Treatment of varicose veins: the present and the future--a questionnaire survey

Treatment of Primary Varicose Veins in Japan: Japanese Vein Study XVII

Purpose: This study aimed at clarifying the changes in treatments for primary varicose veins in Japan. Methods: A questionnaire was mailed to the members of the Japanese Society of Phlebology. The contents of the survey covered the treatment and treatment strategy of varicose vein cases in 2013. The results were examined and compared with the results of previous surveys conducted by the aforesaid society in 1998, 2004 and 2009. Results: Of 36078 patients, 43958 limbs were reported from 201 institutions. Saphenous type was the most common type of varicose veins that developed in patients aged 70-79 years. The C4-6 cases according to the Clinical-Etiology-Anatomy-Pathophysiology (CEAP) classification occurred significantly more in males than in females (p <0.01). For the treatments of saphenous type and of segment type (dilatation of peripheral branch), endovenous laser ablation (EVLA) was performed most frequently (51%), while the frequency of stripping and of high ligation decreased. EVLA was performed with tumescent local anesthesia, which required one day of hospitalization. Conclusion: In our study, the number of patients with varicose veins increased especially in the elderly. Surgical treatments were selected for a number of patients, and EVLA was the most commonly adopted method of treatment in Japan. (This article is a translation of Jpn J Phlebol 2016: 27; 249-57.).

Radiofrequency ablation of varicose veins improves venous clinical severity score despite failure of complete closure of the saphenous vein after 1 year

BACKGROUND AND OBJECTIVES

Endovenous treatment is increasingly supplanting open surgery for the treatment of varicose veins. Among emerging endovenous techniques, radiofrequency ablation (RFA) with a ClosureFast catheter is popular in Korea. The objective of this study was to evaluate and compare the efficacy and patient-reported outcomes of RFA of varicose veins.

METHODS

This is a retrospective study of a prospectively registered database of patients who underwent RFA for varicose veins from 2012 to 2013 in St. Mary's Hospital in Seoul. Korea. Efficient ClosureFast RFA catheters (Medtronic, San Jose, CA, USA) were used. The techniques used for RFA of varicose veins were performed according to the manufacturer's recommendations. Duplex scans and venous clinical severity scores (VCSSs) were used to document treatment outcome and patient symptoms before and after the procedures. Treatment outcomes were estimated before the procedure and 3 months, 6 months, and 12 months after the procedure. Outcomes were analyzed by paired t test, chi-square test, or Fisher's exact test as well as by logistical regression.

RESULTS

A total of 117 patients were evaluated for 183 consecutive RFA procedures (183 limbs). The initial technical success was 97.3% (178/183). The estimated mean VCSS changed over time from 4.0 ± 1.67 at preprocedure to 0.6 ± 1.05, 0.5 ± 1.02, and 0.6 ± 1.14 at 3 months, 6 months, and 12 months after the procedure, respectively. The improved VCSS was maintained 1 year after the procedure (p < 0.001). Recanalization of the saphenous vein was detected in 20 limbs at the 1-year follow up. The treatment failure group also exhibited a significant decline in the VCSS between preprocedure and 12 months (4.8 ± 1.76 vs. 1.8 ± 2.04, p < 0.001). Specifically, in the treatment failure group, 65% of limbs with episodic recanalization (13/20) were reoccluded or recanalized without venous reflux at the 1-year follow up.

CONCLUSION

In this study, RFA of varicose veins had an initial success rate of 97.7% and a significantly improved patient VCSS at 1 year. Patients with episodic recanalization of the saphenous vein also exhibited an improved VCSS with favorable duplex findings at 1 year.

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

BACKGROUND

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

OBJECTIVES

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

DESIGN

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

SETTING

Eleven UK specialist vascular centres.

PARTICIPANTS

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

INTERVENTIONS

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

PRIMARY OUTCOME MEASURES

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

SECONDARY OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

FUTURE WORK

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

TRIAL REGISTRATION

Current Controlled Trials ISRCTN51995477.

