Guidelines for the management of varicose veins

Treatment of varicose veins using the Cryo laser after foam technique

Sclerotherapy is the treatment of choice for telangiectasias and reticular veins. The most common side effects of this procedure are hyperpigmentation and matting, which are feared owing to their aesthetic damage and difficulty of treatment. Combined treatments with laser and hypertonic glucose sclerotherapy have been described with excellent results, but limited to treatment of veins of ≤2 mm in diameter. Cryo laser after foam sclerotherapy is a procedure to treat reticular veins in the lower extremities that utilizes first foam sclerotherapy with polidocanol than immediately followed by transdermal Nd:YAG 1064 laser treatment and we can treat veins ≤5 mm. This report presents a successful case of varicose vein treatment using combined transdermal laser and sclerotherapy with foam sclerotherapy with polidocanol to treat veins >2.5 mm in diameter.

Challenging conventions: Reconsidering the indication for endovenous ablation in CEAP 2 patients

INTRODUCTION

Endovenous ablation may not always be necessary for every patient with chronic venous insufficiency who has an indication for endovenous ablation. This study investigates whether compression stockings and Daflon® can be as effective for some patients with CEAP two in chronic venous insufficiency.

METHODS

In this study, 137 patients who had endovenous ablation indication received plethysmographical hemodynamic tests and were divided into two groups. Group 1 had normal venous hemodynamics and received compression stockings and Daflon®. Group 2 had abnormal function and received laser ablation. All patients were reevaluated after 6 months.

RESULTS

The study showed that there was no statistically significant difference between Groups 1 and 2 in the 6th month measurements after the treatments.

CONCLUSION

As a result, we do not find it appropriate and do not recommend that every patient with complaints of chronic venous insufficiency and an indication for endovenous ablation undergo ablation without evaluating lower extremity venous hemodynamics.

Duplex ultrasound abnormalities of the lower limb veins might precede clinical venous reflux signs in post-Fontan adolescents and young adults

OBJECTIVE

After the Fontan operation (ie, direct anastomosis of the caval veins to the pulmonary arteries, constituting right ventricular bypass circulation), high central venous pressure can lead to peripheral venous stasis and venous valvar insufficiency. We hypothesized that post-Fontan patients are at a higher risk of developing lower extremity venous lesions detectable using duplex ultrasound, even if clinical signs of chronic venous disease might not be evident.

METHODS

A total of 87 transplantation-free survivors after the Fontan procedure who reached adolescence or young adulthood (current age, 15-30 years) participated in a leg vein duplex ultrasound study. The median age at the Fontan procedure, median age at the vein study, and median interval between the two were 3.65 years (interquartile range [IQR], 3.1-5.3 years), 21.7 years (IQR, 18.9-24.7 years), and 16.6 years (IQR, 14.9-19.4 years), respectively. Duplex ultrasound scanning was performed using a venous ultrasound imaging system (Logiq P7; GE Healthcare). The patients were categorized according to the presence of venous reflux (VR) in the superficial, deep, or perforating venous systems: no VR, superficial VR (SVR), deep VR (DVR), perforating VR (PVR), and a combination of multiple venous systems. Correlation of the duplex ultrasound-detected venous lesions with clinical severity using the modified CEAP (clinical, etiological, anatomical, pathophysiological) classification was analyzed using Spearman's correlation analysis.

RESULTS

Leg pain was reported by 48 of 87 patients (55.2%). The duplex ultrasound findings for the cohort were no VR in 21 patients (24.1%), SVR in 22 (25.3%), isolated PVR in 21 (24.1%), and reflux of multiple venous systems in 23 patients, including SVR and PVR in 19, DVR and PVR in 1, and SVR, PVR, and DVR in 3 patients. Although the patients with advanced venous lesions detected by duplex ultrasound tended to have a higher CEAP clinical class (P < .001), VR of any venous system on duplex ultrasound was present even in patients with a lower CEAP clinical class. The CEAP clinical class was C0 for 66 patients (76%), and VR of any venous system was present on duplex ultrasound in 66 patients (76%).

CONCLUSIONS

The prevalence of lower extremity venous lesions detected by duplex ultrasound is strikingly high in post-Fontan adolescents and young adults, and duplex ultrasound-detected venous abnormalities can precede clinical manifestations. Early detection and timely intervention for leg vein problems are mandatory for post-Fontan patients, especially for those considered to have risk factors for developing chronic lower extremity venous disease.

Case report: Use of laparoscopic electrocoagulation rods in endovenous thermal ablation of saphenous trunks in the treatment of varicose veins of the lower extremities

Varicose veins of the lower extremities are a very common condition in vascular surgery. With advances in technology and medicine, minimally invasive endovenous thermal ablation has become the primary approach used to treat patients with moderate or severe varicose veins. Electrocoagulation for thermal ablation is a relatively simple and economical procedure, but standards vary according to location and some limitations exist. We report a case of a 58-year-old female patient with small saphenous varicose veins in the right lower extremity in which an electrocoagulation rod commonly used in laparoscopic surgery was innovatively used instead of a standard variable electrocoagulation device. The venous clinical severity score was used to assess changes in clinical symptoms before and 3 months after the procedure. The procedure was shown to have eliminated venous reflux, improved the patient's clinical symptoms, and venous function. This procedure may be a reliable option for future endovenous electrocoagulation thermal ablation procedures for varicose veins that are simple and convenient to perform.

Strain-gauge venous occlusion plethysmography: An objective and non-invasive approach to the evaluation of venous hemodynamics in patients with acute deep-vein thrombosis undergoing post-pharmacomechanical thrombolysis

OBJECTIVES

Strain-gauge venous occlusion plethysmography (SGVOP) is a means of acquiring hemodynamic data non-invasively, unlike other methods used routinely for the diagnosis and follow-up of venous diseases. The present study compares the plethysmographic data with early- and mid-term routine data of patients with acute deep-vein thrombosis (DVT) who underwent pharmacomechanical thrombolysis.

PATIENTS AND METHOD

Included in this retrospective study were 118 patients with acute DVT, who underwent pharmacomechanical thrombolysis between February 2018 and July 2019. Pre- and post-procedure follow-up data including CIVIQ-20 (quality of life), VCSS (Venous Clinical Severity Score), D-Dimer, Doppler USG results, venous capacity (VC), and venous outflow (VO) obtained by SGVOP were recorded and compared.

RESULTS

In all 118 (100%) patients who underwent the procedure, early- and mid-term patency was seen to have been provided on Doppler USG follow-up, and various degrees of venous insufficiency were identified. A statistically significant improvement was observed in VCSS, CIVIQ-20, D-Dimer, VO, and VC measurements, although when the discrepancies between CIVIQ-20 and plethysmographic measurements were examined individually during the 6-month follow-up, nine (13.1%) patients were identified with comorbidities.

CONCLUSIONS

Pharmacomechanical thrombolysis is an effective treatment approach for patients with acute DVT. Providing non-invasive objective data supporting the diagnosis and follow-up of venous diseases, the SGVOP approach offers significant benefits and should be considered more frequently as a viable therapy.

