Chronic Venous Disease of the Lower Extremities: A State-of-the Art Review

Chronic venous disease is a common disease, the prevalence of which increases with age, and can cause debilitating symptoms that adversely affect the quality of life. The risk factors include family history, female sex, obesity, pregnancy, parity, and history of deep vein thrombosis. Moreover, it is associated with venous obstruction, reflux, or both, which, in turn, leads to ambulatory venous hypertension. Chronic venous disease is the leading cause of leg ulcers, which place a significant cost burden on the health care system. Compression therapy remains the cornerstone of treatment, particularly for more advanced disease. Superficial saphenous vein reflux can be associated with significant symptoms. Catheter techniques, both thermal and nonthermal, have demonstrated efficacy and safety in successful closure and symptom improvement. Deep vein obstruction can be broadly divided into thrombotic and nonthrombotic and can lead to symptomatic chronic venous disease. Recanalization using balloons and stents has been increasingly used and studied in such patients. It is critical to develop training opportunities and guidelines to improve evidence-based and appropriate care for cardiologists treating chronic venous disease.

Ultrasound-guided cyanoacrylate injection for the treatment of incompetent perforator veins

Objective

The use of cyanoacrylate products (CA) in incompetent perforator vein (IPV) treatment has not been thoroughly examined. The primary objective of this study is to describe the technique of ultra sound guided direct injection of IPV with CA, and secondarily to determine early closure rates and safety of this technique.

Methods

A retrospective analysis of patients undergoing IPV injection at two centres between 2015-2018 was conducted. Demographics, CEAP classification and IPV location were collected. Outcomes were assessed at two follow-up appointments.

Results

A total of 83 perforator vein injections were completed. CEAP classifications include C2 – C6 classes. Location of perforators were posteromedial (6%), femoral canal (9%), paratibial (14%), and posterior-tibial (71%). IPV closure rates were 96.3% at initial follow-up (16 ± 2 days). Closure rates decreased to 86.5% at second follow-up (72 ± 9 days). There were no deep vein thromboses during follow-up. One patient developed septic thrombophlebitis that was successfully managed with antibiotics.

Conclusion

Ultrasound-guided CA glue injection is a simple and low risk procedure that effectively closes incompetent perforator veins.

One-year outcomes of radiofrequency ablation of incompetent perforator veins using the radiofrequency stylet device: Cohort study from East Asia

OBJECTIVES

The present study was designed to assess outcomes of patients undergone radiofrequency ablation (RFA) for their incompetent perforator veins (IPVs) with ClosureFast stylets.

METHODS

Data of 165 IPVs in 138 limbs of 117 consecutive patients between July 2017 to Nov. 2019 were retrospectively reviewed. Primary endpoints (technical success rate, complications) and secondary endpoints (VCSS) were analyzed.

RESULTS

The immediate technical success rate was 100%. There were no major complications. The rate of ecchymosis and induration was 5.8%. 129/165 IPVs in 79.5% (93/117) patients had achieved sonographic evaluation at 1 year followed-up, in which 3 perforators were recanalized. VCSS scores at pre-operation and 1-year follow-up were 5.77 ± 1.88 and 2.70 ± 1.39, respectively (t= 29.644, P= .000).

CONCLUSIONS

In conclusion, RFA is safe and effective for the treatment of IPVs. At the 1-year follow-up, the RFA of IPVs showed a low recanalization rate and had a satisfactory improvement on VCSS.

Endothermal ablation for the treatment of clinically significant incompetent lower limb perforating veins: factors influencing the early outcomes

BACKGROUND

To review the clinical experience and early outcomes of endothermal perforator ablation.

METHOD

Retrospective review of an endovenous practice from 2007-2019. Clinically significant incompetent perforators were treated by Endovenous Laser Ablation (EVLA), or segmental radiofrequency ablation (RFA).

RESULT

Complete data were available for 110 of the 116 symptomatic incompetent perforating veins treated. Radiofrequency ablation of 20 perforators produced a 55% perforator closure rate, while 90 EVLA perforator ablations resulted in a closure rate of 80%. Closure rates with EVLA varied by location and perforator length. Closure rates for truncal ablation were 95.5% for RFA and 97.2% for EVLA.

