Standard varicose vein surgery

Endovenous Thermal Ablation for Treatment of Symptomatic Saphenous Veins-Does the Body Weight Matter?

OBJECTIVE

This study aimed to examine whether body weight may affect the effectiveness and safety of endovenous thermal ablation (ETA) for the treatment of symptomatic varicose veins.

METHODS

This retrospective single-center cohort study analyzed the outcomes and patient demographic data with a focus on the body weight of all patients who had ETA of symptomatic varicose veins between September 2017 and October 2020.

RESULTS

A total of 1178 treated truncal veins from 636 patients were analyzed. The mean ± standard deviation body mass index (BMI) was 25.5 ± 4.9. In 2.3% of cases, the patients were underweight (BMI < 18.5), 31.0% were overweight (BMI > 25), and 16.6% were obese (BMI > 30). Complete truncal occlusion was observed 1 year post intervention in 97.6-100% and patients were satisfied or very satisfied in 96.2-100% across BMI groups. Pain was low but significantly higher in the patients with obesity 6 weeks post intervention (visual analog scale 0.84 ± 1.49) and a higher infection rate was observed in the patients with obesity (n = 4/132; 3.0%). No significant association was observed between BMI and bleeding or thromboembolic events.

CONCLUSIONS

Patients with obesity experienced prolonged pain and more infections after ETA, but ETA for varicose vein treatment remains effective and safe, independent of the patient's BMI.

National trend of the treatment for chronic venous diseases in Korea between 2010 and 2020

Purpose

Limited data are available on the nationwide trend of treatments for chronic venous disease (CVD). The aim of the present study was to identify the nationwide trends of CVD treatments in Korea.

Methods

A serial, cross-sectional study was conducted with the use of time trends to analyze patients with CVD between 2010 and 2020. The trends in the number of patients and procedures were analyzed including sclerotherapy, open surgery, and endovenous thermal ablation (ETA). Health Insurance Review and Assessment Service data were used to analyze the trends. For the statistical analysis, MedCalc Statistical software was used. P < 0.05 was considered statistically significant.

Results

A total of 1,867,307 patients with CVD were managed in Korea between 2010 and 2020. The annual number of patients with CVD increased from 143,108 in 2010 to 219,319 in 2020 (risk ratio [RR], 1.53; P < 0.001). The percentage of patients with CVD who had venous ulcer gradually decreased from 3.1% in 2010 to 1.7% in 2020 (RR, 0.86; P < 0.001). The number of conventional surgeries including stripping and local resection of varicose veins decreased from 32,384 in 2010 to 21,792 in 2020 (RR, 0.67; P < 0.001). The number of ETAs performed increased, from 290 in 2011 to 12,126 procedures in 2020 (RR, 41.81; P < 0.001).

Conclusion

The total number of patients with CVD increased during the last 11 years. The number of conventional open surgery and sclerotherapy procedures decreased. On the contrary, the number of ETAs significantly increased in Korea.

Radiofrequency Ablation of Incompetent Short Saphenous Vein: a Case Series

Short saphenous vein (SSV) incompetence proved to be an obstacle in chronic venous insufficiency (CVI) treatment in the endovascular era. In our study, we used to prove that radiofrequency ablation could be done safely with low incidence of side effects. In this prospective case series study, 34 patients suffered from leg varicosity (either primary or recurrent) attended to outpatient clinic and were referred for duplex scan to ensure SSV incompetency. SSV ablation was done using radiofrequency catheter. Operative findings were recorded, and patients were followed for up to 12 months post-surgical procedure to look for complications or recurrences. Successful obliteration of short saphenous vein was done in 52 legs with mean diameter 4.9 SD 1.0 mm and operative time 37.5 SD 13.7 min, the incidence of sural nerve paresthesia was 9%, and no reported cases with DVT. On 12-month follow-up, VCSS reduced significantly from 13 (IQR 12) to 3 (IQR 6) and AVVQ reduced significantly from 27.1 (IQR 18.8) to 5.6 (IQR 7.2); the rate of short saphenous vein obliteration was 98.1% at 6 months and 94.2% at 12 months. Radiofrequency ablation can be recommended for patients with incompetent SSV.

Outcomes of fluoroscopy-guided percutaneous high ligation of the great saphenous vein combined with foam sclerotherapy for symptomatic great saphenous veins

PURPOSE

To evaluate the effectiveness and safety of fluoroscopy-guided percutaneous high ligation (FPHL) combined with fluoroscopy-guided foam sclerotherapy (FGFS) to treat varicose veins of the greater saphenous veins (GSV).