Pain Outcomes Following Mechanochemical Ablation vs Cyanoacrylate Adhesive for the Treatment of Primary Truncal Saphenous Vein Incompetence: The MOCCA Randomized Clinical Trial

Importance

Endovenous thermal ablations (ETAs) are recommended as first-line treatment for truncal vein reflux, have a short recovery time, and are cost-effective. However, ETAs are associated with discomfort during tumescent anesthesia infiltration. To minimize discomfort, nonthermal, nontumescent ablation techniques had emerged in the form of mechanochemical ablation (MOCA) and cyanoacrylate adhesive injection (CAE).

Objective

To assess pain scores immediately after truncal ablation using a 100-mm visual analog scale and 10-point number scale to compare pain-related outcomes following mechanochemical ablation vs cyanoacrylate adhesive treatment.

Design, Setting, and Participants

The Multicenter Randomized II Clinical Trial Comparing Mechanochemical Ablation vs Cyanoacrylate Adhesive for the Treatment of Primary Truncal Saphenous Veins Incompetence study was a prospective multicenter randomized clinical trial conducted at 3 sites between November 2017 and January 2020. Inclusion criteria were primary great or small saphenous varicose veins; exclusion criteria included recurrent varicose veins, current deep venous thrombosis, or serious arterial disease. There were 392 participants screened, 225 were excluded, and 167 participants underwent randomization. Four participants did not receive allocated intervention and were included in the intention-to-treat analysis. Follow-up took place at 2 weeks, and 3, 6, and 12 months.

Interventions

Patients with primary truncal vein incompetence were randomized to receive either MOCA or CAE.

Main Outcomes and Measures

The primary outcome measure was pain score immediately after completing truncal ablation using a 100-mm visual analog scale (VAS) and a 10-point number scale. Secondary outcome measures included degree of ecchymosis, occlusion rates, clinical severity, and generic and disease-specific quality of life (QoL) scores.

Results

Of 167 study participants, 99 (59.3%) were women, and the mean (SD) age was 56 (15.8) years. Overall, 155 truncal veins treated (92.8%) were great saphenous veins. Demographic data and baseline status were comparable between treatment groups. A total of 73 patients (47%) underwent adjunctive treatment of varicosities. Overall median (IQR) maximum pain score after truncal treatment was 23 mm (10-44) on the VAS and 3 (2-5) on the number scale, showing no significant difference in median (IQR) pain measured by VAS (MOCA, 24 [11.5-44.7] mm vs CAE, 20 [9.0-42.0] mm; P = .23) or by number scale (MOCA, 4 [2-5] vs CAE, 3 [2-4]; P = .18). Both groups demonstrated significant and comparable improvement in clinical severity, generic and disease-specific QoL scores, and complete occlusion rates. Four patients treated with CAE developed minor complications (superficial thrombophlebitis and thrombus extensions).

Conclusions and Relevance

To our knowledge, this was the first randomized clinical trial directly comparing nontumescent ablation techniques. The study demonstrated that the MOCA and CAE techniques have a similar periprocedural pain score.

Trial Registration

ClinicalTrials.gov Identifier: NCT03392753.

Detection of residual varicose veins with near infrared light in the early period after varicose surgery and near infrared light assisted sclerotherapy

OBJECTIVES

Varicose veins that cannot be seen with the naked eye can be easily detected with Near Infrared (NIR) light. With a minimally invasive procedure performed with NIR light guided, the need for reoperation is reduced, while optimal treatment of venous insufficiency and symptoms is provided. In this study, the detection of residual varicose veins after varicose vein surgery using NIR light and the results of treatment of sclerotherapy were investigated.

METHODS

In this retrospective study, treatment and clinical outcomes of patients' who underwent NIR light-guided foam sclerotherapy for Clinical-Etiology-Anatomy-Pathophysiology (CEAP) (C1, C2) stage residual varicose veins after surgical varicose treatment between 2014 and 2017 were examined. Data of patients who underwent foam sclerotherapy with NIR light were collected and analyzed.

RESULTS

A total of 151 patients and 171 lower extremity varicose veins were treated with surgery. 55 (35.7%) of the patients were male, and 96 (62.3%) were female. Their age ranges from 20 to 64, with an average age of 45.38. 4 (2.6%) of the patients had phlebectomy. 137 of patients (90.7%) had ligation of perforated veins, phlebectomy, and great saphenous vein (GSV) stripping, 10 of patients (6.6%) had GSV stripping, perforating vein ligation, phlebectomy, and small saphenous vein (SSV) surgery. No residual leakage was observed in the controls of GSV, SSV, and perforating veins by duplex ultrasonography (DUS). In the first month after varicose surgery, an average of 1.64 ± 1.05 sessions of sclerotherapy was applied to patients with CEAP C1, C2 stage residual varicose veins. 70 patients had one session of sclerotherapy, 37 patients had two sessions of sclerotherapy, 20 patients had three sessions of sclerotherapy, and 11 patients had four sessions of sclerotherapy administrated. The need for complementary therapy was required for all female patients; 13 of the male patients did not require complementary sclerotherapy. While single-session sclerotherapy was applied to most male patients (32 (58.18%), 10 (18.18%) patients received two sclerotherapy sessions. After completing sclerotherapy, 7 (4.63%) patients had superficial venous thrombosis, and 13 (8.60%) patients had hyperpigmentation.

CONCLUSION

Surgical treatment is a safe and effective technique in venous insufficiency. Nevertheless, residual varicose veins may remain, and these can be detected noninvasively with NIR light. Foam sclerotherapy with NIR light is a minimally invasive and safe treatment method for small residual varicose veins after the operation. We think that sclerotherapy with NIR light as a complementary treatment is a practical, reliable, and demanding treatment for clinical improvement, especially in female patients.

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.

Interventions for great saphenous vein incompetence

BACKGROUND

Great saphenous vein (GSV) incompetence, causing varicose veins and venous insufficiency, makes up the majority of lower-limb superficial venous diseases. Treatment options for GSV incompetence include surgery (also known as high ligation and stripping), laser and radiofrequency ablation, and ultrasound-guided foam sclerotherapy. Newer treatments include cyanoacrylate glue, mechanochemical ablation, and endovenous steam ablation. These techniques avoid the need for a general anaesthetic, and may result in fewer complications and improved quality of life (QoL). These treatments should be compared to inform decisions on treatment for varicosities in the GSV. This is an update of a Cochrane Review first published in 2011.

OBJECTIVES

To assess the effects of endovenous laser ablation (EVLA), radiofrequency ablation (RFA), endovenous steam ablation (EVSA), ultrasound-guided foam sclerotherapy (UGFS), cyanoacrylate glue, mechanochemical ablation (MOCA) and high ligation and stripping (HL/S) for the treatment of varicosities of the great saphenous vein (GSV).

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, and AMED databases, and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 2 November 2020. We undertook reference checking to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) treating participants for varicosities of the GSV using EVLA, RFA, EVSA, UGFS, cyanoacrylate glue, MOCA or HL/S. Key outcomes of interest are technical success, recurrence, complications and QoL.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, applied Cochrane's risk of bias tool, and extracted data. We calculated odds ratios (ORs) with 95% confidence intervals (CIs) and assessed the certainty of evidence using GRADE.

