The correlation between Caprini score and the risk of venous thromboembolism after varicose vein surgery

BACKGROUND

The study aims to identify the incidence of symptomatic and asymptomatic venous thromboembolism (VTE) after minimally invasive varicose vein surgery and to assess the predictability of the Caprini risk score (CRS).

METHODS

CAPrini Score In Venous Surgery (NCT03041805) is a registry-based prospective study that enrolls patients undergoing minimally invasive open (high ligation, stripping, miniphlebectomy) and endovascular (thermal and non-thermal ablation) surgery on varicose veins. The main inclusion criteria are CRS assessment before intervention and a duplex ultrasound scan performance within 2-4 weeks after surgery. The primary outcome is a combination of asymptomatic or symptomatic DVT, including EHIT of class 2-4 and PE.

RESULTS

Totally 1878 records with defined outcomes were analyzed. The mean age of patients was 46.9±13.3 years; 66% were female. Endovenous laser ablation was performed in 88%. Varicose tributaries were treated in 40%, perforating veins in 3.9% of cases. CRS ranged from 1 to 12 (mean of 4.0±1.5). Prophylactic anticoagulation was prescribed in 20%. The primary outcome was reported in 63 cases (3.4%; 95% CI, 2.7-4.3%), comprising asymptomatic (N.=29, 1.5%) or symptomatic (N.=10, 0.5%) DVT or EHIT (n=28, 1.6%). No PE was reported. A significant correlation was found between CRS and VTE incidence (P=0.001). Under logistic regression CRS (OR, 1.3; 95% CI, 1.1-1.6) along with treatment of tributaries (OR, 6.3; 95% CI, 3.0-13.0) and perforating veins (OR, 10.7; 95% CI, 3.8-30.2) were associated with VTE in the absence of prophylactic anticoagulation.

CONCLUSIONS

The incidence of VTE after ablation of superficial veins is 3.4%, predominantly due to asymptomatic EHIT and DVT, and significantly correlates with CRS.

A randomized clinical trial to assess the impact of laser power with constant linear endovenous energy density on outcomes of endovenous laser ablation (SLEDGE trial)

OBJECTIVE

To date, conflicting evidence has been reported regarding the energy settings to use during endovenous laser ablation (EVLA). In the present study, we evaluated the outcomes of EVLA of the great saphenous veins (GSVs) using different power settings with the same linear endovenous energy density (LEED) of ∼70 J/cm.

METHODS

We performed a single-center, randomized, controlled noninferiority trial with a blinded outcome assessment of patients with varicose veins of the GSV who underwent EVLA with a wavelength of 1470 nm and a radial fiber. The patients were randomly assigned to three groups according to the energy setting: group 1, 5 W power and an automatic fiber traction speed of 0.7 mm/s (LEED, 71.4 J/cm); group 2, 7 W and 1.0 mm/s (LEED, 70 J/cm); and group 3, 10 W and 1.5 mm/s (LEED, 66.7 J/cm). The primary outcome was the rate of GSV occlusion at 6 months. The secondary outcomes were pain intensity along the target vein the next day and at 1 week and 2 months after EVLA, the necessity for analgesics, and the occurrence of significant complications.

RESULTS

From February 2017 to June 2020, 245 lower extremities of 203 patients were enrolled. Groups 1, 2, and 3 included 83, 79, and 83 limbs, respectively. At 6 months of follow-up, 214 lower extremities were examined with duplex ultrasound. GSV occlusion was observed in 72 of 72 limbs (100%; 95% confidence interval [CI], 100%-100%) in group 1 and 70 of 71 limbs (98.6%; 95% CI, 97%-100%) in groups 2 and 3 (P < .05 for noninferiority). No difference was found in the pain level, necessity for analgesics, or rate of any other complications.

CONCLUSIONS

The technical results, pain level, and complications of EVLA were not associated with the combination of energy power (5-10 W) and the speed of automatic fiber traction when a similar LEED of ∼70 J/cm was reached.