FUNDING

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

Radiofrequency thermal ablation versus conventional saphenectomy

BACKGROUND: Varicose veins of the lower limbs have a high prevalence worldwide. New treatment techniques have been developed with the objectives of improving patients' quality of life and reducing recovery times. OBJECTIVE: To evaluate patients with incompetent saphenous veins treated using conventional saphenectomy or radiofrequency ablation (RF), in terms of postoperative status. METHODS: From May 2012 to April 2013 146 varicose veins patients with saphenous insufficiency, 90 of whom were treated with conventional surgery (G1) and 56 with RF ablation (G2), were evaluated prospectively. RESULTS: In G1, 88.61% of patients complained of postoperative pain and needed to take analgesics, compared with 28.85% in G2 (p<0.05). Mean pain rating on an analog scale from 0 to 10 was 3.91±2.13 points for G1 and 1.76±3.01 points for G2 (p<0.05). Recovery periods ranged from 26.63±13.3 days to 18.26±19.37 days, for G1 and G2 respectively. Mean time taken to become totally asymptomatic was 66.78±60.9 days for G1 and 38.38±46.8 days for G2 (p<0.05). CONCLUSIONS: The RF treatment method caused less postoperative pain and resulted in earlier recovery, when compared to conventional saphenectomy.

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.

Compression regimes after endovenous ablation for superficial venous insufficiency – A survey of members of the Vascular Society of Great Britain and Ireland

Introduction

The optimal compression regime following ultrasound guided foam sclerotherapy (UGFS), radiofrequency ablation (RFA) and endovenous laser ablation (EVLA) for varicose veins is not known. The aim of this study was to document current practice.

Methods

Postal questionnaire sent to 348 consultant members of the Vascular Society of Great Britain and Ireland.

Results

Valid replies were received from 41% ( n = 141) surgeons representing at least 68 (61%) vascular units. UGFS was used by 74% surgeons, RFA by 70% and EVLA by 32%, but fewer patients received UGFS (median 30) annually, than endothermal treatment (median 50) – P = 0.019. All surgeons prescribed compression: following UGFS for median seven days (range two days to three months) and after endothermal ablation for 10 days (range two days to six weeks) – P = 0.298. Seven different combinations of bandages, pads and compression stockings were reported following UGFS and four after endothermal ablation. Some surgeons advised changing from bandages to stockings from five days (range 1–14) after UGFS. Following endothermal ablation, 71% used bandages only, followed by compression stockings after two days (range 1–14). The majority of surgeons (87%) also treated varicose tributaries: 65% used phlebectomy, the majority (65%) synchronously with endothermal ablation. Concordance of compression regimes between surgeons within vascular units was uncommon. Only seven units using UGFS and six units using endothermal ablation had consistent compression regimes.

Conclusion

Compression regimes after treatments for varicose veins vary significantly: more evidence is needed to guide practice.

Survey of management of common iliac artery aneurysms by members of the Vascular Society of Great Britain and Ireland

INTRODUCTION

The aim of this study was to determine whether the current management of common iliac artery aneurysms (CIAAs) by vascular surgeons is in tune with existing guidelines for referral.

METHODS

This was a postal survey of members of the Vascular Society of Great Britain and Ireland. The main outcome measures were relative frequency of ruptured CIAA, respondents' size threshold for surveillance versus intervention, and their management strategies for isolated unilateral CIAAs, bilateral CIAAs and aortoiliac aneurysms.

RESULTS

Two hundred and eighty-four (anonymous) replies were received (48% response rate). Respondents estimated that a ruptured abdominal aortic aneurysm (AAA) was 25 times more common than a ruptured CIAA. Most surgeons (64%) would wait until a CIAA reached 4 cm in diameter before considering intervention. This threshold was not affected by other scenarios such as the presence of a bilateral CIAA or a small (4 cm) AAA. Eighty per cent of surgeons would treat a non-ruptured CIAA by stenting, where possible. The majority of surgeons felt that ultrasonography surveillance should be commenced when a CIAA exceeds 1.5 cm, with a surveillance interval of 1 year but with more frequent surveillance for CIAAs wider than 3 cm.

CONCLUSIONS

Existing guidelines that recommend referral for possible intervention for non-ruptured CIAAs at a diameter of 3 cm are out of tune with current practice. Most surgeons in this survey would wait until the diameter was 4 cm.

The incidence and characterization of deep vein thrombosis following ultrasound-guided foam sclerotherapy in 1000 legs with superficial venous reflux

OBJECTIVE

The incidence of deep vein thrombosis (DVT) following ultrasound-guided foam sclerotherapy (UGFS) ranges from 0% to 5.7%. The aim of this study was to assess the incidence of DVT following UGFS in a single vascular center.

METHODS

Patients undergoing UGFS between December 2005 and September 2011 underwent quality control duplex imaging within 2 weeks of treatment. This was performed by an independent senior vascular technologist, and data were entered on a prospectively maintained database. Deep venous segments assessed included common femoral vein, femoral vein, above- and below-knee popliteal veins, gastrocnemius, and tibial veins. DVT when present was labeled as endovenous foam-induced thrombosis (EFIT) type 1 when thrombus was lining <25% of the lumen of the deep vein; type 2 when thrombus extension was 25% to 50%; type 3 when thrombus extension was 50% to 99%; and type 4 when the deep vein was occluded.