MAIN RESULTS

We identified 11 new RCTs for this update. Therefore, we included 24 RCTs with 5135 participants. Duration of follow-up ranged from five weeks to eight years. Five comparisons included single trials. For comparisons with more than one trial, we could only pool data for 'technical success' and 'recurrence' due to heterogeneity in outcome definitions and time points reported. All trials had some risk of bias concerns. Here we report the clinically most relevant comparisons. EVLA versus RFA Technical success was comparable up to five years (OR 0.98, 95% CI 0.41 to 2.38; 5 studies, 780 participants; moderate-certainty evidence); over five years, there was no evidence of a difference (OR 0.85, 95% CI 0.30 to 2.41; 1 study, 291 participants; low-certainty evidence). One study reported recurrence, showing no clear difference at three years (OR 1.53, 95% CI 0.78 to 2.99; 291 participants; low-certainty evidence), but a benefit for RFA may be seen at five years (OR 2.77, 95% CI 1.52 to 5.06; 291 participants; low-certainty evidence). EVLA versus UGFS Technical success may be better in EVLA participants up to five years (OR 6.13, 95% CI 0.98 to 38.27; 3 studies, 588 participants; low-certainty evidence), and over five years (OR 6.47, 95% CI 2.60 to 16.10; 3 studies, 534 participants; low-certainty evidence). There was no clear difference in recurrence up to three years and at five years (OR 0.68, 95% CI 0.20 to 2.36; 2 studies, 443 participants; and OR 1.08, 95% CI 0.40 to 2.87; 2 studies, 418 participants; very low-certainty evidence, respectively). EVLA versus HL/S Technical success may be better in EVLA participants up to five years (OR 2.31, 95% CI 1.27 to 4.23; 6 studies, 1051 participants; low-certainty evidence). No clear difference in technical success was seen at five years and beyond (OR 0.93, 95% CI 0.57 to 1.50; 5 studies, 874 participants; low-certainty evidence). Recurrence was comparable within three years and at 5 years (OR 0.78, 95% CI 0.47 to 1.29; 7 studies, 1459 participants; and OR 1.09, 95% CI 0.68 to 1.76; 7 studies, 1267 participants; moderate-certainty evidence, respectively). RFA versus MOCA There was no clear difference in technical success (OR 1.76, 95% CI 0.06 to 54.15; 3 studies, 435 participants; low-certainty evidence), or recurrence (OR 1.00, 95% CI 0.21 to 4.81; 3 studies, 389 participants; low-certainty evidence). Long-term data are not available. RFA versus HL/S No clear difference in technical success was detected up to five years (OR 5.71, 95% CI 0.64 to 50.81; 2 studies, 318 participants; low-certainty evidence); over five years, there was no evidence of a difference (OR 0.88, 95% CI 0.29 to 2.69; 1 study, 289 participants; low-certainty evidence). No clear difference in recurrence was detected up to three years (OR 0.93, 95% CI 0.58 to 1.51; 4 studies, 546 participants; moderate-certainty evidence); but a possible long-term benefit for RFA was seen (OR 0.41, 95% CI 0.22 to 0.75; 1 study, 289 participants; low-certainty evidence). UGFS versus HL/S Meta-analysis showed a possible benefit for HL/S compared with UGFS in technical success up to five years (OR 0.32, 95% CI 0.11 to 0.94; 4 studies, 954 participants; low-certainty evidence), and over five years (OR 0.09, 95% CI 0.03 to 0.30; 3 studies, 525 participants; moderate-certainty evidence). No clear difference was detected in recurrence up to three years (OR 1.81, 95% CI 0.87 to 3.77; 3 studies, 822 participants; low-certainty evidence), and after five years (OR 1.24, 95% CI 0.57 to 2.71; 3 studies, 639 participants; low-certainty evidence). Complications were generally low for all interventions, but due to different definitions and time points, we were unable to draw conclusions (very-low certainty evidence). Similarly, most studies evaluated QoL but used different questionnaires at variable time points. Rates of QoL improvement were comparable between interventions at follow-up (moderate-certainty evidence).

AUTHORS' CONCLUSIONS

Our conclusions are limited due to the relatively small number of studies for each comparison and differences in outcome definitions and time points reported. Technical success was comparable between most modalities. EVLA may offer improved technical success compared to UGFS or HL/S. HL/S may have improved technical success compared to UGFS. No evidence of a difference was detected in recurrence, except for a possible long-term benefit for RFA compared to EVLA or HL/S. Studies which provide more evidence on the breadth of treatments are needed. Future trials should seek to standardise clinical terminology of outcome measures and the time points at which they are measured.

Radiofrequency Ablation for Axial Reflux Associated with Foam Sclerotherapy for Varicosities in One-Step Approach: A Prospective Cohort Study Comprising Large Diameters Saphenous Veins

OBJECTIVE

This study assessed the outcomes and impact on the quality of life following one-step outpatient radiofrequency ablation (RFA) and ultrasound guided foam sclerotherapy (USGFS) for large reflux with varicosities in the great saphenous vein (GSV).

DESIGN

Prospective, single-centre, analytical cohort.

MATERIALS AND METHODS

Thirty symptomatic patients having reflux in the GSV and varicosities (CEAP C3 to C6) were treated with RFA and USGFS simultaneously, in a single-step procedure, from March 2016 to December 2016. They were followed up at 1 week, 6 months, 1 and 3 years. Clinical outcomes, changes in the Quality of Life (QOL) questionnaires SF-36™, VCSS and AVVQ, evolutive vein occlusion rates were assessed by duplex ultrasound, and ulcer closure was checked.

RESULTS

The sample was divided into two groups: (Group 1) GSV diameter ≥13.0 mm (median 19.0 [14-24]), 17 subjects, and (Group 2) GSV diameter ≤12.9 mm (median 10.3 [10-12]), 16 subjects. No major adverse event was observed, and the postoperative minor adverse event rates were similar between the two groups. A significant improvement was observed in VCSS and AVVQ from the preoperative levels to the sixth month and the third-year follow-up. Twelve of 13 ulcers had healed at 1 year and remained closed until 3 years. The entire sample had a significant increase in all short form 36 domains, except for mental health in the Group 2 (GSV ≥ 13.0 mm). Overall first week occlusion rate for the whole sample was 90.9% and 69.7% at the 3-year follow-up. No difference in occlusion rate was observed between the two groups at any time.

CONCLUSION

Exclusively outpatient combined techniques were safe and feasible in this study with no major adverse events, despite the large diameters of the GSV or ulcer presence. Within 3 years, both diameter groups showed equivalent improvement in all QOL parameters, satisfactory axial occlusion, and maintained ulcer closure.

Feasibility and potential significance of prophylactic ablation of the major ascending tributaries in endovenous laser ablation (EVLA) of the great saphenous vein: A case series

Background

Recurrent varicosities after endovascular laser ablation (EVLA) of the great saphenous vein (GSV) are frequently due to varicose transformed, initially unsealed major ascending tributaries of the saphenofemoral junction (SFJ). Preventive ablation of these veins, especially the anterior accessory saphenous vein, is discussed as an option, along with flush occlusion of the GSV. However, few related data exist to date.