Current status of endothermal heat induced thrombosis

BACKGROUND

There remain many questions regarding the pathophysiology and risk factors for endothermal heat induced thrombosis formation. Moreover, there are a paucity of data on the timing of its occurrence, and there has been no consensus regarding for its treatment. The purpose of this review is to summarize the current knowledge on the pathophysiology, risk factors and treatment strategies for endothermal heat induced thrombosis.

METHODS

The PubMed database was searched from 2001 to present for endothermal heat induced thrombosis, EHIT, deep vein thrombosis, chronic venous insufficiency, varicose veins, endovenous laser and radiofrequency ablation (treatment). All relevant articles identified by the authors mentioning endothermal heat induced thrombosis were included in this review.

RESULTS

A multitude of risk factors, several pathophysiological hypotheses and different treatment strategies are described in the literature.

CONCLUSIONS

Endothermal heat induced thrombosis is marginally understood. There remains a theoretical risk for significant venous thromboembolic complications. With the new uniform classification of EHIT (American Venous Forum), healthcare providers should continue to investigate the nature of this event.

[Possibilities of using the Colibri system for endovenous laser ablation]

AIM

The purpose of the study was to assess efficacy of endovenous laser ablation of major saphenous veins by means of the Mediola single-ring radial light guides with the use of the 'Optical Handpiece MHP02 (Colibri)'.

PATIENTS AND METHODS

This non-comparative prospective study included 430 consecutive patients who underwent a total of 511 endovenous laser ablation procedures from January 2018 to March 2019. The great saphenous vein was subjected to obliteration in 343 (67.1%) cases, the anterior accessory saphenous vein - in 94 (18.4%) cases, and the small saphenous vein - in 74 (14.5%) cases. There were 170 (39.5%) men and 260 (60.5%) women, with a mean age of 52±12.8 years.

RESULTS

The next day after the intervention the patients revisited the clinic for control examination, with the obtained findings demonstrating that occlusion of the target vein had been achieved in all 511 (100%) cases. At 2 months, we examined 411 (95.6%) people with a total of 484 (94.7%) treated veins. After 6 months, 399 (92.8%) people with 472 (92.4%) veins were examined. Recanalization with pathological reflux during the entire follow-up period was registered in 6 (1.3%) cases. Hence, the long-term rate of obliteration amounted to 98.7%.

CONCLUSIONS

1) endovenous laser ablation of major saphenous veins by means of the Mediola laser unit with wavelength of 1470 nm and single-ring radial light guides with the use of the 'Optical Handpiece MHP02 (Colibri)' made it possible to achieve obliteration of the target vein in 98.7% of cases at 6 months of follow up; 2) within the mentioned terms, the need for repeat intervention could appear in 1.1% of cases; 3) the Colibri system provides a possibility of decreasing the final cost of radial light guides for endovenous laser ablation by 30-50%.

[Possibilities of endovenous laser obliteration of subcutaneous veins with tumescence by cold saline solution]

AIM

The purpose of the present study was to assess the possibility of carrying out endovenous laser obliteration (EVLO) with radial light guides on a laser device operating at a wavelength of 1470 nm, using for tumescence only cold normal saline solution without additional sedation or narcosis in patients with allergy to local anaesthetics.

PATIENTS AND METHODS

Our prospective non-comparative single-centre study consecutively included 37 patients who from November 2014 to June 2019 underwent a total of 41 isolated EVLO procedures without simultaneous miniphlebectomy or sclerotherapy of tributaries. Given the previous history of allergy to amide-group local anaesthetics and/or multiple allergic reactions to other agents, these patients received as anaesthesia and tumescence exclusively normal saline solution cooled to a temperature of +3-6ºC, without addition of local anaesthetics or any other therapeutic agents, with neither sedation nor narcosis.