MATERIALS AND METHODS

This was a retrospective study of 113 patients (mean age, 62.1 ± 10.8 years; 60 men) with varicose veins of the GSV (133 limbs) which were treated with FPHL combined with FGFS between April 1, 2019 and October 31, 2019. Demographic and clinical data were collected from these patients before the FPHL procedure, after which FGFS was performed. The preterminal GSV was percutaneously ligated by a percutaneously positioned polypropylene ligature under fluoroscopic guidance. The outcome of ligation was confirmed by venography. Then, foam sclerotherapy was performed under fluoroscopy. At 1-year follow-up, GSV occlusion was evaluated by ultrasound. The venous clinical severity scores (VCSSs) were compared between the preoperative and 1-year follow-up periods.

RESULTS

The technical success rate was 100% (133 limbs). Complete 12-month follow-up was available for 112 limbs (84.2%), and 103 of these limbs (92.0%) remained occluded during this period. The VCSS improved from 4.71 ± 2.15 to 0.74 ± 0.60 (V = 6328, P < .001). During follow-up, there were 16 limbs with thrombophlebitis and 38 limbs with saphenous junction pain; these events were alleviated within 2 weeks of the procedure. There was no deep venous thrombosis or other severe adverse events.

CONCLUSIONS

FPHL combined with FGFS to treat varicose veins in the GSV achieved an occlusion rate of 92% and improved the clinical symptoms within one year; this minimally invasive procedure was safe and effective.

Treatment of chronic venous disorder: A comprehensive review

Chronic venous disorder (CVD) is highly prevalent vascular disorder affecting up to 45% of the general population, with clinical manifestations ranging from teleangiectasias to venous leg ulcers (VLUs). We examined the currently available data in order to provide an updated, comprehensive review on treatment options of CVD. We searched MEDLINE, Cochrane, Scopus, EMBASE, ClinicalTrials, and OpenGrey databases for relevant articles in English published until November 2020. Compression treatment is the mainstay of conservative treatment. Pharmacological treatment can provide significant symptomatic relief and hence it should be considered as part of conservative treatment. Transcutaneous Lacer treatment (TCL) is a safe and effective alternative option to sclerotherapy for treatment of C1 stage. High ligation and stripping (HL/S), ultrasound-guided foam sclerotherapy (UGFS), endovenous thermal ablation (EVTA) systems and non thermal non tumescent ablation (NTNT) systems are safe and efficacious first-line options for treatment of saphenous insufficiency. Interventional treatment of co-existing incompetent perforator veins (IPVs) is not supported by contemporary evidence. Regarding deep venous insufficiency (DVI), treatment of symptomatic femoroiliocaval occlusive venous disease refractory to conservative treatment with percutaneous transluminal venoplasty stenting has produced encouraging results.

Cyanoacrylate Closure of Small Saphenous Vein Insufficiency

BACKGROUND

As minimally invasive techniques were issued, endovenous thermal ablations have emerged. However, the thermal-associated complication has been reported in the treatment of small saphenous vein (SSV) insufficiency, such as sural nerve injury. Recently introduced cyanoacrylate closure (CAC) is a nonthermal modality, so this thermal-associated complication can be avoided.

OBJECTIVE

This retrospective study analyzed the feasibility, safety, and 2-year results of CAC for treating SSV insufficiency, particularly the incidence of sural nerve injury.

MATERIALS AND METHODS

One hundred sixty-three SSV insufficiencies in 128 patients were treated with CAC were reviewed. Pain, venous severity, and quality of life (QoL) scores were evaluated. Postoperative duplex scanning also evaluated anatomical and clinical success rates.

RESULTS

The mean patient age was 56.8 years. The initial technical success rate was 100%. The occlusion rate after 2 years was 96.3%. Pain, venous severity, and QoL scores were improved significantly from 2.4 to 0.0, 4.39 to 0.47, and 11.95 to 2.69, respectively, before and 2 years after CAC. No major complications were observed, such as sural nerve injury.

CONCLUSION

Cyanoacrylate closure for the ablation of SSV insufficiency could be a great alternative to endothermal ablation with an excellent success rate and shorter procedure time.

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.

What is the optimal treatment technique for great saphenous vein diameter of ≥10 mm? Comparison of five different approaches

OBJECTIVE

We aimed to investigate the efficacy and safety of five different treatment approaches in patients with a great saphenous vein (GSV) diameter of ≥10 mm.

METHODS

A total of 697 extremities of 671 patients who were diagnosed with a GSV diameter of ≥10 mm underwent conventional surgery or endovenous therapy for symptomatic varicose veins between January 2012 and January 2017 were included in this retrospective study. All extremities included in the study were divided into five groups as follows: high ligation + stripping (HLS), radiofrequency ablation (RFA), cyanoacrylate closure (CAC), endovenous laser ablation (EVLA) procedures at 980 nm and 1,470 nm wavelengths.