Methods

A consecutive case series of 278 EVLA procedures of the GSV for primary varicosis in 213 patients between May and December 2019 was retrospectively reviewed. The ablations were performed with a 1470 nm dual-ring radial laser and always included flush occlusion of the GSV, and concomitant ablation of its highest ascending tributaries by additional cannulation and ablation when this seemed anatomically appropriate. The initial technical success, comprising occlusion of the GSV and its major tributaries, was set as the primary endpoint. Possible determinants were explored using downstream multiple logistic regression analysis.

Results

The early technical success was 92.8%, with the GSV occluded in 99.6% and the highest ascending SFJ tributary, if present, in 92.4%. Additional ablations of ascending tributaries were performed in 171 cases (61.5%), the latter being associated with success (OR 10.39; 95% CI [3.420–36.15]; p < 0.0001). Presence of anterior as opposed to posterior accessory saphenous vein was another positive predictor (OR 3.959; 95% CI [1.142–13,73]; p = 0.027), while a confluence of the tributary in the immediate proximity to the SFJ had a negative impact (OR 0.2253; 95% CI [0.05456–0.7681]; p = 0.0253). An endothermal heat-induced thrombosis (EHIT) ≥ grade 2 was observed in three cases (1.1%).

Conclusions

A co-treatment of the tributaries is feasible and could improve the technical success of EVLA if a prophylactic closure of these veins is desired, especially if their distance to the SFJ is short. Its effect on the recurrence rate needs further research.

Thromboprophylaxis practice after outpatient endovenous thermal ablation

OBJECTIVE

The use of endovenous thermal ablation (ETA) for the treatment of truncal varicose veins has been increasing worldwide; however, uncertainty remains regarding the need for thromboprophylaxis and follow-up of patients undergoing this minimally invasive procedure. A nationwide survey of among physicians performing ETA was conducted to assess the thromboprophylaxis practice and follow-up protocols after ETA in Switzerland.

METHODS

A questionnaire was sent to all ETA-certified physicians (n = 193) in Switzerland. The survey covered procedure type, thromboprophylaxis (including pharmacologic and compression therapy), duplex ultrasound follow-up examinations, and the management of endovenous heat-induced thrombosis (EHIT).

RESULTS

Overall, 121 responses were received, for a response rate of 62.7%. Of the 121 respondents, 71 were vascular medicine specialists (58.7%) and 46 were general or vascular surgeons (38.0%), representing the two largest groups of specialists, followed by 2 dermatologists (1.7%) and 2 interventional radiologists (1.7%). Pharmacologic thromboprophylaxis after ETA was always used by 86 physicians (71.1%), nearly always by 8 (6.6%), frequently used by 5 (4.1%), rarely used by 21 (17.4%), and never by 1 physician (0.8%). A direct oral anticoagulant drug was the preferred type of thromboprophylaxis used by 92 physicians (77.3%). The first dose of thromboprophylaxis was mostly administered immediately after intervention by 53 physicians (53.7%). The duration of postablation thromboprophylaxis ranged from 1 to 21 days, with 7 to 10 days used by 57 physicians. Compression therapy was used by all physicians, with large variation in duration ranging from 1 to 42 days after a single ETA session and after ETA with concomitant phlebectomy. Postablation duplex ultrasonography was performed routinely by 120 respondents (99.2%), and 84 respondents (69.4%) performed two to three duplex ultrasound scans. Management of EHIT depended on the EHIT class and differed widely among the physicians.

CONCLUSIONS

Our nationwide survey on thromboprophylaxis practices after ETA of truncal varicose veins in Switzerland showed that most physicians use pharmacologic thromboprophylaxis, with a direct oral anticoagulant drug the preferred agent. However, the timing of the first dose and the duration of thromboprophylaxis varied widely among the respondents, reflecting the uncertainty in this domain owing to the absence of high-quality evidence-based guidelines.

Feasibility and technique of endovenous laser ablation (EVLA) of recurrent varicose veins deriving from the sapheno-femoral junction-A case series of 35 consecutive procedures

Aim

To assess the feasibility and technical success of endovenous laser ablation (EVLA) of recurrent varicose veins arising from the former sapheno-femoral junction (SFJ).

Methods

We retrospectively analyzed all EVLA procedures treated in our institution by one surgeon between March 2019 and April 2020 and selected all consecutive cases with SFJ recurrence occuring after surgical high ligation and stripping or endovenous thermal ablation for incompetence of the great saphenous vein (GSV) in superficial venous insufficiency. The feasibility, technical success as determined by duplex ultrasound on the postoperative visit, complications and rate of endothermal heat-induced thrombosis (EHIT) were recorded. A subgroup definition was performed based on sonographic morphology of the recurrence and resulting strategy of ablation.

Results

Thirty-five limbs with SFJ recurrence in 34 patients were treated with EVLA in order to shut down the highest refluxing point. In 22 interventions, it was required to switch off a short stump or a neovascularization by direct puncture (Subgroup 1). In 13 treatments, the presence of residual GSV segments, or persistent, varicose transformed major tributaries like the anterior accessory great saphenous vein, enabled cannulation and advancing the laser fiber from distal to the former SFJ (Subgroup 2). The EVLA procedures could be successfully carried out in all 35 cases. There were no major complications, no thromboembolism or EHIT, and no local groin complications. In one case, the patient developed a phlebitic response that required temporary medication. Technical success was achieved with 34/35 treatments (97.1%). When comparing the subgroups, the morphological pattern of the SFJ recurrence and the resulting technique of puncture, cannulation and ablation did not influence the result.

Conclusions

The results of this case series suggest that SFJ recurrences can also be successfully treated in situations where there are tortuous or short stumps that require direct puncture and ablation.

Anterior accessory saphenous vein confluence anatomy at the sapheno-femoral junction as risk factor for varicose veins recurrence after great saphenous vein radiofrequency thermal ablation

BACKGROUND

Varicose veins recurrence rate remained almost unchanged despite the constant technological advancement in its treatment. The aim of this study is to evaluate the variable accessory saphenous vein (ASV) anatomy at the sapheno-femoral junction (SFJ) as a possible risk factor for recurrent varicose vein (RVV) after great saphenous vein (GSV) radiofrequency thermal ablation (RTA).

METHODS

Two-hundred consecutive patients affected by chronic venous disease (mean age 52.4±10.3 years; 187 women; CEAP C2-C6; 25.2±1.4), underwent to RTA from 2014 to 2016, at our Institute. Preoperatively all patients underwent duplex-ultrasound scanning, reporting the anatomical site, extension of reflux and the ASV anatomy at the SFJ. Duplex ultrasound and physical examination was performed postoperatively at 1, 6 and 12 months, and yearly thereafter.

RESULTS

Patients were divided in two groups based on the anatomical site of reflux: group A (N.=187) including GSV and SFJ, group B (N.=82) including SFJ reflux. There was no preoperative statistical difference between the two groups. At a mean follow-up of 29.7±2.4 months, a freedom from recurrent varicose vein and GSV recanalization was: 100% and 100% at 1 month, 95.9% and 99.1% at 1 year, 93.7% and 96.7% at 3 years, respectively. A higher rate of RVV was documented for patients in group A at 3-year of follow-up (P=0.042). Cox regression analysis found, among five potential predictors of outcome, that direct confluence of ASV in SFJ (HR=1.561; 95% CI: 1.0-7.04; P=0.032) was a negative predictors of 1-year RVV.