RESULTS

The great saphenous vein was subjected to coagulation in 33 (80.5%) cases, the anterior accessory saphenous vein in 5 (12.2%), and the small saphenous vein in 3 (7.3%) cases. The median of the mean diameter of the veins at 3 cm from the saphenofemoral or saphenopopliteal junction amounted to 10 mm (1st quartile 8.2; 3rd quartile 11). The median of the mean length of the coagulated vein - 45 cm (1st quartile 22; 3rd quartile 51), the median of the average amount of the administered normal saline solution - 300 ml (1st quartile 200; 3rd quartile 450), the median of the average amount of normal saline per 1 centimetre of the venous length - 8.7 ml (1st quartile 7.5; 3rd quartile 10). All patients without exception tolerated the intervention. The process of laser obliteration was not discontinued due to pronounced perioperative pain syndrome in any case. All patients after the procedure answered the question 'Would you repeat a similar intervention if the need arises?' in the affirmative. All the 41 (100 %) veins subjected to coagulation were obliterated at early terms of follow up, with no ultrasonographic evidence of recanalization.

CONCLUSION

The obtained findings suggest a possibility of performing EVLO in patients with an allergy-burdened history in relation to local anaesthetics using for tumescence exclusively normal saline solution chilled to a temperature of +3-6ºC, with no additional sedation or narcosis. Such an approach makes it possible, on the one hand, not to change the organization of outpatient phlebological care and on the other hand to refuse from involving anaesthesiological support. Besides, it is absolutely safe in relation to the risk for the development of allergic reactions.

[Stenting of calcified iliofemoral venous segment in post-thrombotic syndrome]

Stenting of the iliac veins in patients with post-thrombotic syndrome is an intervention associated with a low risk of complications, high primary and secondary patency rates, low incidence of restenosis, leading to a significant decrease in the severity of symptoms of chronic venous disease and a high rate of trophic ulcer healing, as compared with conservative therapy. Unlike subcutaneous veins, the formation of calcinates in deep veins after endured thrombosis is of considerably less frequent occurrence. Described in the article is a clinical case report concerning successful stenting of the iliofemoral venous segment in a female patient presenting with post-thrombotic syndrome, a trophic ulcer of the crus, and the presence of linear calcinosis in the lumen of the iliac veins and common femoral vein. This case report demonstrates the possibilities of contemporary endovenous techniques in treatment of this cohort of patients. Despite calcified segments, stenting was performed without technical obstacles and with a favourable clinical outcome. Such interventions may be regarded as justified and safe provided the operating surgeon has appropriate skill and experience.

[Damage to subcutaneous nerves in endovenous laser coagulation of the great saphenous vein]

The purpose of this study was to assess the incidence of the development of symptoms of damage to subcutaneous nerves after endovenous laser coagulation (EVLC) of the great saphenous vein (GSV), as well as to determine the effect of these symptoms on quality of life (QoL) of patients. Our retrospective study enrolled a total of 119 patients (mean age 50±13.9 years) subjected to 151 isolated EVLC of the GSV. The average volume of the injected anaesthetic per 1 cm of the vein's length amounted to 8.5±1.9 ml. Puncture of the GSV at the level of the thigh was performed in 37 (24.5%) cases, at the level of the crus in 114 (75.5%) cases. The intervention was performed at the power 5-10 W and linear density of energy approximately 70 J/cm. The median of the follow up period amounted to 264 days. The patients were interrogated by phone. The questionnaire included leading, understandable for patients questions about the presence of postoperative complaints characteristic of damage to subcutaneous nerves, as well as the question about the effect of these complaints on quality of life. The complaints characteristic of damage to subcutaneous nerves were reported for 61 (40.4%) operated limbs, with these symptoms decreasing quality of life only in 7 (4.6%) cases. All respondents noted gradual regression of the symptoms with time. The median of symptom relief amounted to 2 months. The analysis of interrelationship between the level of puncture by the thirds of the femur and crus and the damage of subcutaneous nerves demonstrated no statistically significant association (p=0.108), unlike the analysis by the femur/crus level, wherein the infragenicular puncture significantly increased the risk of traumatisation of subcutaneous nerves (p=0.022). No statistically significant differences by the frequency of damage to subcutaneous nerves depending on the power of energy were revealed (p=0.662). The obtained findings make it possible to recommend EVLC, including with puncture of the GSV below the knee, for patients with varicose veins in this basin.

