PREVAIT after modern open surgery and endothermal ablation: a systematic review

INTRODUCTION

Presence of varices after operative treatment (PREVAIT) is a common finding after varicose vein surgery, and has been shown to significantly reduce the quality of life of those it affects. As such, long-term results after varicose vein interventions have to be taken into account when choosing a technique. This study aims to systematically review current evidence on the recurrence of varicose veins after three different techniques: conventional surgery (HLS), endovenous laser ablation (EVLA) and radiofrequency ablation (RFA).

EVIDENCE ACQUISITION

A literature search was performed on the PubMed and Web of Science databases, which returned 546 studies. Fourteen studies were included. Data were extracted using predefined forms.

EVIDENCE SYNTHESIS

A total of 2795 patients were included, for a total of 3056 legs treated. 503 legs (16.5%) were treated by HLS, 1791 (58.6%) by EVLA and 762 (25.0%) by RFA. PREVAIT was reported in 34.4% for patients treated by HLS, for a mean follow-up comprised between 18 months and 5 years; 16.6% by EVLA, for a mean follow-up between 112 days and 5 years and 6.7% of those treated by RFA, for a mean follow-up between 106 days and 5 years. Regarding patterns of recurrence, the development of new varicose veins was the most commonly reported mechanism of recurrence after HLS (range: 29.8-91%) and EVLA (range: 40-81.6%), but not RFA, where recanalization of the occluded saphenous trunk accounted for up to 67.0% of the cases. Only one study reported quality of life related recurrence, and included patients treated by HLS and EVLA, but not RFA. Aberdeen Varicose Vein Questionnaire (AVVQ) score, physical functioning domains of the SF-36 score and patient satisfaction were significantly worse in patients with clinical recurrence. Re-intervention rates after recurrence were reported in 5 studies, ranging between 7.7% and 37.7% for HLS and 0-57.0% for EVLA. Only one study reported data on re-intervention for RFA patients, which was 6.67%.

CONCLUSIONS

Recurrence is a reliable indicator of long-term efficacy of a varicose vein treatment and appears to occur more frequently after HLS. Although there are several mechanisms of recurrence, the development of new varicose veins was the most commonly observed. There is clear heterogeneity among definitions of recurrence and follow-up periods in literature.

Six Year Extension Study of Patients From a Randomised Clinical Trial Comparing Venefit, Radiofrequency Induced Thermal Therapy, and Endovenous Radiofrequency Ablation for Treatment of Incompetent Great Saphenous Veins

OBJECTIVE

To compare long term outcomes after great saphenous vein (GSV) treatment with three radiofrequency (RF) thermal devices: Venefit (Closurefast), Radiofrequency Induced Thermal Therapy (RFITT), and Endovenous Radiofrequency (EVRF).

DESIGN

A 72 month follow up of patients who were treated in the randomised 3RF study.

METHODS

A total of 172 participants from the 3RF study were invited to take part in a single visit, long term, follow up study. Failure of GSV closure was assessed with duplex ultrasound (DUS) and constituted the primary outcome. Patients completed questionnaires for secondary outcomes: Aberdeen Varicose Vein Questionnaire (AVVQ), Euroqol 5D (EQ-5D), and patient reported varicose veins measured by counting vein occupying boxes in AVVQ question 1.

RESULTS

Twenty-two patients (12%) had already been re-treated. Of the remainder, 13 (7%) could not be contacted, 20 (11%) declined invitation, and one did not consent. Therefore, 116 (64%) and 95 (53%) participants completed questionnaires and DUS, respectively. Failure of GSV closure on 72 month DUS was 16%, 21%, and 37% for Venefit, RFITT, and EVRF, respectively (p = .14), whilst outcomes for all failures were 14%, 17%, and 44% (p < .001) (Venefit vs. EVRF: p < .001; RFITT vs. EVRF: p < .001; and Venefit vs. RFITT: p = .63). There were no between group differences in AVVQ or EQ-5D scores. Rates of patient reported presence of any varicose veins were high for all groups (97%, 92%, and 97% after Venefit, RFITT, and EVRF, respectively; p = .48). The EVRF treated participants reported more extensive recurrence than the Venefit and RFITT participants (p = .008).