CONCLUSIONS

Sapheno-femoral junction morphology may affect recurrent varicose veins formation. In particular, a concomitant incompetence of the accessory saphenous vein or its directly confluence into the SFJ could represent an indication to simultaneous treatment by non-surgical techniques (RTA or laser) and avoid surgical ligation.

Impact on venous haemodynamics after treatment of great saphenous vein incompetence using plethysmography and duplex ultrasound

Objectives

To evaluate postoperative venous haemodynamics and quality of life after treatment of great saphenous vein (GSV) incompetence.

Methods

Radiofrequency ablation and high ligation and stripping were performed in 62 patients (65 limbs) and 58 (65 limbs), respectively. Phlebectomies were performed in both modalities. Strain-gauge plethysmography on the foot combined with superficial venous occlusion was used to measure refilling time after knee bends. Strain-gauge plethysmography, duplex ultrasound and quality of life were assessed before and one month after treatment.

Results

Duplex ultrasound displayed successful intervention in all but two limbs. Refilling time increased similar in radiofrequency ablation and high ligation and stripping after treatment ( p < 0.001). Postoperatively, strain-gauge plethysmography detected remaining reflux in 71% of the patients. Multivariate analysis showed that two or more incompetent calf branches were associated with remaining reflux (OR 4.82 (95% CI: 1.33–17.5), p = 0.02). No difference in quality of life was seen in patients with remaining reflux.

Conclusions

Despite successful treatment, a majority of the limbs showed remaining reflux, in which incompetent calf branches appear to play an important role. Clinicaltials.gov: Lower Limb Venous Insufficiency and the Effect of Radiofrequency Treatment Versus Open Surgery. Nr: NCT02397226

Endovenous Laser Ablation with and Without Concomitant Phlebectomy for the Treatment of Varicose Veins: A Retrospective Analysis of 954 Limbs

BACKGROUND

Endovenous laser ablation (EVLA) with concomitant phlebectomy is commonly performed in many institutions. However, phlebectomy is associated with cosmetic complications such as surgical scarring, hemorrhage, and hematoma. This study aims to compare the need for additional sclerotherapy during follow-up after EVLA with and without concomitant phlebectomy.

METHODS

Between November 2013 and December 2018, we performed EVLA on 1,363 limbs in 1,009 patients with symptomatic primary varicose veins, of which 954 limbs in 771 patients with great saphenous vein (GSV) or small saphenous vein (SSV) insufficiency were included in this study. Data were collected prospectively and supplemented with retrospective medical record review. Demographic and clinical characteristic profiles were collected. The outcomes of EVLA with or without concomitant phlebectomy were compared. Logistic regression was used to assess predictors for additional sclerotherapy after EVLA.

RESULTS

CEAP classification (P < 0.001), operative time (P < 0.001), laser device type (P < 0.001), length of the treated vein (P < 0.001), linear endovenous energy density (P < 0.001), and tumescent local anesthesia volume (P < 0.001) differed significantly. Pain after EVLA was significantly more frequent in the nonphlebectomy group than in the phlebectomy group (P = 0.005). During follow-up, 34 of 954 limbs (3.6%) underwent additional sclerotherapy for residual visible varicose veins after EVLA. No statistical difference was found in the rate of additional sclerotherapy between the groups (P = 0.849). Logistic regression showed that female sex (odds ratio [OR], 6.18; 95% confidence interval [CI], 1.86-20.6; P = 0.003) is significantly associated with additional sclerotherapy, and concomitant phlebectomy is not a significant predictor of additional sclerotherapy (OR, 0.844; 95% CI, 0.375-1.90; P = 0.682).

CONCLUSIONS

Patient preference for additional sclerotherapy was comparable between those who underwent EVLA with and without concomitant phlebectomy. This result supports our present strategy of avoiding simultaneous phlebectomy at the time of primary EVLA.

Saphenous reflux patterns in C2 patients: A record of 1196 ultrasound reports

Objectives

To describe saphenous reflux patterns in patients classified as CEAP C2 by analysis of 2027 vascular ultrasound examination reports.

Methods

A total of 2027 venous mapping studies were reviewed and 1196 patients classified as CEAP C2 were selected. Patients were classified according to patterns of reflux for the great saphenous vein and for the small saphenous vein, and rates of great saphenous vein and small saphenous vein reflux were analyzed for both sexes.

Results

The overall prevalence of saphenous vein reflux was 45%. Males had significantly higher great saphenous vein reflux prevalence than females ( p < 0.001). The most common great saphenous vein reflux pattern in females was segmental reflux and the most common pattern in males was proximal reflux.

Conclusions

Saphenous vein reflux is common in C2 patients and is more frequent in males. Standardization of classifications of reflux patterns is very important for correct management of the disease.

European College of Phlebology guideline for truncal ablation

Background

The purpose of the guideline was to achieve consensus in the care and treatment of patients with chronic venous disease, based on current evidence.

Method

A systematic literature search was performed in PubMed, Embase, Cinahl, and the Cochrane library up until 1 February 2019. Additional relevant literature were added through checking of references. Level of evidence was graded through the GRADE scale and recommendations were concluded.

Results

For the treatment of great and small saphenous vein reflux, endovenous ablation with laser or radiofrequency was recommended in preference to surgery or foam sclerotherapy. If tributaries are to be treated it should be done in the same procedure. Treatment with mecanicochemical ablation and glue can be used but we still need long term follow up results.

Conclusion

For the treatment of truncal varicosities, endovenous ablation with laser or radiofrequency combined with phlebectomies is recommended before surgery or foam.

Lessons Learned After 366 Thermoablated Veins

In the past few years, advances in surgical techniques have improved outcomes in varicose veins treatment. The aim of this retrospective study was to determine whether the use of laser and different parameters influenced morbidity rates and the learning curve for all technology improvements during the period. From 2009 to 2018 we performed 366 vein procedures using endovenous laser technique for varicose veins. During this period, negative outcomes diminished with adoption of new strategies and skills. Laser wavelength, radial fibre, ultrasound guidance, anaesthetic intumescence, laser power and energy, and hospital setting were changed during the evaluation period. Laser technology requires many parameter adjustments, there is an understandable steeper learning curve at first. The use of new strategies and improved procedure steps allowed us to achieve a significant improvement in morbidity rates in the group of patients operated on using the 1,470 nm laser and in later quintiles.

Compliance with compression therapy in primary chronic venous disease: Results from a tropical country

OBJECTIVES

To describe compliance rates of compression therapy in a cohort of patients with chronic venous disease and also to describe frequent causes of non-compliance.

METHODS

A total of 889 patients with primary chronic venous disease were prescribed compression therapy after being evaluated by vascular surgeons. Subjects had a first visit during which time compression therapy was prescribed in addition to a follow-up visit. Strength of compression, type, prescription duration, and reasons of non-compliance were queried at follow-up.

RESULTS

Only 31.8% of the patients reported wearing compression therapy as prescribed, 31.4% reported wearing compression most days, 28.3% reported wearing compression intermittently, and 8.5% of the patients reported not wearing compression at all. The main reasons of non-compliance were: uncomfortable (49.4%), too difficult to put on (34.5%), skin problems (itching) (21.5%), and unattractive (19.8%).