RESULTS

Among all groups, despite lower recurrence rates in HLS group than the other groups, there was no significant difference at 6 months and 1 year among the HLS, EVLA at 1,470 nm wavelength, and RFA groups. The recurrence rates of EVLA at 980 nm wavelength and CAC groups were found higher than other groups.

CONCLUSIONS

In conclusion, our study results show that although HLS seems to be an effective method for the treatment of a GSV diameter of ≥10 mm with a low recurrence rate, it does not statistically significantly differ from EVLA at 1,470 nm wavelength and RFA. Therefore, we believe that EVLA at 1,470 nm wavelength and RFA can be preferred over HLS with low pain scores in this patient population.

Endovenous radiofrequency for chronic superficial venous insufficiency: Clinical outcomes and impact in quality of life

BACKGROUND

Endovenous treatment of lower limb varicose veins is progressively replacing conventional surgery. The authors are investigating radiofrequency (RFA) results in terms of vein occlusion, complications, patient's satisfaction and quality of life in a single centre.

METHODS AND MATERIALS

A retrospective analysis of medical charts with a prospective follow-up was performed on data about patients undergoing RFA for insufficiency of great saphenous vein (GSV).

RESULTS

A total number of 135 patients (164 limbs) (63% n 85 female; 37% n 50 male; mean age of 53.9 years, range 24-85 years; mean VCSS score (Venous Clinical Severity Score) 6, range 4-22) were included. Complete obliteration of GSV was obtained in 98.2% of the cases. No device- or procedure-related adverse events occurred. No deep venous thromboses, pulmonary embolism, phlebitis, major bleeding, paraesthesia nor skin burn were detected. Patients returned to normal activities in a mean of 8 days (range 5-10). One-month postoperatively, the mean quality of life scores 6 (range 5-9) and mean satisfaction score was 6 (range 4-8) in a scale from 0 to 8. At a median follow-up of 11 months (range 2-18), mean VCSS was 3.9 (range 2-8).

CONCLUSIONS

Radiofrequency guarantees good functional outcomes and low rate of complications. It is associated with high satisfaction rate and quality of life score.

Early results of mechanochemical ablation for small saphenous vein incompetency using 2% polidocanol

OBJECTIVE

The aim of the present study was to investigate the early results of mechanochemical ablation (MOCA) for the treatment of small saphenous vein (SSV) incompetence.

METHODS

We performed a single-center, retrospective analysis of a prospectively collected database of 60 patients treated with MOCA for single-axis SSV incompetence. All procedures were performed with the patient under local anesthesia using the ClariVein catheter (Merit Medical, South Jordan, Utah) combined with 2% polidocanol and, where appropriate, additional microphlebectomy. The primary study endpoint was to assess the SSV occlusion rate at the 1-, 6-, and 12-month follow-up examinations. The secondary endpoints included the Venous Clinical Severity Score, quality of life (QoL) assessment, periprocedural pain, and further complications after the intervention and during the follow-up period. Patient QoL was assessed using the Aberdeen Varicose Vein Questionnaire. Pain was measured using a 100-mm visual analog scale.

RESULTS

Technical success was achieved in 100% of the cases. The mean visual analog scale score on the first postoperative day was 15 mm. No major events were recorded. No neurological complications or deep vein thrombosis were observed. Minor complications included ecchymosis in 3.3% of cases (2 of 60), transient phlebitis of the SSV in 5% of cases (3 of 60), and itching in 3.3% of cases (2 of 60). At the 1-, 6-, and 12-month follow-up examinations, the occlusion rate was 100% (60 of 60), 98.3% (57 of 58), and 92.6% (50 of 54). The median Venous Clinical Severity Score had significantly decreased from 5 (interquartile range [IQR], 3-6) at baseline to 2 (IQR, 1-4) at the 1-month follow-up (P < .001), 1 (IQR, 1-2) at the 6-month follow-up (P < .001) and 1 (IQR, 0-1) at the 12-month follow-up (P < .001). The mean Aberdeen Varicose Vein Questionnaire score had improved from the baseline score of 25 ± 14.61 to 15.81 ± 13.76 at the 1-month follow-up (P < .001), to 9.81 ± 7.42 at the 6-month follow-up (P < .001) and 4.73 ± 3.32 at the 12-month follow-up (P < .001).

CONCLUSIONS

The results of our study have shown that MOCA is a feasible, safe, and painless procedure for the treatment of SSV incompetence with an occlusion rate of 92.6% at the 12-month examination. No sural nerve injuries or other major complications were observed. The procedure also provided good clinical results and positive effects on patient QoL.