CONCLUSION

Early closure rates following endothermal ablation of incompetent lower limb perforating veins are lower than those obtained for truncal ablation. EVLA perforator closure appears to be more effective than segmental RFA in most situations but short treatment lengths and location at the ankle are associated with the poorest outcomes.

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.

Endovascular reflux-elimination of perforating veins by RFITT and foam sclerotherapy

Introduction: During the last years, many endovascular techniques have been developed in order to eliminate not only the reflux in stem veins but in perforating veins and their tributaries, too.

Aim: The aim of this study was to use endo -vascular RFITT and the foam sclerotherapy for the occlusion of perforating veins as the prime source of reflux and their tributaries.

Material and Methods: The Celon method was used for the thermal treatment. Polydocalon with the concentration 1% and 2% with DSS technique was used for the foam sclerotherapy. The RFITT was accomplished in 127 perforating veins in total. This group was divided into three subgroups. The first one consists of patients where only RFITT was carried out (n= 41), in the second, there were patients with RFITT realized with sclerotherapy during one session (n= 48), in the third, RFITT was completed with sclerotherapy in one month after the RFITT intervention (n= 38). The control group included perforating veins treated only with sclerotherapy (n= 81). The power setting 6W was used on the generator during the RFITT with CelonProSurge micro and 18W for usage of Celon ProCurve probe.

Results: The effectiveness of the procedure in the group 1 was 8.8%, in the group two 93.7%, in the group three 92.1% and in the control group 76.5% in one year follow up. There was no significant difference between the effectiveness in groups 1, 2 and 3. The marginal difference was among all three groups with RFITT and the control group. Significant differences were in the parameter of the extinction of visible varicose veins with the reflux from perforators. The extinction was faster in group 3 than in group 2 and in the control group and the slowest was in group 1. The significant difference was observed between groups 2 and 3 compared with group 1 and the margin difference was between groups 2 and 3 compared with the control group. No significant difference was observed between groups 1 and the control group.

Conclusions: All procedures are effective. The most important is the combination of RFITT and the sclerotherapy one month after thermal intervention. This is associated with a low risk of recanalization and the fastest extinction of visible varicose veins.

One-year results of the use of endovenous radiofrequency ablation utilising an optimised radiofrequency-induced thermotherapy protocol for the treatment of truncal superficial venous reflux

Background

In previous in vitro and ex vivo studies, we have shown increased thermal spread can be achieved with radiofrequency-induced thermotherapy when using a low power and slower, discontinuous pullback. We aimed to determine the clinical success rate of radiofrequency-induced thermotherapy using this optimised protocol for the treatment of superficial venous reflux in truncal veins.

Methods

Sixty-three patients were treated with radiofrequency-induced thermotherapy using the optimised protocol and were followed up after one year (mean 16.3 months). Thirty-five patients returned for audit, giving a response rate of 56%. Duplex ultrasonography was employed to check for truncal reflux and compared to initial scans.

Results

In the 35 patients studied, there were 48 legs, with 64 truncal veins treated by radiofrequency-induced thermotherapy (34 great saphenous, 15 small saphenous and 15 anterior accessory saphenous veins). One year post-treatment, complete closure of all previously refluxing truncal veins was demonstrated on ultrasound, giving a success rate of 100%.

Conclusions

Using a previously reported optimised, low power/slow pullback radiofrequency-induced thermotherapy protocol, we have shown it is possible to achieve a 100% ablation at one year. This compares favourably with results reported at one year post-procedure using the high power/fast pullback protocols that are currently recommended for this device.

Treatment of incompetent perforators in recurrent venous insufficiency with adhesive embolization and sclerotherapy

Recurrent lower limb venous insufficiency is often a challenge in clinical practice and is most commonly due to incompetent perforators. Many of these patients do not have adequate symptom relief with compression and require some form of treatment for incompetent perforator interruption. Various treatment methods have been tried with different efficiencies.

Objective

To evaluate the feasibility, efficiency and safety of an outpatient combined cyanoacrylate adhesion–sodium tetradecyl sulphate sclerotherapy for treatment of patients with symptoms of persistent or recurrent lower limb venous insufficiency secondary to incompetent perforators.