CONCLUSIONS

Compliance with compression therapy in chronic venous disease is still a subject of concern as most patients are not using compression therapy as prescribed.

Vein diameter is a predictive factor for recanalization in treatment with ultrasound-guided foam sclerotherapy

OBJECTIVE

Ultrasound-guided foam sclerotherapy (UGFS) is a low-cost and minimally invasive treatment option for varicose veins. There is a relative paucity of outcome reports.

METHODS

UGFS procedures at a tertiary public hospital between 2010 and 2017 were studied. Either the great saphenous vein (GSV) or small saphenous vein (SSV) was treated. Pretreatment, in-treatment, 6-week, and 1-year post-treatment ultrasound reports were analyzed. The primary outcome was to determine whether vein diameter predicts obliteration failure.

RESULTS

There were 457 treatments completed in 290 patients. The GSV was targeted in 372 (81%). Mean vein diameters of the GSV were not different from those of the SSV (GSV, 5.7 mm; SSV, 6.2 mm; P = .18); 109 (24%) had a Clinical, Etiology, Anatomy, and Pathophysiology score of at least 4. Of the 457 UGFS procedures, 360 (78.8%) were for primary veins. Baseline information, including vein diameter, was not different between primary and recurrent veins. At 6 weeks, complete obliteration, partial recanalization, and complete recanalization rates were 54.9%, 29.1%, and 16%, respectively. Of those with complete obliteration at 6 weeks, the recanalization rate at 1 year was 25%. Increasing vein diameter was associated with recanalization at 1 year (obliteration, 4.9 mm; recanalization, 5.7 mm; P = .03), especially for primary veins (4.8 vs 5.8 mm; P = .009). Multivariate analysis showed similar outcome. Vein diameter of >6 mm had good specificity (88%) but poor sensitivity (43%) for predicting obliteration failure. There were 15 (3%) new-onset deep venous thromboses reported on follow-up, all of which were from treatment of primary veins (P = .049).

CONCLUSIONS

Only 44% of UGFS procedures were observed to have complete obliteration at 1 year after a single intervention. Significant recanalization developed at 1 year. Increased vein diameter was associated with recanalization. The impact on clinical recurrence is unknown.

Mechanochemical ablation versus cyanoacrylate adhesive for the treatment of varicose veins: study protocol for a randomised controlled trial

BACKGROUND

Thermal ablation techniques have become the first-line treatment of truncal veins in the management of chronic venous disease (CVD). Despite excellent outcomes, these methods are often associated with pain; generally due to their use of heat and the necessity of fluid infiltration around the vein. More recently, novel non-thermal techniques, such as mechanochemical ablation (MOCA) and cyanoacrylate adhesive (CAE) have been developed to overcome these unwelcome effects. So far, the novel techniques have been found to have similar efficacy to thermal methods, yet no direct comparisons between the non-thermal treatment techniques have been conducted to date, giving rise to this study.

METHODS/DESIGN

This is a prospective, multicentre, randomised clinical trial, recruiting patients with truncal saphenous incompetence. Patients will be randomised to undergo either MOCA or CAE truncal ablation, followed by treatment of any varicosities. All patients will be required to wear compression stockings for 4 days post intervention. The primary outcome measure is the pain score immediately following completion of truncal ablation, measured by a 100-mm Visual Analogue Scale (VAS). The secondary outcomes are entire treatment pain scores, clinical scores, quality of life scores, occlusion rates, time to return to usual activities/work at 2 weeks, 3, 6 and 12 months. Re-intervention rate will be considered from the third month. Cost-effectiveness will be assessed for each intervention at 12 months. The study is powered to detect a mean 10-mm difference in maximum pain score. Allowing for loss to follow-up, the total target recruitment is 180 patients.

DISCUSSION

The study will be the first study to compare MOCA against CAE and is designed to determine which method causes less pain. Completion of this study is expected to be the end of 2019.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03392753 . Registered on 17 November 2017.

Report of the Society for Vascular Surgery and the American Venous Forum on the July 20, 2016 meeting of the Medicare Evidence Development and Coverage Advisory Committee panel on lower extremity chronic venous disease

On July 20, 2016, a Medicare Evidence Development and Coverage Advisory Committee panel assessed the benefits and risks of currently used lower extremity chronic venous disease (CVD) treatments and their effects on health outcome of the American adult population. The main purpose of the meeting was to advise the Centers for Medicare & Medicaid Services on coverage determination for interventions used for treatment of CVD. A systematic review of the Agency for Healthcare Research and Quality was presented, followed by lectures of invited experts and a public hearing of representatives of professional societies and the industry. After discussing critical issues, the panel voted for key questions. This report summarizes the presented evidence to support recommendations of the Society for Vascular Surgery/American Venous Forum coalition and the presentations on selected discussion topics. These included important venous disease evidence gaps that have not been sufficiently addressed, venous disease treatment disparities and how they may affect the health outcomes of Medicare beneficiaries, and mechanisms that might be supported by the Centers for Medicare & Medicaid Services to improve the evidence base to optimize the care of patients with lower extremity CVD.

Sclerotherapy for Reticular Veins in the Lower Limbs: A Triple-Blind Randomized Clinical Trial

Importance

Reticular veins are subdermal veins located in the lower limbs and are mainly associated with aesthetic complaints. Although sclerotherapy is the treatment of choice for reticular veins in the lower limbs, no consensus has been reached regarding to the optimal sclerosant.

Objective

To compare the efficacy and safety of 2 sclerosants used to treat reticular veins: 0.2% polidocanol diluted in 70% hypertonic glucose (HG) (group 1) vs 75% HG alone (group 2).

Design, Setting, and Participants

Prospective, randomized, triple-blind, controlled, parallel-group clinical trial with patients randomly assigned in a 1:1 ratio between the 2 treatment groups from March through December 2014, with 2 months' follow-up. The study was conducted in a single academic medical center. Eligible participants were all women, aged 18 to 69 years, who had at least 1 reticular vein with a minimum length of 10 cm in 1 of their lower limbs.

Interventions

The patients underwent sclerotherapy in a single intervention with either 0.2% polidocanol plus 70% HG or 75% HG alone to eliminate reticular veins.

Main Outcomes and Measures

The primary efficacy end point was the disappearance of the reticular veins within 60 days after treatment with sclerotherapy. The reticular veins were measured on images obtained before treatment and after treatment using ImageJ software. Safety outcomes were analyzed immediately after treatment and 7 days and 60 days after treatment and included serious adverse events (eg, deep vein thrombosis and systemic complications) and minor adverse events (eg, pigmentation, edema, telangiectatic matting, and hematomas).

Results

Ninety-three women completed the study, median (interquartile range) age 43.0 (24.0-61.0) years for group 1 and 41.0 (27.0-62.0) years for group 2. Sclerotherapy with 0.2% polidocanol plus 70% HG was significantly more effective than with 75% HG alone in eliminating reticular veins from the treated area (95.17% vs 85.40%; P < .001). No serious adverse events occurred in either group. Pigmentation was the most common minor adverse event, with a 3.53% treated-vein pigmentation length for group 1 and 7.09% for group 2, with no significant difference between the groups (P = .09).

