion: RFA and sclerotherapy have proved to be safe and efficacious. Computed tomography (CT) venous mapping aids in delineating complex venous anatomy and in ruling out deep vein thrombosis (DVT) in cases with discrepancy on Doppler ultrasound. Strict compliance of procedural and post-procedural protocol can assure promising results and futuristic value.

Success rate and factors predictive of redo endothermal ablation of Small Saphenous veins

OBJECTIVE

Endothermal ablation as endothermal laser ablation (EVLA) or Radiofrequency ablation (RFA) is being progressively more employed for small saphenous vein (SSV) insufficiency treatment. Prior studies have shown recurrence rates of 0% to 10% in incompetent small saphenous veins (ISSVs). The objective of this study is to determine the efficacy of redo venous ablations for symptomatic recanalized SSVs and to predict factors related with recanalization.

METHODS

A retrospective analysis of 2,566 procedures in 1,752 patients with CVI due to ISSVs from 2012 to 2018 was performed, using individual chart review for data extraction. All 2,566 procedures were performed using endothermal ablation in patients who failed initial conservative management. Postoperative duplex ultrasound scans were performed within 3 to 7 days. We defined a successful obliteration as a lack of color flow by postoperative duplex scan. We defined recanalization as the presence of reflux on duplex ultrasound in the target vessel at follow-up. We conducted follow-ups every 3 months in the first year, followed by every 6 months subsequently.

RESULTS

Among the 2,566 procedures, redo ablation was performed in 91 ISSVs (86 patients), including 58 women and 28 men. 54 procedures were performed on the left lower extremity, 37 were performed on the right lower extremity. The average Body Mass Index (BMI) was 32.2 ± 7.66. The mean age was 62.4 ± 15.10 years. Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) classes of the patients were: C1, 0; C2, 0; C3, 29; C4, 43; C5, 1; and C6, 18. The mean maximum diameter of the targeted veins, for the redo procedures, was 4.51± 1.33 mm. Forty procedures were performed using EVLA, 51 were performed using RFA. Initial technical success was 98.9%. Redo procedures had an early closure of 96.7%. At follow up after a mean duration of 24.9 ± 14.9 months, closure was 96.5%. No correlation was found between successful obliteration in the redo procedure and age, gender, CEAP, laterality, EVLA vs. RFA, BMI, or vein diameter.

CONCLUSIONS

Rates of successful closure for ISSVs on initial and redo procedures are comparable. The data validate the potential usefulness of performing redo SSV ablations.

Risk factors for saphenous vein recanalization after endovenous radiofrequency ablation

Target vein recanalization is defined as the postoperative detection of blood flow in a venous segment previously ablated. It can be occurred after thermal-tumescent procedures, as radiofrequency (RFA) and endovenous laser (EVLA) ablation techniques. Despite several papers described and analyzed incidence and consequences of recanalization, limited data are published on risk factors for this condition. The aim of this general review is to investigate clinical and instrumental risk factors for great and small saphenous veins recanalization after RFA, indicating their impact in the follow-up period.

Effectiveness of Endovenous Radiofrequency Ablation for Elderly Patients with Varicose Veins of Lower Extremities

Objective: The purpose of this study was to evaluate safety and effectiveness of endovenous radiofrequency ablation (RFA) for elderly patients. Materials and Methods: We enrolled 140 patients (194 limbs) who underwent RFA for varicose veins of lower extremities. Patients were divided into two groups; elderly patients (more than 75 years old, E-group, n=36) and young patients (under 75 years old, Y-group, n=104), and perioperative data were analyzed and compared between two groups. Results: In E-group, there were more than patients with hypertension, ischemic heart disease, malignant tumor, and cerebrovascular disease. A partial recanalization was observed in only one limb (0.6%) in Y-group. Endovenous heat induced thrombosis (EHIT) was identified four limbs (2.8%) in Y-group and two limbs (4.1%) in E-group. All EHITs were class 1 by Kabnick classification, and they disappeared within one month after interventions, without antithrombotic therapy. No other major complications were observed. There were no significantly differences for preoperative mean venous clinical severity scores (VCSS) (Y : E=4.84 : 4.47) and postoperative VCSS (Y : E=1.16 : 1.19, 0.35 : 0.58, 0.15 : 0.06, 0.05 : 0.06 at 1, 3, 6, 12 months after) in both groups. Conclusion: RFA for elderly patients is a safe and effective strategy for varicose veins of lower extremities.