[Vein morphology after endovenous laser coagulation at different power and similar linear density of energy]

The purpose of the study was to assess the depth of damage to the venous wall after endovenous laser coagulation (EVLC) at different power of the unit - 5, 7 and 10 W and similar linear density of energy (LDE) - approximately 70 J/cm. Our prospective comparative morphological study with blinding included a total of 30 patients subjected to EVLC of the great saphenous vein using the unit with a wavelength of 1,470 nm and radial light guides with automatic traction. The patients were divided into three groups, each comprising 10 patients. The unit's power (W) during EVLC and velocity of light guide traction (mm/s) in group one amounted to 5 and 0.7 (LDE - 71.4 J/cm), in group two to 7 and 1.0 (LDE - 70 J/cm) and in group tree to 10 and 1.5 (LDE - 66.7 J/cm), respectively. The coagulated veins were then procured from mini approaches and subjected to three sections made at a distance of 2 mm from each other. Specimens were stained with haematoxylin-eosin and picrofuxin according to the van Gieson technique. Then, in four places of each section (at 3, 6, 9 and 12 hours) we assessed the depth of the damage to the venous wall and calculated the average percentage of alteration - the ratio of the depth of the lesion to the venous wall thickness. The average depth of damage to the venous wall (μm) amounted in the first group to 122.9 ?m, in the second group to 182.9 μm, and in the third group to 267 μmm. The index of alteration (%) averagely amounted: in group one to 25.7, in group two to 37.9 and in group three (at a power of 10 W) to 55.5 (p=0.0001 when comparing each of the groups (the Kruskal-Wallis test)). Hence, despite an inconsiderable decrease of the LDE from the first to the third group, as power increased, the depth and percentage of damage to venous walls increased statistically significantly. It follows from the above-mentioned that: 1) an increase in power (from 5 to 10 W) of the unit during EVLC at comparable LDE (approximately 70 J/cm) leads to a deeper damage of the venous wall; 2) it is necessary to carry out a clinical study aimed at comparing different modes of coagulation, with the assessment of the frequency of recanalization and the level of pain syndrome.

[Efficacy of using rivaroxaban for treatment of heat-induced thrombosis after endovenous laser ablation]

AIM

The study was aimed at assessing efficacy of using rivaroxaban for treatment of endothermal heat-induced thrombosis (EHIT) after endovenous laser ablation (EVLA) of saphenous veins.

MATERIAL AND METHODS

Our prospective study included a total of 1,326 patients subjected to 1,514 EVLAs. In 1,091 (72.1%) cases the great saphenous vein (GSV) was ablated, in 124 (8.2%) cases the anterior accessory vein (AAV) was treated and in 299 (19.7%) cases the small saphenous vein (SSV) was treated. Heat-induced thrombosis developed in 21 (1.4%) cases: in 19 cases in the basin of the great saphenous vein and in 2 cases in the anterior accessory saphenous vein. No heat-induced thromboses in the basin of the small saphenous vein were observed. In 9 (0.6%) cases there was class 1 EHIT (according to the Kabnick classification), class 2 EHIT was noted in 10 (0.7%) cases and class 3 EHIT was observed in 2 (0.1%) cases. All patients with EHIT were given rivaroxaban: patients with class 1 EHIT received it at a single daily dose of 20 mg, patients with class 2 and 3 EHIT - at a dose of 15 mg twice daily. In one (4.8%) case the drug had to be discontinued on day two due to the development of dyspeptic events. All patients were found to have complete regression of the heat-induced thrombus within 6-25 days. No cases of clinical manifestations of pulmonary artery thromboembolism were observed. A conclusion was drawn that in clinical practice EHIT is an important and insufficiently studied problem. Rivaroxaban may be used as an oral agent for treatment of heat-induced thromboses after EVLA. Further studies are required to examine its efficacy and safety profile.

[Simultaneous treatment of carotid paraganglioma and stenosis of the carotid arteries]

The article deals with a rare clinical case of a combination of two pathological processes in the area of the bifurcation of carotid arteries, i. e. carotid paraganglioma and critical atherosclerotic stenosis of the internal carotid artery. The first clinical manifestation of atherosclerotic stenosis was cerebral infarction. The additional examination was followed by surgical treatment - removal of the carotid paraganglioma and simultaneous eversion carotid endarterectomy. The postoperative period was uneventful. In the available literature similar combinations are mentioned only sporadically.