Conclusions and Relevance

Sclerotherapy with 0.2% polidocanol diluted in 70% HG was superior to 75% HG alone in sclerosing reticular veins, with no statistical difference for complications. Pigmentation occurred in both groups, with no statistical difference between them. No serious adverse events occurred in either group.

Trial Registration

clinicaltrials.gov Identifier: NCT02054325.

Comparison of ultrasound-guided endovenous laser ablation and radiofrequency for the varicose veins treatment: An updated meta-analysis

PURPOSE

To investigate and compare the relative efficacy, recurrence and complications of endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) for the treatment of varicose veins patients.

METHODS

Searches were applied to the Cochrane Library as well as MEDLINE, EMBASE, BIOSIS databases. 12 articles published in English (10 randomized controlled trials and 2 cohort study) were identified from specialized trails. Fixed effect model and Random effect model were applied to compare the vein ablated length, pain scores (3days and 10days), quality of Life, occlusion, over all complication, thrombophlebitis, haematoma and recanalization between the EVLA and RFA group. The results were expressed as odds ratio (OR) or relative risk (RR) and 95% confidence intervals (CI) for categorical outcomes.

RESULTS

12 reported studies with a combined total of 1577 patients were included. vein ablated length (SMD:0.37, 95%CI: 0.04 to 0.77), 3days pain scores (SMD:11.25, 95%CI: 3.42 to 25.92) and 10days (SMD:0.79,95%CI: 0.48 to 2.05),1 month quality of Life (SMD: 0.09,95%CI: 0.28 to 0.10) and 1 year (SMD: 0.04,95%CI: 0.21 to 0.13), occlusion (OR:1.05,95%CI:0.41 to 2.73), thrombophlebitis (RR:1.03,95%CI:0.56 to 1.92), haematoma (OR:1.55, 95%CI:0.54 to 4.45) and recanalization (OR:0.68,95%CI:0.43 to 1.09) following RFA showed no difference when compared with EVLA. These results were not statistically significant. RFA was associated with the lower overall complication (OR: 3.49, 95%CI:1.36 to 8.96) in patients with varicose veins compared to the EVLA treatment.

CONCLUSION

EVLA and RFA seem to be the same safe and effective on clinical efficacy (vein ablated length, 3days and 10days pain scores, 1 month and 1 year quality of life, occlusion, thrombophlebitis, haematoma and recanalization). Data on RFA seems to having potential benefits from reducing risk of overall complication than EVLA, which is needed by large high-quality prospective randomized trials.

Minimally invasive treatments for perforator vein insufficiency

Incompetent superficial veins are the most common cause of lower extremity superficial venous reflux and varicose veins; however, incompetent or insufficient perforator veins are the most common cause of recurrent varicose veins after treatment, often unrecognized. Perforator vein insufficiency can result in pain, skin changes, and skin ulcers, and often merit intervention. Minimally invasive treatments have replaced traditional surgical treatments for incompetent perforator veins. Current minimally invasive treatment options include ultrasound guided sclerotherapy (USGS) and endovascular thermal ablation (EVTA) with either laser or radiofrequency energy sources. Advantages and disadvantages of each modality and knowledge on these treatments are required to adequately address perforator venous disease.

The management of varicose veins

This study aimed to review the current management modalities for varicose veins. There are a variety of management modalities for varicose veins. The outcomes of the treatment of varicose veins are different. The papers on the management of varicose veins were reviewed and the postoperative complications and efficacy were compared. Foam sclerotherapy and radiofrequency ablation were associated with less pain and faster recovery than endovenous laser ablation and surgical stripping. Patients undergoing endovenous laser ablation and radiofrequency ablation are most likely to have a faster recovery time and earlier return to work in comparison with those undergoing conventional high ligation and stripping. A randomized controlled study in multiple centers is warranted to verify which approach is better than others for the treatment of varicose veins.

EVLTraining®: aplicativo para treino do cálculo da densidade de energia endovenosa linear

Resumo Contexto O reconhecimento da termoablação endovenosa como tratamento da insuficiência de veias safenas traz a necessidade de maior conhecimento e compreensão do método. A densidade de energia endovenosa linear (linear endovenous energy density – LEED) é a variável mais aceita para padronização, cada vez mais amplamente divulgada. Não deve ser utilizada apenas para comparação de resultados científicos – deve também ser usada no intraoperatório para a realização do procedimento com segurança. Objetivos Desenvolver aplicativo para mensuração da LEED e avaliar sua aplicabilidade. Métodos O aplicativo para iOS EVLTraining® foi desenvolvido para equipamentos portáteis com o intuito de padronizar a emissão energética em procedimentos de termoablação endovenosa. Resultados O aplicativo criado mostrou equivalência com as medidas aplicadas no procedimento cirúrgico. Conclusões O software EVLTraining® permite o treino prévio de cirurgião e equipe para a velocidade de tração da fibra ótica que será aplicada.

The Role of Matrix Metalloproteinases in Diabetic Wound Healing in relation to Photobiomodulation

The integration of several cellular responses initiates the process of wound healing. Matrix Metalloproteinases (MMPs) play an integral role in wound healing. Their main function is degradation, by removal of damaged extracellular matrix (ECM) during the inflammatory phase, breakdown of the capillary basement membrane for angiogenesis and cell migration during the proliferation phase, and contraction and remodelling of tissue in the remodelling phase. For effective healing to occur, all wounds require a certain amount of these enzymes, which on the contrary could be very damaging at high concentrations causing excessive degradation and impaired wound healing. The imbalance in MMPs may increase the chronicity of a wound, a familiar problem seen in diabetic patients. The association of diabetes with impaired wound healing and other vascular complications is a serious public health issue. These may eventually lead to chronic foot ulcers and amputation. Low intensity laser irradiation (LILI) or photobiomodulation (PBM) is known to stimulate several wound healing processes; however, its role in matrix proteins and diabetic wound healing has not been fully investigated. This review focuses on the role of MMPs in diabetic wound healing and their interaction in PBM.

Morphology and Progression in Primary Varicose Vein Disorder Due to 677C>T and 1298A>C Variants of MTHFR

Background

Clinical assessment and prognostic stratification of primary varicose veins have remained controversial and the molecular pathogenesis is unknown. Previous data have suggested a contribution of the MTHFR (methylenetetrahydrofolate reductase) polymorphism c.677C>T.

Methods

We collected blood and vein specimens from 159 consecutive patients undergoing varicose vein surgery, or autologous vein reconstruction for arterial occlusive disease as controls. We compared the frequencies of c.677C>T and another polymorphism of MTHFR, c.1298A>C, with morphology and types of complicated disease. Morphology was recorded as a trunk or perforator type and peripheral congestive complication was defined as chronic venous insufficiency (CEAP C3–6) associated with edema and skin manifestations.

Findings

Multivariate analysis of genotypes for c.677C>T and c.1298A>C indicated that c.677C>T was associated significantly with the trunk phenotype (43/53 patients, 81%, p < 0.01), while c.1298A>C was associated significantly with the perforator phenotype (18/24 patients, 75%, p < 0.01) of primary varicose veins. Accordingly, when both c.677C>T and c.1298A>C displayed a heterozygous genotype, the patients were more likely to present with both phenotypes. Additionally, c.1298A>C was found to be strongly linked to the congestive complication (34/51 patients, 67%, p < 0.01).