Outcome of ClosureFAST radiofrequency ablation for large-diameter incompetent great saphenous vein

Purpose

There is limited data on the outcomes of radiofrequency ablation (RFA) for large diameter saphenous veins. This study aimed to determine whether the large-diameter great saphenous vein (GSV) affected closure rate, complications, and clinical and quality of life (QoL) improvement.

Methods

From January 2012 to September 2016, a total of 722 limbs were treated with ClosureFAST RFA in a single center. Patients were divided into 2 groups according to the vein diameter measured 3 cm below the saphenofemoral junction (group A ≤ 12 mm, group B > 12 mm). Vein closure was evaluated with duplex scan at 3–5 days, 1, 3, 6, and 12 months postoperatively. The incidence of complications, improvements in symptoms (measured by the Venous Clinical Severity Score [VCSS]) and QoL (measured by the Aberdeen Varicose Vein Symptom Severity Score [AVSS]) were evaluated.

Results

Groups consisted of 663 GSVs in group A (mean diameter, 6.00 ± 1.74 mm) and 59 in group B (mean diameter, 13.17 ± 1.28 mm). Vein closure rates at 12 months were 98.9% in group A and 100% in group B (P = 0.428). There was no significant difference in the incidence of complications. Both groups showed marked improvements in the VCSS and the AVSS with no significant differences.

Conclusion

For large-diameter veins, RFA showed comparable outcomes in terms of closure rate, complications, clinical and QoL improvements.

Endovenous Photocoagulation Using a Diode Laser for Complicated Varicose Veins Related to Stasis Ulcers

BACKGROUND

The objective of this study was to assess the efficacy and safety of endovenous laser photocoagulation (EVLP) at a wavelength of 810 nm for treating complicated venous insufficiency associated with venous ulcers.

MATERIALS AND METHODS

A retrospective review of 110 patients with 180 legs having chronic venous insufficiencies associated with varicose veins treated over an 8-year period was conducted. Patients ranged from 16 to 80 years of age and included 85 women and 25 men. Of the 110 patients, 32 (29.10%) patients with 40 legs having varicose veins were defined as having complicated varicose veins associated with venous ulcers. All 32 patients received EVLP treatment using a diode laser. Complications were evaluated at 3 weeks (early), 6 weeks (late), and 6 months (final) after EVLP treatment. The primary efficacy and final outcome measurement were determined through quantitative assessment using Hach's and clinical, etiological, anatomical, and pathophysiological classification. Safety was evaluated for each treatment group by monitoring adverse effects.

RESULTS

Early complications were swelling, local paresthesia, pigmentation, minor superficial thermal injury, superficial phlebitis, and localized hematomas. All complications and ulcerations resolved completely within 2 weeks. No recurrence occurred after the study's 6-month follow-up period. Based on paired t test analysis, clinically significant differences in severity scores were discovered, which were based on Hach's classification before and after EVLP treatment at a wavelength of 810 nm. All patients achieved improvement from clinical, etiological, anatomical, and pathophysiological class C6 to C5. Permanent adverse effects were not observed.

CONCLUSIONS

Endovenous laser photocoagulation at the wavelength of 810 nm permitted the use of appropriate light doses for treating complicated varicose veins associated with venous ulcers and resulted in significant improvement in lesions.

Is radiofrequency ablation of varicose veins a valuable option? A systematic review of the literature with a cost analysis

BACKGROUND

Since the 1990s, new techniques for the treatment of varicose veins have emerged, including radiofrequency ablation (RFA) and laser treatment. We performed a study to compare the safety, efficacy and outcomes of RFA compared to those of open surgery and laser ablation for the treatment of varicose veins. We also carried out a cost analysis of RFA compared to open surgery to assess whether RFA could help free up operating room time by being performed in an outpatient context.

METHODS

We conducted a systematic literature review (publication date May 2010-September 2013 for articles in English, January 1991-September 2013 for those in French). We used several checklists to measure the quality of the studies. We also collected data on costing.

RESULTS

The literature search identified 924 publications, of which 38 were retained for analysis: 15 literature reviews, 1 good-practice guideline and 22 new primary studies. The overall level of evidence was low to moderate owing to the limited sample sizes, lack of information on patient characteristics and lack of standardization of the outcome measures. However, the results obtained are consistent from study to study. In the short and medium term, RFA is considered as effective as open surgery or laser treatment (moderate level of evidence) and presents fewer major and minor complications than open surgery (low level of evidence). Radiofrequency ablation can be performed on an outpatient basis. We calculated that RFA would be about $110-$220 more expensive per patient than open surgery.