Methods

Eighty-three limbs of 69 patients with symptoms of persistent or recurrent lower limb venous insufficiency secondary to incompetent perforators were treated with cyanoacrylate embolization of incompetent perforators and sclerotherapy of dilated collateral veins (surface branch varicose veins). Technical success, procedural pain, perforator occlusion, venous occlusion, clinical improvement and ulcer healing were assessed. Follow-up was done three- and six-month post-procedure.

Results

Procedure could be successfully performed in all patients. One hundred and ninety-one perforators were treated in total. Perforator and varicose veins occlusion rate was 100%. Deep venous extension of cyanoacrylate occurred in four (4.8%) patients, with no adverse clinical outcome. Venous clinical severity score improved from a baseline of 8.18 ± 3.60 to 4.30 ± 2.48 on three-month follow-up and 2.42 ± 1.52 on six-month follow-up (p < 0.0001). All ulcers showed complete healing within three months. Significant prolonged thrombophlebitis occurred in 38.5% of limbs.

Conclusion

Combined cyanoacrylate adhesion and setrol sclerotherapy is technically easy, has a lot of advantages including being an outpatient procedure and highly efficacious but with a guarded safety profile.

Current state of the treatment of perforating veins

Perforating veins may play a role in the development of chronic venous insufficiency and ulceration. There is renewed interest in minimally invasive treatments vs historic surgical options. Current indications for treatment, technical success, and evidence for clinical efficacy are summarized. Existing recommendations include perforator closure in Clinical, Etiology, Anatomy, and Pathophysiology class 5 or class 6 disease through percutaneous thermal ablation, subfascial endoscopic perforator surgery, open surgery, or sclerotherapy. Closure rates for percutaneous thermal ablation are reported as 60% to 80% initially. More recanalization and de novo perforator formation have been reported than after thermal saphenous closure. Ultrasound-guided foam sclerotherapy has shown promise in perforator closure and wound healing, but with variable success rates. Regardless of method used, successful closure of perforators appears predictive of wound healing with minimal morbidity. However, the power and design of all studies supporting this are far from robust, and more work is needed.

Debate: whether venous perforator surgery reduces recurrences

Superficial venous surgery and perforator vein surgery, specifically, have a long and varied history in the evolution of vascular surgery, especially because venous disease continues to be extremely common. As with other areas of our specialty, perforator vein procedures have progressed from being purely open operations to becoming less invasive procedures. Despite this, there remains much discussion (as well as overt disagreement) about whether perforator vein surgery is actually appropriate and beneficial in the first place. Surgeons have no level I evidence from randomized controlled studies to determine whether perforator vein surgery does or does not reduce the chances of recurrence of superficial venous varicosities, so we must rely on the evidence as it currently is. Perhaps not surprisingly, our two experts have assembled divergent opinions on the role of perforator venous surgery in contemporary practice.

Guidelines of the First International Consensus Conference on Endovenous Thermal Ablation for Varicose Vein Disease--ETAV Consensus Meeting 2012

AIM

Endovenous thermal ablation (ETA) procedures are catheter-directed, ultrasound (US)-guided thermal methods for treatment in varicose veins disease. Radiofrequency, laser or steam energy thermally denatures vein wall collagen, leading first to vein wall inflammation, then fibrosis and finally to occlusion. The aim of this guideline is to give evidence-based recommendations for ETA procedures.

METHODS

These guidelines were drafted during a consensus meeting of a group of experts in the field of ETA in June 2012 (Hvar, Croatia) under the auspices of the International Union of Phlebology (IUP). These guidelines review the present state of knowledge as reflected in peer-reviewed published medical literature. The recommendations of these guidelines are graded according to the American College of Chest Physicians Task Force recommendations on Grading Strength of Recommendations and Quality of Evidence in Clinical Guidelines.

RESULTS

Recommendations on the use of ETA procedures were made based on the quality of evidence for efficacy, safety, tolerability, cosmetic outcome, patient satisfaction/preference and, where appropriate, on the experts' opinion. Health economics were not considered, since differences in national health systems and pricing make it difficult to form general conclusions that are relevant at an international level.