The classic saphenofemoral junction and its anatomical variations

Background The intraoperative anatomy of the saphenofemoral junction can vary from the 'textbook' description of six independent proximal tributaries: three medial - superficial external pudendal, deep external pudendal and the posteromedial thigh branch - and three lateral - superficial epigastric, superficial circumflex iliac and the anterolateral thigh branch. Varicose veins can recur following inadequate initial open surgery with failure to identify, ligate and divide these tributaries. An appreciation of common anatomical variations could minimise recurrence rates following surgery. This study aimed to identify common anatomical variations within our patient cohort. Methods This prospective observational study documented diagrammatically the anatomy of saphenofemoral junction in a consecutive series of 172 patients undergoing unilateral, primary saphenofemoral junction ligation for symptomatic superficial venous insufficiency. Diagrams recorded the number of tributaries and their relationship to the saphenofemoral junction, the existence of bifid systems and the relationship of the external pudendal artery to the saphenofemoral junction. Results In sum, 110 women and 62 men with a mean age of 47.2 (IQR 21-77) years were studied. The median number of saphenofemoral junction tributaries was 4 (IQR 0-7). In 74 cases (43.0%), at least one tributary drained directly into the common femoral vein (IQR 0-4), commonly the deep external pudendal (91.9%). The anterolateral thigh branch was identified in 62 cases (35.8%) and the posteromedial thigh branch in 93 cases (53.8%). The external pudendal artery was identified in 150 cases (87.2%) and was superficial to the great saphenous vein in 36 cases (20.9%). Conclusions Significant variations exist in the saphenofemoral junction anatomy. Familiarity with anatomical saphenofemoral junction variations is imperative to ensure operative success and reduce recurrence. Thorough dissection of the common femoral vein is necessary not only to ensure all proximal tributaries are identified and ligated but also as a safety mechanism in preventing avulsion trauma of direct common femoral vein tributaries.

Randomized trial of radiofrequency ablation versus conventional surgery for superficial venous insufficiency: if you don't tell, they won't know

OBJECTIVES:

This study compared radiofrequency ablation versus conventional surgery in patients who had not undergone previous treatment for bilateral great saphenous vein insufficiency, with each patient serving as his own control.

METHOD:

This was a randomized controlled trial that included 18 patients and was carried out between November 2013 and May 2015. Each of the lower limbs of each patient was randomly assigned to undergo either radiofrequency ablation or conventional surgery. Clinical features (hyperpigmentation, hematoma, aesthetics, pain, skin burn, nerve injury, and thrombophlebitis) were evaluated at one week, one month, and six months postoperatively. Hemodynamic assessments (presence of resection or occlusion of the great saphenous vein and recurrent reflux in the sapheno-femoral junction and in the great saphenous vein) were performed at one month, six months, and 12 months postoperatively. The independent observer (a physician not involved in the original operation), patient, and duplex ultrasonographer were not made aware of the treatment done in each case. Clinicaltrials.gov: NCT02588911.

RESULTS:

Among the clinical variables analyzed, only the aesthetic evaluation by the physicians was significant, with radiofrequency ablation being considered better than conventional surgery (average, 0.91 points higher: standard deviation: 0.31; 95% confidence interval: -1.51, -0.30; p=0.003). However, in our study, we observed primary success rates of 80% for radiofrequency ablation and 100% for conventional surgery.

CONCLUSIONS:

If the physician is not required to inform the patient as to the technique being performed, the patient will not be able to identify the technique based on the signs and symptoms. Our study revealed that both techniques led to high levels of patient satisfaction, but our results favor the choice of conventional surgery over radiofrequency ablation, as patients who underwent conventional surgery had better hemodynamic assessments.

Ultrasound-guided foam sclerotherapy of great saphenous vein with 2% polidocanol - one-year follow-up results

Introduction

Ultrasound-guided foam sclerotherapy (UGFS) of varicose veins is a useful treatment option. It is a relatively safe method in the case of limited, small varicose veins. In theory, a justified concern could be raised that the injection of an active drug into the large superficial venous vessels may potentially cause life-threatening consequences.

Aim

To assess the safety and efficacy of UGFS using a 2% solution of polidocanol (Aethoxysklerol 2%) in the case of great saphenous vein incompetence.

Material and methods

Fifty-two patients with great saphenous vein incompetence underwent ultrasound-guided foam sclerotherapy. The efficacy criterion was the elimination of reflux measured ultrasonographically and withdrawal or decrease of complaints: 1 week, and 1, 3, 6 and 12 months after the treatment. Complications of sclerotherapy were reported during follow-up.