CONCLUSION

Radiofrequency ablation is a valuable alternative to open surgery and would free up operating room time in a context of low accessibility.

Endovenous Laser Application

Introduction: Endoluminal vein treatment is a promising minimal invasive treatment option for peoples suffering from varicose veins. The basic mechanism underlying this procedure is to selectively induce heat in the vessel wall with the result of denaturation of proteins and shrinkage of collagen fibers due to energy application. So far energy could be applied either as RF-current, laser light or water steam. The different approaches to deliver such forms of energies are described.

Methods: Investigations on heat dependent vein tissue effects were performed. The degree of shrinkage and wall thickening due to heat induction was calculated. Tensile test on vein tissue were performed. Investigation using the radial emitting laser fibre in the ox-foot-model under reproducible condition were done and wavelengths dependent tissue reaction were explored.

Results: The experiments clearly demonstrate the degree of the shrinkage of length and diameter, the thickening of the vein wall, as well as the decrease of the elasticity of the tissue. The optical irradiation pattern of the radial emitting laser fiber serves for safe and reproducible energy application directly to the vein wall. Using a laser wavelength with high absorption by the tissue water needs reduced irradiation and irradiance compared to wavelengths with less water absorption. Conclusion: An experimental approach to improve laser application for endovenous varicose treatment is described. Laser parameters and treatment parameters were found which are now under clinical testing. The demonstrated tissue effects may help to find further arguments for clinical findings and sensations described by the patients during follow-up.

Prospective study of safety and effectiveness in the use of radiofrequency ablation for incompetent great saphenous vein ≥12 mm

OBJECTIVE

The objective of this study was to assess the outcomes of radiofrequency ablation (RFA) in incompetent great saphenous vein (GSV) according to its diameter.

METHODS

This was a prospective single-center study including all patients treated with RFA from September 2014 to December 2015. The sample was divided according to the maximum GSV diameter measured on duplex ultrasound scan (A, <12 mm; B, ≥12 mm). Second-generation catheters (ClosureFast; Covidien, Mansfield, Mass) and tumescent anesthesia were used. Clinical stage (according to Clinical, Etiology, Anatomy, and Pathophysiology [CEAP] classification), quality of life (measured by the 14-item Chronic Venous Insufficiency Questionnaire), and pain on visual analog scale were recorded before the procedure and during follow-up. Technical success was defined as GSV occlusion on duplex ultrasound scan. Safety was defined as incidence and type of adverse events at 10 days, 1 month, 6 months, and 12 months.

RESULTS

There were 257 patients included, 183 (71%) with GSV diameter <12 mm and 74 (29%) with GSV diameter ≥12 mm. Mean GSV diameter was 8 ± 2 mm (4-11 mm) and 14 ± 2 mm (12-21 mm), respectively. Before the procedure, although a tendency toward greater clinical severity was observed in group B, no significant differences were found in the percentage of patients in C4 and C5 categories (A, 10%; B, 22%), median pain perception (A, 40; B, 39), or median quality of life value on the 14-item Chronic Venous Insufficiency Questionnaire scale (A, 27; B, 27). The rate of GSV occlusion at 1 month (n = 221) was 97% in group A and 100% in group B (P = .325); at 6 months (n = 158), it was 97% and 98%, respectively (P > .999); and at 12 months (n = 90), it was 99% and 96% (P = .481). There was a significant improvement in pain and quality of life in both groups, without differences between them. Finally, no differences between groups were found in terms of adverse events. Paresthesias were the most frequent event (A, 4%; B, 5%; P = NS), which disappeared during follow-up in half of the cases. Regarding major adverse events, there was only one case of deep venous thrombosis in group B.

CONCLUSIONS

RFA is safe and effective for the treatment of GSV ≥12 mm at midterm.

Mechanochemical ablation causes endothelial and medial damage to the vein wall resulting in deeper penetration of sclerosant compared with sclerotherapy alone in extrafascial great saphenous vein using an ex vivo model

BACKGROUND

Nonthermal, tumescentless devices are the next generation of minimally invasive devices to treat varicose veins. We aimed to investigate the effects of mechanochemical ablation (MOCA) using ClariVein (Vascular Insights, Quincy, Mass) on ex vivo great saphenous vein with histology and immunofluorescent staining.