RESULTS

A total of 1166 UGFS treatments were performed in 1000 legs (776 patients). Complete occlusion of the treated veins was seen in 84.5% of the legs after one session of treatment. Overall, 17 DVTs were detected (1.5%) with no DVTs detected in legs undergoing multiple treatments. Of the 17 episodes of DVT, 16 legs had DVT following treatment for truncal reflux (658 legs; 2.43%). Seven DVTs were EFIT type 1, two were type 2, two were type 3, and five were type 4. One DVT was seen in the gastrocnemius vein alone. Two of 1166 treatments (0.2%) resulted in a symptomatic DVT, both of which were EFIT type 4. On regression analysis, there was an increase in the risk of DVT when ≥10 mL of foam was injected (odds ratio, 4.63; 95% confidence interval, 1.44-14.9; P = .01).

CONCLUSIONS

The incidence of duplex-detected DVT following foam sclerotherapy is low and may be associated with the injection of ≥10 mL of foam.

Haemostatic activation and inflammatory response after three methods of treatment of great saphenous vein incompetence

OBJECTIVE

The purpose of this study was to compare the activation of haemostasis and inflammatory response after three different methods of treatment of great saphenous vein (GSV) incompetence.

MATERIAL AND METHODS

Forty-five patients with GSV incompetence were assigned to one of the three types of treatment: high ligation and stripping (HL&S), radiofrequency ablation with ClosureFast (RFA) and endovenous laser ablation (EVLA) with 810 nm diode laser with miniphlebectomy if required. Peripheral blood samples were obtained in the morning before the surgery and 24 hours and 10 days after the procedure. The concentrations of C-reactive protein (CRP), D-dimer, prothrombin fragment 1 + 2 (F1 + 2), antigen of tissue plasminogen activator (t-PA) and von Willebrand factor (vWF) antigen and activity of plasminogen activator inhibitor (PAI-1) were determined. The results were statistically analysed with SPSS for Windows 15.0.

RESULTS

Thirty-eight patients completed the study: 13 from RFA, 14 from EVLA and 11 from HL&S group. The baseline data did not differ among groups. There was a significant increase of D-dimer in HL&S group after 24 hours (P = 0.002). The changes in RFA and EVLA groups did not show statistical significance (P = 0.092). PAI-1 decreased in RFA patients after 24 hours (P = 0.02), did not change in EVLA patients, and tended to increase after HL&S (P = 0.08). The highest CRP increase was observed in HL&S group (P = 0.003). No significant changes in F1 + 2, t-PA and vWF were observed in any group of patients at 24 hours. At 10 days, a further significant increase of D-dimer (P = 0.04) and CRP (P = 0.018) concentrations in HL&S but not RFA and EVLA patients was observed.

CONCLUSIONS

Endovenous thermal ablation is associated with significantly less activation of haemostasis and inflammatory response when compared with HL&S.

Treatment Options, Clinical Outcome (Quality of Life) and Cost Benefit (Quality-adjusted Life Year) in Varicose Vein Treatment

Varicose veins are an extremely common condition causing morbidity; however, with current financial pressures, treatment of such benign diseases is controversial. Many procedures allow the treatment of varicose veins with minimal cost and extensive literature supporting differing approaches. Here we explore the underlying evidence base for treatment options, the effect on clinical outcome and the cost-benefit economics associated with varicose vein treatment. The method of defining clinical outcome with quality-of-life assessment tools is also investigated to explain concepts of treatment success beyond abolition of reflux.

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.

Ultrasound-guided foam sclerotherapy is a safe and clinically effective treatment for superficial venous reflux

OBJECTIVE

To test the hypothesis that ultrasound-guided foam sclerotherapy (UGFS) is a safe and durable treatment for superficial venous reflux (SVR) associated with CEAP clinical grade 2-6 disease.

METHODS

This was an interrogation of a prospectively gathered computerized database.