CONCLUSION

Long term technical outcomes after RF ablation for GSV varicose veins were significantly better after Venefit and RFITT compared with EVRF treatment. However, quality of life scores showed no differences after 72 months. Rates of patient reporting any varicose veins were high for all treatments.

CLINICALTRIALS

gov Identifier: NCT04720027.

Five-Year Outcomes of a Randomized Trial of Treatments for Varicose Veins

BACKGROUND

Endovenous laser ablation and ultrasound-guided foam sclerotherapy are recommended alternatives to surgery for the treatment of primary varicose veins, but their long-term comparative effectiveness remains uncertain.

METHODS

In a randomized, controlled trial involving 798 participants with primary varicose veins at 11 centers in the United Kingdom, we compared the outcomes of laser ablation, foam sclerotherapy, and surgery. Primary outcomes at 5 years were disease-specific quality of life and generic quality of life, as well as cost-effectiveness based on models of expected costs and quality-adjusted life-years (QALYs) gained that used data on participants' treatment costs and scores on the EuroQol EQ-5D questionnaire.

RESULTS

Quality-of-life questionnaires were completed by 595 (75%) of the 798 trial participants. After adjustment for baseline scores and other covariates, scores on the Aberdeen Varicose Vein Questionnaire (on which scores range from 0 to 100, with lower scores indicating a better quality of life) were lower among patients who underwent laser ablation or surgery than among those who underwent foam sclerotherapy (effect size [adjusted differences between groups] for laser ablation vs. foam sclerotherapy, -2.86; 95% confidence interval [CI], -4.49 to -1.22; P<0.001; and for surgery vs. foam sclerotherapy, -2.60; 95% CI, -3.99 to -1.22; P<0.001). Generic quality-of-life measures did not differ among treatment groups. At a threshold willingness-to-pay ratio of £20,000 ($28,433 in U.S. dollars) per QALY, 77.2% of the cost-effectiveness model iterations favored laser ablation. In a two-way comparison between foam sclerotherapy and surgery, 54.5% of the model iterations favored surgery.

CONCLUSIONS

In a randomized trial of treatments for varicose veins, disease-specific quality of life 5 years after treatment was better after laser ablation or surgery than after foam sclerotherapy. The majority of the probabilistic cost-effectiveness model iterations favored laser ablation at a willingness-to-pay ratio of £20,000 ($28,433) per QALY. (Funded by the National Institute for Health Research; CLASS Current Controlled Trials number, ISRCTN51995477.).

Great uncertainty regarding treatment of varicose vein recurrence

Introduction: Although varicose vein recurrence is common and 10–30 % of all varicose vein surgery is done for recurrence of some sort, there are very few studies that can guide us to the best re-treatment option. With the introduction of minimal invasive endovenous treatments there is a variety of possible options besides traditional open surgical techniques.

Method: The Scandinavian Venous Forum held a symposium at the GSP meeting in Lü-beck 2012 and this review article is based on data from the presentations at that symposium. Further data has been added regarding new knowledge that was not available a year ago, from PubMed search and article references.

Results: The most common reasons for recurrence are discussed and also the discrepancy between neovascularization (NV) and recurrence due to technical failures. It is likely that NV is the most commonly duplex detected type of recurrence following open groin surgery, less common early after endovascular techniques. However, technical or tactical failures are the most common reasons for redo surgery because of symptomatic recurrence. NV seldom leads to symptomatic recurrences and thus a need for re- treatment. There is a risk that the stumps left following endovenous treatments will become a source for symptomatic recurrence after 5–10 years and indications of that have been reported in the few available 5 year RCT-reports following laser treatments. Treatment of recurrence due to stumps in the groin can be done safely within a reasonable operating time through a medial approach and the stump itself can generally not be treated with any of the endovenous alternative methods. Foam treatment can be used for most other recurrent veins but the durability is unknown. Endovascular thermal ablation can only be used for reopened or remaining saphenous veins and accessory saphenous veins while tributaries have to be treated by stab excisions or foam.