METHODS

Extrafascial great saphenous veins were harvested during surgery for varicose veins and were treated ex vivo for 10 to 11 minutes with either liquid sclerotherapy or the use of ClariVein, with and without 3% sodium tetradecyl sulfate. Veins were sectioned and subjected to hematoxylin and eosin staining and immunofluorescent staining for endothelial and smooth muscle cell markers (CD31 and α-actin) to assess overall damage and cell death in the vein wall compared with control sections.

RESULTS

Histologic observations confirmed intimal damage from ClariVein, as has been previously shown; however, medial damage was also evident, which was not observed in control or liquid sclerotherapy sections. Immunofluorescent staining in the three sections studied showed a 42% decrease in CD31 staining and 27% mean reduction in α-actin staining up to a depth of 300 μm with liquid sclerotherapy. This cytotoxic effect was significantly enhanced by MOCA with a reduction in CD31 staining just above 60% and a 46% mean decrease in α-actin staining noted up to a depth of 300 μm. Far greater reductions in staining compared with sclerotherapy were observed up to a depth of 600 μm.

CONCLUSIONS

MOCA using 3% sodium tetradecyl sulfate increases the penetration of the sclerosant and its effect into the vein wall and shows superior rates of tissue destruction compared with liquid sclerotherapy alone. In this model, it appears not solely to damage the endothelium but also to shear the medial layer, creating small lesions into which sclerosant can flow and exert its cytotoxic effect.

Radiofrequency ablation of varicose veins

Background: In the search of alternative techniques to high ligation and stripping (HL/S) in the treatment of varicose veins, catheter-ablation methods have been implemented since 1998. Besides endovenous laser techniques (ELT) radiofrequency ablation (RFA) is a successful device in treating insufficiency of the Great (GSV) and Small saphenous vein (SSV). Methods: This review article sums up publications on Closure Plus™, ClosureFAST™, RFITT® (Celon Method), and EVRF®. It discusses the actually favorized treatment protocols and study results. Results of meta-analysis are presented, too.

Results: The Closure Plus™ catheter was the first radiofrequency technique to be licensed in Europe in 1998. Trials and meta-analyzes show occlusion rates of 81–89 % after 5 years. The consecutive technique was the ClosureFAST™ (CLF) catheter that was introduced in 2007 and offered more standardization in treatment. Published data show occlusion rates of 98 % after 5 years and low profile on complications. Also in 2007 a bipolar radiofrequency technique called RFITT was presented. Due to lack of standards in treatment protocol it could not get accepted as well as CLF despite of good treatment results (92–98 % occlusion rates after 12 months) and low complications. A new RFA device called EVRF® shows weak evidence so far.

Conclusion: Radiofrequency ablation of varicose veins has become a well-established treatment alternative to HL/S mostly represented by CLF.

Effect of Diameter of Saphenous Vein on Stump Length after Radiofrequency Ablation for Varicose Vein

Purpose:

Radiofrequency ablation (RFA) has gained popularity for treatment of varicose veins. The diameter of the saphenous vein should be considered before RFA because occlusion of the vein may differ depending on its diameter. Until now, however, there have been few data about the correlation between the diameter of the saphenous vein and the stump length after RFA. The purpose of our study was to investigate its correlation.

Materials and Methods:

A retrospective review was performed from prospectively collected data of RFA patients between March 2009 and December 2011. Preoperatively, the saphenous vein diameter was measured. Ablation was initiated 2 cm distal from the junction. Postoperatively, stump length was measured at 1 week and 6 months. After 2 years, we measured the length from the saphenofemoral junction to the leading point of occlusion for great saphenous vein, and length from the saphenopopliteal junction to the leading point of occlusion for small saphenous vein. The paired t-test, independent t-test, and correlation analysis were used for statistical analysis. P-value <0.05 was considered statistically significant.

Results:

During the study period, RFA was performed in 201 patients. Endovenous heat-induced thrombosis developed in 3 patients (1.5%). After 2 years, the stump length was obtained in 74 limbs. The mean diameter and stump length of the saphenous vein were 6.7±1.8 mm and 12.5±8.5 mm, respectively. Correlation analysis showed that the Pearson correlation coefficient of these factors was −0.017.

Conclusion:

There was no correlation between the diameter of saphenous vein and stump length.

Radiofrequency ablation of varicose veins: Best practice techniques and evidence

Scope of the review

This article systematically reviews the practice of radiofrequency ablation of lower limb varicose veins. We present the clinical evidence and best practice techniques for currently available devices.

