Endovenous cyanoacrylate ablation for chronic venous insufficiency and varicose veins among Asians

Introduction: Endovenous cyanoacrylate glue (CAG) ablation for the treatment of chronic venous insufficiency (CVI) and varicose veins has shown non-inferior outcomes with an excellent safety profile, high patient satisfaction rate, and excellent efficacy when compared to the gold standard of endothermal ablation. A review of the current literature for CAG use in CVI showed that most studies and longer-term data are from Caucasian-based populations, which are subject to different anatomical venous variations and socio-economical contexts. This review aimed to gather the current evidence for CAG use in Asian CVI patients. Methods: Asian studies for the use of CAG in CVI were included in this review. Successful ablation rates, quality of life improvement and novel complications such as glue hypersensitivity reactions are described, along with anatomical descriptions of superficial venous anatomy in study patients. Use of CAG in Singapore and Asia was addressed. Results: CAG has been gaining traction as an option for CVI treatment in Asians. In Singapore, it has been adopted with comparable low complication rates and significant improvement of quality of life after treatment. As we increase our understanding of the variations in venous anatomy in the Asian population, new techniques such as retrograde deployment of the device and use of CAG ablation for venous leg ulcers have been developed. Conclusion: Further robust evidence in terms of large randomised control trials along with costeffectiveness studies are needed to determine the true value of CAG ablation in the Asian setting.

[A new-type device for endovasal laser obliteration of varicose veins]

The purpose of the study was to work out a Russian-made, simple-to-manufacture, safe, inexpensive and efficient device for performing endovasal laser obliteration (EVLO) of varicose veins, with the underlying principle of endoluminal distribution of the total laser energy into several flows. The development of this device was based on the principle of dividing the total laser radiation into two energy flows. One flow has a shape of circularly formed, continuous field of laser radiation of specified width within the angular range from 50 to 90°, which ensures the main energetic contribution to thermal impact on the vascular wall. The second energetic flow is formed in the part of the tip having a shape of a truncated cone, along the axis of the optical fibre within the angular range from 10 to 50°, which ensures additional thermal effect of radiation on the narrowing walls of the venous channel. Starting from 2016, EVLO with the use of the developed device was performed in a total of 50 patients with class C2-C3 varicose veins. The morphogenesis of the occurring restructuring of the venous wall was studied intraoperatively and in various time periods. Tissue specimens obtained intraoperatively demonstrated in the majority of cases complete or partial intimal detachment, swelling, disorganization of the middle membrane, adventitial loosening with thrombosis of the elements of the vasa vasorum in the majority of portions. The histological specimens harvested at 10 to 14 days were found to contain in the venous wall clear-cut distinct evidence of actively commensing connective-tissue proliferation. At 1 month of follow up the specimens of the veins treated with EVLO using the developed device showed the beginning of collagenisation of the wall, with finally fibrous restructuring and wall hyalinosis by month 3 after EVLO. The proposed device for EVLO of varicose veins makes it possible to act upon the venous wall simultaneously with two energy flows which excludes negative thermal action of excess energy of laser radiation on the vascular wall while using unidirectional radiation in the form of one or even two, but thin rings and, thus, dramatically decreasing reducing the risk for the development of complications. Implementation of the new device into the phlebological practice in Russia in conditions of complete import substitution has significant economic benefit.

Frequency and severity of hypersensitivity reactions in patients after VenaSeal™ cyanoacrylate treatment of superficial venous insufficiency

Objective

Hypersensitivity reaction presenting as a distinctive erythematous rash has been reported following VenaSeal™ cyanoacrylate adhesive closure. We report the frequency of hypersensitivity reactions, time to onset, duration, and severity of symptoms in patients treated with cyanoacrylate adhesive closure at a single institution. Patient and procedural factors associated with hypersensitivity reactions were evaluated.

Methods

A combined retrospective/prospective review of cyanoacrylate adhesive closure-treated patients was conducted over five years. Data collected from electronic medical records were reviewed for the presence of hypersensitivity reactions along with the time of onset, duration of symptoms, and severity of reaction. Severity was classified as mild if no treatment or over the counter medication was provided, moderate if steroids were required, and severe if the reaction lasted >30 days or required vein excision.

Results

Three hundred and seventy-nine limbs were treated in 286 patients (313 treatment days). Hypersensitivity reactions occurred in 18 patients (5.8% treatments, 6.3% patients). Thirteen were mild (4.2%), four were moderate (1.3%), and one was severe (0.3%). No patient or procedural predictive factors for hypersensitivity reaction were identified other than a trend towards decreased hypersensitivity reactions in patients with Clinical, Etiologic, Anatomic, Pathophysiologic (CEAP) clinical class C4–C6 (p = .06). Second limb treatment on a subsequent day was performed in 27 patients, and no hypersensitivity reactions occurred. Symptom onset time ranged from 1 to 23 days, with a mean of 13 days (confidence interval (CI) ±3.5 days). Duration of symptoms ranged from 3 to 28 days (mean 10.8 CI ±4.9 days).

Conclusions

Hypersensitivity reactions occurred in 6.0% of patients treated with cyanoacrylate adhesive closure, but most were mild and self-limited. Severe reactions were uncommon. No predictive patient or procedural factors were found to be associated with hypersensitivity reactions other than a trend towards decreased risk in patients with advanced CEAP clinical class. Previous cyanoacrylate adhesive closure treatment was not a predictive factor for hypersensitivity reaction in patients undergoing treatment at a later date.

Persistent type IV hypersensitivity after cyanoacrylate closure of the great saphenous vein

The VenaSeal (Medtronic, Minneapolis, Minn) cyanoacrylate closure system is a nonthermal technique for ablating saphenous veins using a proprietary n-butyl cyanoacrylate. One possible side effect is an allergic reaction to cyanoacrylate. We report the case of a 49-year-old woman treated with cyanoacrylate closure who developed a persistent type IV hypersensitivity reaction. The patient elected to have the vein excised, and the histologic features were consistent with a type IV hypersensitivity reaction.

[Retrospective analysis of results of using cyanoacrylate composition for varicose vein ablation]

The method of cyanoacrylate ablation of varicose veins is currently considered as a possible alternative to traditional methods of thermal obliteration. One of significant advantages of this method is no need for performing tumescent anaesthesia. Over the period from 1995 to 2002, cyanoacrylate obliteration of varicose veins was carried out in a total of 96 patients, with clinical assessment of the complication rate and efficacy at various time intervals, with the maximum follow-up period amounting to 3 years. In addition to clinical assessment of the results, presented are the findings of histological examinations of morphological changes occurring in the venous wall and lumen after administration of cyanoacrylate on days 3, 7, 10, 14, 21, 30 and 90. The conclusion was drawn on feasibility of carrying out prospective studies on using various glue compositions of both Russian and foreign manufacture in order to determine all benefits and disadvantages of this group of chemical compounds for more successful and wider implementation of them into clinical practice of modern phlebology.