Results

Decrease or withdrawal of complaints of chronic venous insufficiency was reported in 96% of cases (50 patients). Disappearance or decrease of varicose veins was noted in all patients (100%). During examination after 12 months, full success of ultrasound was achieved in 38 (73%) cases, and 11 (21%) patients presented a partial desired effect according to the consensus from Tegernsee. Persistence of reflux longer than 1 s in the treated great saphenous vein was reported in 3 (6%) cases. Serious complications, such as deep vein thrombosis, pulmonary embolism, dyspnea, anaphylaxis, or neurological abnormalities, were not recorded.

Conclusions

Ultrasound-guided foam sclerotherapy of incompetent great saphenous vein and varicosities with 2% polidocanol was found to be an effective and safe method of treatment during 1 year of observation. However, longer observation is necessary.

The Incidence, Clinical Importance and Management of Incompetent Gastrocnemius Vein

PURPOSE

To report the incidence, clinical importance and management of the incompetent gastrocnemius vein.

METHODS

The incompetency was examined by duplex and pulse-Doppler ultrasound at the popliteal fossa in a standing position between July 2006 and August 2014.

RESULTS

Among 1805 legs surveyed, 14 legs showed primary incompetent gastrocnemius vein (0.78%). The incompetency was in medial gastrocnemius vein in 13 legs (93%). Clinical manifestation was varicose vein in the small saphenous territory in nine, varicose vein in great saphenous territory in one, congestive dermatitis in two, calf clamp in one and no symptom in one. The nine cases with varicose vein in the small saphenous territory received surgical management. These included three cases with residual varicose veins after saphenopopliteal disconnection and stripping small saphenous vein. The root of the gastrocnemius vein was divided leaving no complication. In cases without varicose vein in small saphenous territory, an elastic compression socks was useful in some degree.

CONCLUSIONS

Incompetency of gastrocnemius vein was not so rare. When a case is accompanied by small saphenous varicose veins, division of the root of gastrocnemius vein along with small saphenous vein stripping is recommended in order to reduce residual varicose vein.

Assessment of the efficacy and safety of steam vein sclerosis as compared to classic surgery in lower extremity varicose vein management

Introduction

For the last 10 years, endovenous thermal ablation methods have gradually predominated over the classic Babcock procedure in varicose vein treatment. Steam vein sclerosis is the newest thermal ablation technique.

Aim

To assess the efficacy and safety of steam vein sclerosis as compared to the Babcock procedure in lower extremity varicose vein treatment.

Material and methods

One hundred and two adult subjects with varicose veins of clinical grade C2 to C6 according to the CEAP classification, treated with varicose vein surgery between 2010 and 2012, were enrolled in the study. These were subdivided into two groups: the study group of 52 patients treated with endovenous steam vein sclerosis and the control group of 50 patients treated with the Babcock procedure. A single lower extremity with isolated great or small saphenous vein insufficiency was operated on in each subject. The groups were compared for demography, disease severity, involved veins, potential perioperative and postoperative complications, as well as treatment efficacy based on the VCSS score reduction.

Results

There were no statistically significant differences between the groups in terms of demography, disease severity, involved veins, or perioperative and postoperative complications. The treatment efficacy of both methods, assessed based on the recurrence rate and the quantitative VCSS score reduction, was similar. Clinically significant recanalisation was observed in 1 (1.9%) patient in the study group.

Conclusions

The efficacy and safety analysis shows that steam vein sclerosis is a safe, simple method which can be recommended as effective varicose vein treatment.

Mechanochemical endovenous Ablation versus RADiOfrequeNcy Ablation in the treatment of primary great saphenous vein incompetence (MARADONA): study protocol for a randomized controlled trial

Background

Radiofrequency ablation (RFA) is associated with an excellent outcome in the treatment of great saphenous vein (GSV) incompetence. The use of thermal energy as a treatment source requires the instillation of tumescence anesthesia. Mechanochemical endovenous ablation (MOCA) combines mechanical endothelial damage, using a rotating wire, with the infusion of a liquid sclerosant. Tumescence anesthesia is not required. Preliminary experiences with MOCA showed good results and low post-procedural pain.

Methods/Design

The MARADONA (Mechanochemical endovenous Ablation versus RADiOfrequeNcy Ablation) trial is a multicenter randomized controlled trial in which 460 patients will be randomly allocated to MOCA or RFA. All patients with primary GSV incompetence who meet the eligibility criteria will be invited to participate in this trial. The primary endpoints are anatomic and clinical success at a one-year follow-up, and post-procedural pain. The secondary endpoints are technical success, complications, operation time, procedural pain, disease-specific quality of life, time taken to return to daily activities and/or work, and cost-efficiency analyses after RFA or MOCA. Both groups will be evaluated on an intention to treat base.

Discussion

The MARADONA trial is designed to show equal results in anatomic and clinical success after one year, comparing MOCA with RFA. In our hypothesis MOCA has an equal anatomic and clinical success compared with RFA, with less post-procedural pain.