Conclusion: Long term reports of results of redo surgery are limited but suggest reasonably good results from open surgical intervention and are non-existent for the endovenous techniques. So far groin recurrence seems best treated surgically by an indirect approach, preferably medial. More studies are needed to find the best treatment regime for varicose vein recurrence in general and hybrid procedures might be the way forward by combinations of different techniques.

The effectiveness of various interventions versus standard stripping in patients with varicose veins in terms of quality of life

Purpose Lower limb varicose veins have a significant effect upon the quality of life and a considerable socioeconomic impact despite their relatively benign nature. The aim of this study is to compare the effects of various therapeutic strategies among patients with varicose veins to surgical ligation and vein stripping on the basis of quality of life. Methods PubMed/Medline and Scopus databases were systemically searched from 1 January 2000 until 23 December 2015 for studies reporting outcome on the quality of life of different treatment techniques for varicose veins. We used Cohen's d to make the outcomes of the reported scales comparable. Heterogeneity was calculated with the use of the Q statistic and the I². Results A total of 1047 participants were randomized across all analyzed trials. The number of participants in a single trial ranged from 30 to 308. The majority of participants in any trial were C2 on the CEAP scores. Overall, the quality of evidence was low. For the meta-analysis performed at 12 months postintervention (seven studies, n = 1047 patients) and after random effects meta-analyses due to high heterogeneity, no differences are observed between intervention and surgical ligation and vein stripping. The pooled estimate is -0.001 and the 95% confidence interval is -0.069 to 0.067 with a p = 0.98. In the case of the 24 months, postintervention analysis (six studies, n = 840 patients) the inference is almost identical. The effect of various interventional modes of treatment compared to surgical ligation and vein stripping is negligible in terms of clinical outcomes and quality of life so that surgical ligation and vein stripping versus the other interventional procedures were equally effective approaches to treat great saphenous vein incompetence in terms of quality of life measurements. Conclusion The procedures were at least equally efficient in treating patients with varicose vein disease in terms of quality of life assessment tools at 12 and 24 months compared to surgical ligation and vein stripping.

A review of a new Dutch guideline for management of recurrent varicose veins

In 2013, the new Dutch guideline for "Venous Pathology" was published. The guideline was a revision and update from the guideline "Diagnostics and Treatment of Varicose Veins" from 2009 and the guideline "Venous Ulcer" from 2005. A guideline for "Deep Venous Pathology" and one for "Compression Therapy" was added to the overall guideline "Venous Pathology." The chapter about treatment of recurrent varicose veins after initial intervention was recently updated in 2015 and is reviewed here. The Dutch term "recidief varices" or the French "récidive de varices" should be used analogous to the English term "recurrent varicose veins." The DCOP Guideline Development Group Neovarices concluded that "recidief" in Dutch actually suggests recurrence after apparent successful treatment and ignores the natural progression of venous disease in its own right. So the group opted to use the term "neovarices." In the Dutch guideline, neovarices is meant to be an all embracing term for recurrent varicose veins caused by technical or tactical failure, evolvement from residual refluxing veins or natural progression of varicose vein disease at different locations of the treated leg after intervention. This report reviews the most important issues in the treatment of varicose vein recurrence, and discusses conclusions and recommendations of the Dutch Neovarices Guideline Committee.

Clinical effectiveness and cost-effectiveness of foam sclerotherapy, endovenous laser ablation and surgery for varicose veins: results from the Comparison of LAser, Surgery and foam Sclerotherapy (CLASS) randomised controlled trial

BACKGROUND

Foam sclerotherapy (foam) and endovenous laser ablation (EVLA) have emerged as alternative treatments to surgery for patients with varicose veins, but uncertainty exists regarding their effectiveness in the medium to longer term.

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of foam, EVLA and surgery for the treatment of varicose veins.

DESIGN

A parallel-group randomised controlled trial (RCT) without blinding, and economic modelling evaluation.

SETTING

Eleven UK specialist vascular centres.

PARTICIPANTS

Seven hundred and ninety-eight patients with primary varicose veins (foam, n = 292; surgery, n = 294; EVLA, n = 212).

INTERVENTIONS

Patients were randomised between all three treatment options (eight centres) or between foam and surgery (three centres).