RESULTS

Between March 23, 2004 and December 31, 2009, 977 patients (1252 legs) underwent UGFS for unilateral (702 legs) or bilateral (550 legs) SVR in association with CEAP clinical grade 2-3 (n = 868), 4 (n = 232), or 5/6 (n = 152) disease. The following reflux in 1417 venous segments was treated: primary great saphenous vein (GSV) (n = 745); recurrent GSV (n = 286), primary small saphenous vein (SSV) (n = 189), recurrent SSV (n = 50); primary anterior accessory saphenous vein (AASV) (n = 93); recurrent AASV (n = 46); vein of the popliteal fossa (VOPF) (n = 5), and Giacomini vein (GV) (n = 3). Three hundred forty-eight legs (27.8%) had undergone previous surgery. Three patients suffered post-UGFS deep vein thrombosis (DVT) and one a pulmonary embolus (PE), all within the first month (0.4% venous thrombo-embolic complication rate). Five patients (0.5%) had transient visual disturbance at the time of, or shortly after, treatment. No other neurologic or serious complications were reported. During a mean (range) follow-up of 28 (<1 to 68) months, 161 (12.9%) legs underwent a further session of UGFS for truncal VV at a mean (range) of 17 (<1 to 63) months following the first treatment. In 52 legs, retreatment was due to the development of new SVR and in 109 legs was for true recurrence (8.7% complete or partial recanalization rate leading to treatment). There was no significant difference in retreatment rates between UGFS for GSV and SSV reflux or between UGFS for primary or recurrent disease.

CONCLUSION

UGFS for CEAP 2-6 SVR is associated with a low complication and retreatment rate. However, as patients are at risk of developing recurrent and new SVR they should be kept under review. Further UGFS for new or recurrent disease is simple, safe, and effective.

Randomized clinical trial of VNUS® ClosureFAST™ radiofrequency ablation versus laser for varicose veins

Background

Endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) are both associated with excellent technical, clinical and patient-reported outcomes for the treatment of varicose veins. The aim of this study was to compare the techniques in a randomized clinical trial.

Methods

Consecutive patients with primary great saphenous vein reflux were randomized to EVLA (980 nm) or RFA (VNUS® ClosureFAST™) at a single centre. The primary outcome measure was postprocedural pain after 3 days. Secondary outcome measures were quality of life at 6 weeks, determined by the Aberdeen Varicose Vein Questionnaire (AVVQ) and Short Form 12 (SF-12®), and clinical improvement assessed by the Venous Clinical Severity Score (VCSS). Analyses were performed on the basis of intention to treat using multivariable linear regression.

Results

Some 131 patients were randomized to EVLA (64 patients) or RFA (67). Mean(s.d.) pain scores over 3 days were 26·4(22·1) mm for RFA and 36·8(22·5) mm for EVLA (P = 0·010). Over 10 days, mean(s.d.) pain scores were 22·0(19·8) mm versus 34·3(21·1) mm for RFA and EVLA respectively (P = 0·001). The mean(s.d.) number of analgesic tablets used was lower for RFA than for EVLA over 3 days (8·8(9·5) versus 14·2(10·7); P = 0·003) and 10 days (20·4(22·6) versus 35·9(29·4) respectively; P = 0·001). Changes in AVVQ, SF-12® and VCSS scores at 6 weeks were similar in the two groups: AVVQ (P = 0·887), VCSS (P = 0·993), SF-12® physical component score (P = 0·276) and mental component score (P = 0·449).

Conclusion

RFA using VNUS® ClosureFAST™ was associated with less postprocedural pain than EVLA. However, clinical and quality-of-life improvements were similar after 6 weeks for the two treatments. Registration number: ISRCTN66818013 (http://www.controlled-trials.com).

The treatment of varicose veins: an investigation of patient preferences and expectations

Objectives

A number of modalities are now available for the treatment of varicose veins. The aim of the study was to investigate the factors considered important by patients when contemplating treatment of their varicose veins.

Methods

Consecutive new patients referred to a vascular surgery service were invited to complete a short anonymous questionnaire prior to their consultation. The questionnaire consisted of 13 multiple choice questions relating to symptoms, potential varicose vein treatments and patient knowledge of existing therapies.

Results

Of 111 patients, there were 83 complete responses (75%). Symptoms of pain or aching were reported as moderate or severe by 77/103 (75%) of patients and significantly limited the activities of 47/101 (47%). Although the majority (89/103 [86%]) of patients were aware of surgery, only 52/103 (51%) knew of the existence of endothermal ablation (either laser or radiofrequency) and only 23/103 (22%) were aware of foam sclerotherapy. Some 58/92 (63%) were in favour of local anaesthetic treatment. Most patients (74/103, 72%) felt inadequately informed to express a preference regarding treatment type prior to their consultation, although 24/103 (23%) expressed a preference for endovenous treatment. Interestingly, 74/92 (80%) stated that the opinion of their vascular surgeon would be likely to or definitely influence their treatment decision and the majority of patients stated that what they had read in magazines (54/80, 64%) or on the Internet (51/85, 60%) would have no influence on their decision regarding treatment, respectively.