Trial registration

Clinicaltrials NCT01936168

Radiofrequency Ablation as First-line Treatment of Varicose Veins

Endovascular radiofrequency ablation is a minimally invasive method to safely treat symptomatic refluxing varicose veins. A retrospective chart review was used to determine patient demographics, disease severity, treatment algorithm, and outcome in patients who underwent radiofrequency ablation of symptomatic refluxing veins that had failed conservative management. Statistical analysis was done using GraphPad Demo Version (San Diego, CA). Two hundred forty-one limbs in 179 patients (average age, 53 years; 73% females, 27% males) were treated. Preprocedure Clinical Etiological Anatomic and Pathologic (CEAP) scores were C2s: 236, C3s: 4, and C5s:1. Procedures were performed in the office using tumescent anesthetic; all patients could ambulate immediately after the procedure. Postprocedure total occlusion (TO) rate was seen in 93 per cent of limbs (223 limbs) at 3 months and 91 per cent of limbs (220 limbs) at 12 months posttreatment. No relationship was found between patients who did not have total occlusion and age, sex, diameter of veins, CEAP scores, preoperative reflux time, and volume of tumescent anesthetic ( P > 0.05). The VNUS procedure is an in-office, minimally invasive procedure with a low complication rate and quick recovery. Total occlusion rates are high and there is improvement in disease severity after treatment.

Superficial venous insufficiency from the infernal to the endothermal

This review presents the common diseases associated with superficial venous insufficiency of the leg. These include varicose veins, swelling, skin damage and ulceration. The benefits and rationale behind treatment are discussed, followed by the historical advances from ancient mortality and prayer to the modern endovenous revolution. Finally, an overview of modern treatment options will discuss the evidence supporting the gold standard of endothermal ablation and the cost effectiveness of treatment at this time of challenging resource limitation.

Endovenous laser ablation versus conventional surgery in the treatment of small saphenous vein incompetence

INTRODUCTION

In this multicenter, randomized controlled trial, endovenous laser ablation (EVLA) is compared with conventional surgery for the treatment of varicose veins based on incompetence of the small saphenous vein and the saphenopopliteal junction (SPJ).

METHODS

In two Dutch hospitals, 189 patients were enrolled and randomized to receive EVLA (810-nm laser) or ligation of the SPJ. End points were success rate measured with duplex ultrasound (6 weeks post-treatment), perioperative pain, quality of life, duration of surgery, difficulty of surgery, complications, cosmetic results, and number of days to resume work and normal activities. Pain was measured on a visual analog scale (VAS). Quality of life was assessed using the Aberdeen Varicose Vein Questionnaire (AVVQ) and Euro Qol-5D. The follow-up duration in this article is 6 weeks.

RESULTS

One hundred seventy-five patients have been treated and analyzed. One hundred eighteen patients (67%) underwent EVLA, and 57 patients (33%) underwent ligation of the SPJ. The patient characteristics were similar in both groups. In the surgery group, 21% residual incompetence of the SPJ was seen after 6 weeks, compared with 0.9% in the laser group. Both treatment modalities reduced pain after 6 weeks. One week post-treatment, patients in the EVLA group temporarily experienced more pain compared with the surgery group (31 vs 18 on a VAS from 0 to 100). There were no significant differences between the two groups with respect to quality of life. Both treatments did show improvement in quality of life. Also with regard to the cosmetics, there were no differences, aside from the fact that patients rated their scar as more beautiful after EVLA. After EVLA, patients could return to work more quickly. The operation time was longer in the surgery group. After 2 weeks, there were significantly more neurological complications in the surgery group: 18 (31%) vs 16 (17%) patients in the EVLA group. Ten percent of patients in the surgery group developed a surgical site infection vs 0% in the EVLA group.

CONCLUSIONS

EVLA provides an excellent alternative to conventional surgery in the treatment of symptomatic varicose veins due to an incompetent small saphenous vein with SPJ. EVLA has a superior immediate success rate, is easier and faster, and has fewer complications.

Causes of recurrent lower limb varicose veins after surgical interventions in 141 limbs – Five-year retrospective analysis of two centers

Aim

The purpose of this study was to explore the causes of recurrent lower limb varicose veins after surgical interventions.

Methods

A retrospective five-year survey was conducted on patients who underwent second surgery due to recurrent lower limb varicose veins after surgical interventions. A total of 141 limbs (112 cases), including 72 cases of left lower limbs, 47 of right lower limbs and 22 of both limbs, were involved in the study. All patients underwent lower limb venography (141 limbs were anterograde and 28 cases were retrograde), and then examined with color-Doppler ultrasound.