Interpretation

Both polymorphisms of MTHFR may be involved in the morphological specification of primary varicose veins and contribute to the development of complicated disease.

Funding

None.

•

MTHFR polymorphism c.677C>T characterizes axial trunk and c.1298A>C perforator type morphology in primary varicose veins.

•

Mutant genotypes are associated with complicated phenotypes of the disease.

•

Genetic hint for distinct perforator type morphology associating further with congestive (CEAP C3–6) disease is provided.

The management of varicose veins

This study aimed to review the current management modalities for varicose veins. There are a variety of management modalities for varicose veins. The outcomes of the treatment of varicose veins are different. The papers on the management of varicose veins were reviewed and the postoperative complications and efficacy were compared. Foam sclerotherapy and radiofrequency ablation were associated with less pain and faster recovery than endovenous laser ablation and surgical stripping. Patients undergoing endovenous laser ablation and radiofrequency ablation are most likely to have a faster recovery time and earlier return to work in comparison with those undergoing conventional high ligation and stripping. A randomized controlled study in multiple centers is warranted to verify which approach is better than others for the treatment of varicose veins.

Relative importance of iliac vein obstruction in patients with post-thrombotic femoral vein occlusion

BACKGROUND

Patients with femoral vein occlusion rapidly develop collateral flow through the deep femoral vein, an embryonic collateral. In contrast, iliac vein collateralization is sparser and functionally poorer. It is not uncommon to have femoral vein occlusions associated with iliac vein obstruction, even though the femoral vein occlusion is often more readily apparent on venograms and duplex scans, whereas the iliac vein obstruction may remain occult. We examined whether percutaneous stent correction of iliac vein obstruction associated with femoral vein occlusions would yield symptomatic relief.

METHODS

During a 13-year period, 39 patients with femoral vein occlusions underwent stenting of associated iliac vein stenoses.

RESULTS

Median age was 51 years (17-86 years). The male-to-female and right-to-left ratios were 1:3 and 1:2, respectively. The clinical class of the Clinical, Etiologic, Anatomic, and Pathologic (CEAP) classification was as follows: C0-2 (with pain), two of 39 (5%); C3, 19 of 39 (48%); C4, 10 of 39 (26%); C5, one of 39 (3%); and C6, seven of 39 (18%). Concurrent ablation of a refluxive saphenous vein was performed in seven of 39 (18%). Reintervention was carried out in 14 of 39 limbs (36%). Median follow-up was 26 months (1-154 months). Median iliac vein stenosis was 80% (40%-100%). Primary, primary assisted, and secondary patency rates at 2 years were 57%, 88%, and 96%, respectively. Pain grade (visual analog scale, 0-10) improved from median 5 (0-9) to 3 (0-8) after stenting (P < .03); 12% were completely relieved of pain. Cumulative improvement in pain (≥ 3 of 10 on the visual analog scale) was 87% at 2 years. Median swelling (grade 0, none; grade 1, pitting; grade 2, ankle edema; grade 3, gross) improved from median 3/3 (0-3) to 2/3 (0-3) (P = .09, NS). Among 22 of 39 limbs (56%) with grade 3 swelling before stenting, seven of 22 limbs (32%) with grade 3 swelling improved (≥ 1 grade) after stent placement. In the 15 of 22 limbs (68%) with residual grade 3 swelling after stenting, subjective improvement was reported by all. Four of seven active ulcers (54%) healed. There were no obstructive sequelae after concurrent saphenous ablation. Saphenous flow in the erect position was not different from that of controls with patent femoral veins.

CONCLUSIONS

Percutaneous stenting of associated iliac vein obstruction in symptomatic limbs with femoral vein occlusion yields satisfactory clinical relief. The saphenous vein has little collateral role in this pathologic process and can be safely ablated if it is refluxive, in line with prior observations.

Role of interventional radiologists in the management of lower extremity venous insufficiency

Lower extremity venous insufficiency affects over half of all women. Interventional radiologists should be aware of the clinical evaluation of women with venous insufficiency and classification of disease. Endovascular therapies available for treatment of lower extremity venous insufficiency include: endovenous laser ablation, radiofrequency endovascular ablation, and sclerotherapy. The interventional radiologist should be versed on which therapy to select in each clinical presentation and the procedural techniques. The authors review the role of the interventional radiologist in managing this lower extremity venous disorder.

Management of chronic venous disease by general practitioners in Serbia: a cross-sectional study

BACKGROUND

Chronic venous disease (CVD) is one of the most prevalent medical conditions in the general population worldwide.

OBJECTIVE

To evaluate the management of CVD provided by general practitioners (GPs).

METHODS AND MATERIALS

The 2-center cross-sectional study comprised 2284 patients with CVD diagnosed and treated by GPs. Demographic and clinical data were obtained by physical examinations and standardized interviews.

RESULTS

Patients were counseled about different types of therapy; lifestyle advice was recommended to 88.8%, venoactive drugs to 90.8%, compression therapy to 44.0% of patients, anticoagulants to 16.7%, surgical treatment to 8.3%, and other types of therapy were recommended to 7.8% of patients. The most common types of treatment were dual and triple therapies recommended to 39.5% and 33.1%, respectively. The number of therapies recommended to patients increased with CVD progression. Treatment was not recommended to < 1% of patients. Only 8.4% of patients were referred to a vein specialist.

CONCLUSIONS

Although GPs had undergone special medical training about CVD before they were included in the study, some patients did not receive complete management of their condition. Continuous training of GPs and clinical guidelines for the management of CVD may help GPs to make adequate decisions.

Compression therapy versus surgery in the treatment of patients with varicose veins: A RCT

OBJECTIVE

Superficial venous reflux and varicose veins are common. The aim of this randomized controlled trial was to assess effectiveness of compression therapy compared with surgery for superficial venous reflux.

METHODS

153 patients with CEAP class C2-C3 and superficial venous reflux were randomized to receive either conservative treatment (compression stockings) (n = 77) or surgery (n = 76). Clinical examination including duplex ultrasound (DUS) was performed at entry and 1 and 2 years after randomization (compression group) or surgery (surgery group). Venous Clinical Severity Score without compression stockings (VCSS-S), Venous Segmental Disease Score (VSDS), Venous Disability Score (VDS), and health-related quality of life (HRQoL) were assessed at entry and at the follow-ups. Data were analysed on an intention-to-treat basis and according to the actual treatment performed.

RESULTS

At 2 years, 70/76 patients in the surgery group and 11/77 patients in the compression group had been operated on. VCSS-S decreased from 4.6 to 3.5 in the compression group (p < .01) and from 4.8 to 0.6 in the surgery group (p < .001). VSDS decreased from 7.7 to 7.0 in the compression group and from 8.2 to 0.9 in the surgery group (p < .0001). HRQoL did not change in the compression group, but improved significantly in the surgery group.

CONCLUSION

The surgical elimination of non-complicated superficial venous reflux is an effective treatment when compared with providing compression stockings only.