PRIMARY OUTCOME MEASURES

Disease-specific [Aberdeen Varicose Vein Questionnaire (AVVQ)] and generic [European Quality of Life-5 Dimensions (EQ-5D), Short Form questionnaire-36 items (SF-36) physical and mental component scores] quality of life (QoL) at 6 months. Cost-effectiveness as cost per quality-adjusted life-year (QALY) gained.

SECONDARY OUTCOME MEASURES

Quality of life at 6 weeks; residual varicose veins; Venous Clinical Severity Score (VCSS); complication rates; return to normal activity; truncal vein ablation rates; and costs.

RESULTS

The results appear generalisable in that participants' baseline characteristics (apart from a lower-than-expected proportion of females) and post-treatment improvement in outcomes were comparable with those in other RCTs. The health gain achieved in the AVVQ with foam was significantly lower than with surgery at 6 months [effect size -1.74, 95% confidence interval (CI) -2.97 to -0.50; p = 0.006], but was similar to that achieved with EVLA. The health gain in SF-36 mental component score for foam was worse than that for EVLA (effect size 1.54, 95% CI 0.01 to 3.06; p = 0.048) but similar to that for surgery. There were no differences in EQ-5D or SF-36 component scores in the surgery versus foam or surgery versus EVLA comparisons at 6 months. The trial-based cost-effectiveness analysis showed that, at 6 months, foam had the highest probability of being considered cost-effective at a ceiling willingness-to-pay ratio of £20,000 per QALY. EVLA was found to cost £26,107 per QALY gained versus foam, and was less costly and generated slightly more QALYs than surgery. Markov modelling using trial costs and the limited recurrence data available suggested that, at 5 years, EVLA had the highest probability (≈ 79%) of being cost-effective at conventional thresholds, followed by foam (≈ 17%) and surgery (≈ 5%). With regard to secondary outcomes, health gains at 6 weeks (p < 0.005) were greater for EVLA than for foam (EQ-5D, p = 0.004). There were fewer procedural complications in the EVLA group (1%) than after foam (7%) and surgery (8%) (p < 0.001). Participants returned to a wide range of behaviours more quickly following foam or EVLA than following surgery (p < 0.05). There were no differences in VCSS between the three treatments. Truncal ablation rates were higher for surgery (p < 0.001) and EVLA (p < 0.001) than for foam, and were similar for surgery and EVLA.

CONCLUSIONS

Considerations of both the 6-month clinical outcomes and the estimated 5-year cost-effectiveness suggest that EVLA should be considered as the treatment of choice for suitable patients.

FUTURE WORK

Five-year trial results are currently being evaluated to compare the cost-effectiveness of foam, surgery and EVLA, and to determine the recurrence rates following each treatment. This trial has highlighted the need for long-term outcome data from RCTs on QoL, recurrence rates and costs for foam sclerotherapy and other endovenous techniques compared against each other and against surgery.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN51995477.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 27. See the NIHR Journals Library website for further project information.

Quality of Life after Surgery for Varicose Veins and the Impact of Preoperative Duplex: Results Based on a Randomized Trial

In a prospective randomized study, we found that the addition of a preoperative duplex scan before varicose vein (VV) surgery reduced recurrences and reoperations after 2 years. The aim of the present study was to investigate whether this correlates with an improved quality of life (QoL). We studied 293 patients scheduled for VV surgery with or without preoperative duplex. QoL was assessed preoperatively at 1 month, 1 year, and 2 years with the Short Form-36 (SF-36). Scores were compared with matched reference groups from the Swedish population. The 237 complete responders (81%) had a mean age of 47 (range 22-73) years, 169 (71%) were women, and 43 (18%) had skin changes. Both groups of VV patients scored significantly worse than the reference group in the domain Bodily Pain preoperatively (p < 0.001) and better after 1 year (p = 0.04), with no difference found after 2 years. There was no significant difference in QoL between the duplex and control groups at any time. We conclude that preoperative duplex before VV surgery did not significantly improve QoL after 2 years in spite of improved surgical results. VV surgery per se improved QoL as measured with the SF-36.