Results

The major causes that urged patients to undergo second surgery are clinical changes graded above CEAP IV (93.6%), limb edema without changes on skin (5%), and single varicosity (1.4%). Up to 127 (83%) limbs exhibited perforating venous reflux, 67 (47.5%) limbs had varied degrees of deep venous insufficiency and 68 (48.2%) limbs had through or above-the-knee great saphenous vein trunk residual.

Conclusions

Preoperative venography before operation is indispensible in confirming the diagnosis and operation strategies. Patients with severe primary deep venous reflux and symptoms up to C3 may need simultaneous repair of the deep venous valves.

A rare case of acute compartment syndrome after saphenectomy

Saphenectomy is one of the most validated criteria to treat varicose veins of the lower legs. Although many complications were well described, little is known about compartment syndrome due to muscle ischemia caused by constrictive bandages applied after stripping of varicose veins. We presented a case of successful conservative treatment of compartment syndrome after saphenectomy. Rehabilitation was found effective in improving fatigue, stiffness and tenderness showing the effectiveness of the combined conservative-rehabilitative treatment. However conservative treatment could not be considered the treatment of choice in daily practice. A severity score assessment of compartment syndrome should be useful to assess to which patients is allowed to not perform fasciotomy.

Successful reduction of clinical relevant neovascularization with a modified crossectomy combined with a barrier technique after 10-year follow-up

OBJECTIVE

The aim of this retrospective study was to assess the long-term results of stripping the insufficient great saphenous vein (GSV) with stump coagulation, closure of the cribriform fascia and some additional measures, which will be described in detail.

METHODS

Patients treated from 1998 to 1999 for varicose veins had been invited in 2009 for follow-up colour-coded duplex sonography and had been asked to answer a quality-of-life questionnaire. In 2009, the examinations for the study were conducted at a clinic of angiology by an independent and experienced sonographer.

RESULTS

From a total of 165 patients, 91 (136 limbs) had been willing to participate in the study. Duplex ultrasound after a mean follow-up of 10.7 years revealed only clinically non-relevant (∅ < 0.3 cm) neovascularizations in 1.5% of all treated legs. No clinical relevant varicosities from the groin had developed.

CONCLUSION

The crossectomy combined with stump coagulation and suture of the fossa ovalis, completed with some additional measures, is a successful method to reduce neovascularization and recurrent varicosities, even for redo-crossectomies, without increasing the risk of perioperative complications.

Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose veins

BACKGROUND

This randomized trial compared four treatments for varicose great saphenous veins (GSVs).

METHODS

Five hundred consecutive patients (580 legs) with GSV reflux were randomized to endovenous laser ablation (980 and 1470 nm, bare fibre), radiofrequency ablation, ultrasound-guided foam sclerotherapy or surgical stripping using tumescent local anaesthesia with light sedation. Miniphlebectomies were also performed. The patients were examined with duplex imaging before surgery, and after 3 days, 1 month and 1 year.

RESULTS

At 1 year, seven (5.8 per cent), six (4.8 per cent), 20 (16.3 per cent) and four (4.8 per cent) of the GSVs were patent and refluxing in the laser, radiofrequency, foam and stripping groups respectively (P < 0.001). One patient developed a pulmonary embolus after foam sclerotherapy and one a deep vein thrombosis after surgical stripping. No other major complications were recorded. The mean(s.d.) postintervention pain scores (scale 0-10) were 2.58(2.41), 1.21(1.72), 1.60(2.04) and 2.25(2.23) respectively (P < 0.001). The median (range) time to return to normal function was 2 (0-25), 1 (0-30), 1 (0-30) and 4 (0-30) days respectively (P < 0.001). The time off work, corrected for weekends, was 3.6 (0-46), 2.9 (0-14), 2.9 (0-33) and 4.3 (0-42) days respectively (P < 0.001). Disease-specific quality-of-life and Short Form 36 (SF-36(®)) scores had improved in all groups by 1-year follow-up. In the SF-36(®) domains bodily pain and physical functioning, the radiofrequency and foam groups performed better in the short term than the others.

CONCLUSION

All treatments were efficacious. The technical failure rate was highest after foam sclerotherapy, but both radiofrequency ablation and foam were associated with a faster recovery and less postoperative pain than endovenous laser ablation and stripping.

Deficiencies in venous experience in UK vascular trainees: a survey of Rouleaux Club members

Objective

The aim of this study was to evaluate the training experience of current UK vascular trainees in the modern management of venous disease.

Method

A web-based questionnaire of the 145 members of the Rouleaux Club (www.rouleauxclub.com), which represents UK vascular trainees. Members were asked to complete the survey between June and October 2009 with regular email reminders being sent out to non-responders.