Methods

Manufacturer’s instructions-for-use were requested for all radiofrequency devices. The MEDLINE and EMBASE databases were searched using the following keywords: ‘varicose veins’ AND ‘radiofrequency’ OR ‘radio frequency’ OR ‘Venefit’ OR ‘ClosureFAST’ OR ‘RFiTT’ OR ‘EVRF’ OR ‘VeinCLEAR’, generating 240 articles. Titles and abstracts were screened, yielding 63 articles directly relevant to the scope of the review. Reference lists for publications were also searched to identify further manuscripts of relevance. The Cochrane Database and current National Institute for Clinical and Healthcare Excellence guidelines for varicose veins were also searched from relevant articles.

Results

Four radiofrequency ablation (RFA) systems are currently commercially available. Generic practice methods (common to all RF systems) and device-specific techniques are described. The weight of current evidence relates to the use of Covidien Venefit™ (formerly VNUS ClosureFAST™), which clearly demonstrates clinical advantages over open surgery at least to 2 years follow up. However, contemporary studies of the radiofrequency-induced thermal therapy device (RFiTT®), show that in experienced hands, clinical equivalence to the Venefit™ procedure can be achieved. The evidence base for EVRF® and VeinCLEAR™ devices is currently weak and absent, respectively.

Conclusions

Despite widespread uptake of RFA and acceptance of its clinical advantages over open surgery there is a paucity of Class 1 A evidence. This results from incongruent reporting of clinical outcome measures within existing literature. Similarly, lack of long-term follow-up studies precludes comparison of the durability of short- and medium-term advantages of RFA with the longer term results of open surgery. There remains scope for a large prospective high-quality trial to assess the clinical, anatomical and cost-effectiveness outcomes for the four commercially available RFA devices, with a particular focus on long-term follow up.

Consensus for the Treatment of Varicose Vein with Radiofrequency Ablation

The objective of this paper is to introduce the schematic protocol of radiofrequency (RF) ablation for the treatment of varicose veins. Indication: anatomic or pathophysiologic indication includes venous diameter within 2–20 mm, reflux time ≥0.5 seconds and distance from the skin ≥5 mm or subfascial location. Access: it is recommended to access at or above the knee joint for great saphenous vein and above the mid-calf for small saphenous vein. Catheter placement: the catheter tip should be placed 2.0 cm inferior to the saphenofemoral or saphenopopliteal junction. Endovenous heat-induced thrombosis ≥class III should be treated with low-molecular weight heparin. Tumescent solution: the composition of solution can be variable (e.g., 2% lidocaine 20 mL+500 mL normal saline+bicarbonate 2.5 mL with/without epinephrine). Infiltration can be done from each direction. Ablation: two cycles’ ablation for the first proximal segment of saphenous vein and the segment with the incompetent perforators is recommended. The other segments should be ablated one time. During RF energy delivery, it is recommended to apply external compression. Concomitant procedure: It is recommended to do simultaneously ambulatory phlebectomy. For sclerotherapy, it is recommended to defer at least 2 weeks. Post-procedural management: post-procedural ambulation is encouraged to reduce the thrombotic complications. Compression stocking should be applied for at least 7 days. Minor daily activity is not limited, but strenuous activities should be avoided for 2 weeks. It is suggested to take showers after 24 hours and tub baths, swimming, or soaking in water after 2 weeks.

Tumescentless endovenous radiofrequency ablation with local hypothermia and compression technique

Introduction

Modern surgical management of chronic venous insufficiency is possible since the development of catheter-based minimally invasive techniques, including radiofrequency ablation (RFA) and the application of colour Doppler sonography. RFA technology requires the use of tumescent anaesthesia, which prolongs the operating time. Instilling tumescent anaesthesia percutaneously below the saphenous fascia is the steepest part of the learning curve. In our study, we compared operative and postoperative results of tumescentless RFA and RFA with tumescent anaesthesia, to investigate the necessity of tumescent anaesthesia.

Methods

A total of 344 patients with Doppler-confirmed great saphenous vein insufficiency underwent RFA between January and December 2012. Patients were divided into two groups according to anaesthetic management. Group 1 consisted of 172 patients: tumescent anaesthesia was given before the ablation procedure, and group 2 contained 172 patients: a local hypothermia and compression technique was used; no tumescent anaesthesia was administered. The visual analogue scale (VAS) was used and ecchymosis scores of the patients were recorded. Clinical examinations were performed at each visit and Doppler ultrasonography was performed in the first and sixth month.