Conclusion

Only a minority of patients referred with varicose veins were aware of endovenous treatments or felt adequately informed to express a treatment preference prior to consultation. Over half of patients expressed a preference for local anaesthetic therapy and a preference for a single visit treatment, although most would be strongly influenced by the opinion of their vascular surgeon and not influenced by media advertising.

Pain Following 980-nm Endovenous Laser Ablation and Segmental Radiofrequency Ablation for Varicose Veins: A Prospective Observational Study

Objectives: The aim of this study was to evaluate postoperative pain following endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) and identify risk factors for increased pain. Methods: Patients undergoing either segmental RFA (VNUS Closure Fast TM, VNUS Medical Technologies, San Jose, California) or EVLA (980 nm) for varicose veins completed a preoperative disease-specific quality-of-life questionnaire (Aberdeen Varicose Vein Questionnaire [AVVQ]) and a diary card recording postoperative pain, return to normal activities, and return to work. Median 3- and 10-day pain scores were calculated. Results: In all, 81 patients returned diary cards (RFA = 45, EVLA = 36). Patients receiving RFA reported less postoperative pain than those receiving EVLA at 3 days (14.5 vs 25.8 mm, P = .053, Mann-Whitney U test) and 10 days (13 vs 23.3 mm, P = .014, Mann-Whitney U test) and returned to work earlier than those receiving EVLA (median 5 vs 9 days, P = .022). Conclusions: Patients treated with segmental RFA had less postoperative pain and returned to work quicker than those treated with EVLA.

Endovenous treatments for varicose veins – over-taking or over-rated?

Objectives

A variety of endovenous therapies for the treatment of superficial venous incompetence are currently available. The aim of this study was to evaluate the prevalence of endovenous techniques used by consultant vascular surgeons in the United Kingdom.

Methods

An anonymous online survey of 16 multiple choice questions relating to the nature and provision of treatment for varicose veins was devised. Consultant members of the Vascular Society of Great Britain and Ireland were invited to participate by email.

Results

A total of 108/352 (31%) surgeons completed the survey. The majority offered surgery as the first-line treatment for primary great saphenous vein (GSV) and small saphenous vein (SSV) incompetence (69% and 74%, respectively). Endovenous procedures were offered as first-line treatment by 32/108 (29.6%) for GSV reflux, 36/51 (70.6%) surgeons performed these under local anaesthetic and 21/51 (41.2%) were performed as an outpatient procedure. The most important factor influencing treatment decisions was considered to be patient preference by 77/108 (71.3%) surgeons, although 48/61 (78.7%) respondents were restricted by primary care trusts with regard to endovenous treatments, and 33/108 (30.6%) offered different treatments to private patients.

Conclusion

Traditional surgery remains the most commonly offered treatment for patients with varicose veins. The provision of endovenous therapies varies greatly, and there are significant differences in local availability regarding these treatments.

Evaluation of published reports of foam sclerotherapy: what do we know conclusively?

Objectives

The aim was to evaluate the published literature to assess what is conclusively known about optimal technique and outcome for foam sclerotherapy.

Methods

A literature search was performed for randomised controlled trials, meta-analyses and observational studies using appropriate statistical techniques with survival analysis for long-term outcome.

Results

Foam is more effective than liquid for ultrasound-guided sclerotherapy. Both sclerosants commonly used are equally effective for sclerotherapy for small veins. Ultrasound signals appear in the systemic circulation in most patients after foam sclerotherapy but do not appear to be associated with serious complications.

Conclusion

Little else is known about the optimal preparation of foamed sclerosants and the best technique for administering foam for sclerotherapy. Long-term studies are required to determine outcome for various techniques. There is an opportunity for many controlled trials to assess results.

Standard varicose vein surgery

This article examines the practice of standard varicose vein surgery including sapheno-femoral and sapheno-popliteal ligation, perforator surgery and surgery for recurrent varicose veins. The technique of exposure of the sapheno-femoral junction and the sapheno-popliteal junction is outlined and advice given on avoidance of complications for both. The evidence regarding methods of closure over the ligated sapheno-femoral junction is examined as is the requirement for stripping and the use of different types of stripper. The requirement to strip the small saphenous vein and the extent of dissection necessary in the popliteal fossa is also examined. Complications of standard varicose vein surgery are outlined. The frequency of wound infection, nerve injury, vascular injury and venous thromboembolism are listed and strategies to avoid these complications are examined.