Results

One hundred and twenty-three trainees (85% response rate) representing all 17 UK training Deaneries responded. Seventy-eight per cent reported having received no formal venous duplex training either for diagnosis of venous disease or to guide endovenous therapy. Operative experience of great and small saphenous vein surgery improved with years of training. Surgical experience for recurrent varicose veins was poor. Experience with endovenous techniques was limited and variable. No experience of endovenous laser ablation or radiofrequency ablation was reported by 39% and 67% of trainees, respectively. Experience and/or training with foam sclerotherapy was limited to <40%. Many of those reporting no experience with endovenous ablation techniques were within the final two years of their training. Less than 25% of trainees reported having had any experience (assisted/performed) of advanced venous interventions such as thrombolysis techniques for deep venous thrombosis, inferior vena cava filter placement/removal, venous stenting or deep venous reconstruction. Less than a quarter of trainees are currently involved in the acute management of deep venous thrombosis. The majority (76%) of current trainees would like a formal approved UK venous training course to be offered.

Conclusion

The current level of training in the management of venous disease will not allow UK vascular trainees to become the competent all round vascular specialists of the future.

Pharmacological treatment in patients with C4, C5 and C6 venous disease

Background

A range of surgical, endovenous, physical and medical treatments are available for patients with chronic venous disease. The aim of this review was to evaluate the evidence for pharmacological agents used for the treatment of chronic venous disease.

Methods

A literature search was performed using Pubmed, Embase, Cochrane and Google Scholar databases. The initial search terms ‘varicose vein’, ‘venous ulcer’, ‘venous disease’ and ‘lipodermatosclerosis’ were used to identify relevant clinical studies of pharmacotherapy in patients with chronic venous disease (C4–C6).

Results

A huge range of naturally occurring and synthetic drugs have been studied in patients with chronic venous disease. For patients with C4 venous disease, micronized purified flavonoid fraction (MPFF), oxerutin, rutosides and calcium dobesilate may reduce venous symptoms and oedema. MPFF and pentoxifylline have been shown to improve venous ulcer healing when used in addition to multilayer compression bandaging. The clinical benefits of other medications remain unproven. Reliability of meta-analyses was limited by study heterogeneity, small sample sizes and lack of long-term follow-up.

Conclusions

In prospective randomized studies, MPFF (Daflon®), other flavonoid derivatives and pentoxifylline have demonstrated clinical benefits in patients with C4–C6 venous disease. Pharmacotherapy should be part of a range of treatment options in the modern management of patients with chronic venous disorders.

Varicose vein surgery: stripping versus the CHIVA method: a randomized controlled trial

OBJECTIVE

The objective of this randomized study was to compare the efficacy of the CHIVA method for the treatment of varicose veins with respect to the standard treatment of stripping.

CONTEXT

Varicose veins are a sign of chronic venous disorder. For over a century, varicose veins have been treated with surgical ablative techniques, with stripping being the standard treatment. Currently, postsurgical varicose veins recurrence (20%-80%) is a common, complex, and costly problem. Ambulatory Conservative Hemodynamic Management of Varicose Veins (CHIVA) is a new option for treating chronic venous disorder.

METHODS

In this open-label, randomized controlled trial, 501 adult patients with primary varicose veins were treated in a single center. They were assigned to an experimental group, the CHIVA method (n = 167) and 2 control groups: stripping with clinic marking (n = 167) and stripping with duplex marking (n = 167). The outcome measure was clinical recurrence within 5 years, assessed clinically by previously trained independent observers. Duplex ultrasonography was also used to assess recurrences and causes.

RESULTS

In an intention-to-treat analysis, clinical outcomes in the CHIVA group were better (44.3% cure, 24.6% improvement, 31.1% failure) than in both the stripping with clinic marking (21.0% cure, 26.3% improvement, 52.7% failure) and stripping with duplex marking (29.3% cure, 22.8% improvement, 47.9% failure) groups. The ordinal odds ratio between the stripping with clinic marking and CHIVA groups, of recurrence at 5 years of follow-up, was 2.64, (95% confidence interval [CI]: 1.76-3.97, P < 0.001). The ordinal odds ratio of recurrence at 5-years of follow-up, between the stripping with duplex marking and CHIVA group, was 2.01 (95% CI: 1.34-3.00, P < 0.001). This trial is registered at ISRCTN and carries the following ID number: ISRCTN52861672, available at: http://isrctn.org.

CONCLUSIONS

The present results indicate that, thanks to specific venous hemodynamic evaluation, the CHIVA method is more effective than stripping with clinical marking or stripping with duplex marking to treat varicose veins. When carrying out a stripping intervention, Duplex marking does not improve the clinical results of this ablative technique.