Results

Mean ablation time was significantly lower in group 2 compared to group 1 (7.2 vs 18.9 min; p < 0.05). Skin burn and paresthesia did not occur. The immediate occlusion rate was 100% for both groups. No significant difference was found between the groups in terms of VAS and ecchymosis scores. All patients returned to normal activity within two days. The primary closure rate of group 1 was 98.2% and group 2 was 98.8% at six months, and there was no significant difference between the groups (p > 0.05).

Conclusion

Eliminating tumescent infusion is a desirable goal. Tumescentless endovenous RFA with local hypothermia and compression technique appears to be safe and efficacious. Our technique shortens the operation time and prevents patient procedural discomfort.

Comparing the Effectiveness of 1064 vs. 810 nm Wavelength Endovascular Laser for Chronic Venous Insufficiency (Varicose Veins)

BACKGROUND AND OBJECTIVE

The objective of this study was to compare the efficacy and safety of Endovenous Laser Photocoagulation (EVLP) at wavelengths of 1064 nm versus 810 nm for chronic venous insufficiency (varicose veins) in a large series of patients.

STUDY DESIGN/MATERIALS AND METHODS

A retrospective review was conducted of 108 patients with chronic venous insufficiency treated over a 8-year period. Subjects' ages ranged between 16 to 79 years; there were 83 females and 25 males, all of whom were Asian. Patients (n=54) received EVLP at wavelengths of 1064 nm (EVLP-1064 nm), Nd:YAG laser. Subsequent patients (n=54) received 810 nm (EVLP-810 nm), Diode laser. The primary efficacy measurement was the quantitative assessment of final outcome for 1064 nm versus 810 nm. Patients were monitored for adverse effects as well.

RESULTS

Complications were observed at 3 weeks (early), 6 weeks (late) and 6 months after EVLP. In both groups, the commonest complication in early convalescence was swelling. This was followed by Local paraesthesia, pigmentation, superficial burns, superficial phlebitis, and localized hematomas. At 6 weeks postoperatively, local paraesthesia, persistent hyperpigmentation, and minimal scarring were presented. These problems all disappeared completely after the 6 months study period. Based on chi-squared analysis, there were clinical, and statistically significant differences in the severity score of final results favoring the EVLP-810 nm group.

CONCLUSION

All patients achieved good or excellent improvement after EVLP-1064nm and EVLP-810nm. However, the difference of final outcome was significant, and indicates that improvement was greater in the Diode group. Further studies of different wavelengths and optimization of cryogen spray cooling (CSC) may lead to improved results in the eradication of varicose veins.

Endovenous radiofrequency ablation (venefit procedure): impact of different energy rates on great saphenous vein shrinkage

BACKGROUND

Despite adequate treatment of varicose veins, recurrences and primary failures still occur. This article hypothesizes that increasing the dose of radiofrequency ablation (RFA) could improve efficacy through inducing a greater shrinkage of the treated vein.

METHODS

A comparative clinical study of 67 extremities with varicose veins caused by great saphenous vein (GSV) reflux treated with RFA ClosureFAST was conducted. Group 1 (n = 22) received 1 treatment cycle (20 sec) and group 2 (n = 45) received 2 cycles (40 sec) along the GSV trunk. Clinical and duplex follow-up were performed at day 4, and at 1, 3, and 6 months. The main outcomes measured were GSV diameters, occlusion rate, and secondary effects. Statistical analysis was performed using the Student's t test, linear mixed model, Bland-Altman plot, Lin's concordance correlation coefficient, and intraclass correlation coefficient.

RESULTS

Both groups were comparable for demographic and specific study variables with a very low intraobserver variability. The immediate occlusion rate was 100% for both groups. Group 2 showed a quicker and greater reduction in medium diameter along the period of the study (P = 0.0074). Beyond the 6-month period of study, 1 partial GSV recanalization in group 1 and 1 complete GSV recanalization in an obese patient in group 2 were detected. No skin burns, paresthesia, or deep vein thromboses appeared.

CONCLUSIONS

Two cycles of RFA treatment in all segments of the GSV achieves quicker and greater vein shrinkage of the medium diameter without an increase in side effects. Further studies are needed to evaluate the implications in terms of intermediate and long-term clinical efficacy.