O078 Why do patients decline to participate in clinical trials? The view of potential participants having varicose vein treatments

Introduction

Varicose veins are prevalent throughout the UK population, affecting a third of adults. Various treatments exist and must be validated by rigorous testing. Randomised control trials (RCTs) are the accepted gold standard in the hierarchy of evidence, comparing the effectiveness of interventions. Poor recruitment is common among surgical trials and threatens their success. To ensure adequate participation, the underlying barriers to recruitment need to be identified. The objective of this study was to identify the reasons for refusal in four varicose vein RCTs. Secondary aims analysed patient characteristics to assess patient trends.

Methods

A qualitative survey was offered to eligible patients refusing recruitment, recording their reasons. Patients were identified and given an information leaflet before confirming a decision. Patient characteristics, demographics and themes were assessed using qualitative and statistical analysis. Ethical approval was not required.

Results

Overall, 115/429 of patients refused RCT participation and all (n=115) completed the survey. Patients mainly expressed refusal due to preferences for different treatments (25%) followed by employment commitments (14%). Follow-up procedures dissuade patients and anxiety was associated with patient characteristics. Females are more concerned about their autonomy (26.4%) whereas males express worry about external obligations (14.6%). Misunderstanding the severity of risks of treatments and varicose veins elevated concerns across both genders.

Conclusion

Unwillingness to participate is determined by individual circumstances, patient bias and altruism. Multiple factors influence decision making such as familial views and personal demographics. Creating a more robust recruitment process relies on encouraging the acceptance of clinical equipoise and targeting patient beliefs through enhanced communication and improving accessibility.

Take-home message

Patients undergoing recruitment into surgical trials are influenced by their ability to understand and recall information, patient preference and individual characteristics which are influenced by demographics such as anxiety and employment. Targeting these identified barriers to participation will improve accessibility into RCTs.

Effect of footplate neuromuscular electrical stimulation on functional and quality-of-life parameters in patients with peripheral artery disease: pilot, and subsequent randomized clinical trial

BACKGROUND

Supervised exercise programmes for intermittent claudication have poor access and limited compliance. Neuromuscular electrical stimulation (NMES) may be an effective alternative. A proof-of-concept study and RCT were conducted.

METHODS

In study 1, eligible patients underwent baseline assessment; treadmill testing for initial (ICD) and maximum (MCD) claudication distance; EuroQoL Five Dimensions five-level instrument (EQ-5D-5L™) and Intermittent Claudication Questionnaire (ICQ) assessment; and measurement of ultrasound haemodynamics of the superficial femoral artery. After familiarization with the NMES device, participants underwent a 30-min session of stimulation with concomitant recording of haemodynamic measures at 15 min, and after device cessation. Measurements were repeated after 6 weeks of daily use of NMES. In study 2, consecutive patients underwent baseline assessment before online randomization to a supervised exercise programme only, or adjunctive NMES treatment for 6 weeks, followed by repeat measurements.

RESULTS

Study 1 (20 patients) showed a significant improvement in MCD (46 per cent; P < 0·001) and ICD (71 per cent; P < 0·001). The RCT (42 patients) showed a significant adjunctive benefit of NMES in ICD (46 per cent; P = 0·014). Improvements were seen in the ICQ (9 points; P = 0·009) and EQ-5D-5L™ (P = 0·007) in study 1, and there was a significant adjunctive benefit of NMES on the ICQ score in patients who did supervised exercise (11·2 points; P = 0·031). Blood volume flow and time-adjusted mean velocity increased significantly with the device on (P < 0·050). Overall, NMES compliance exceeded 95 per cent.

CONCLUSION

Footplate NMES significantly improved walking distance in patients with intermittent claudication when used independently and also as an adjunct to supervised exercise. Registration number: trial 1, NCT02436200; trial 2, NCT02429310 (http://www.clinicaltrials.gov).

Truncal varicose vein diameter and patient-reported outcome measures

Background

Varicose veins and chronic venous disease are common, and some funding bodies ration treatment based on a minimum diameter of the incompetent truncal vein. This study assessed the effect of maximum vein diameter on clinical status and patient symptoms.

Methods

A prospective observational cohort study of patients presenting with symptomatic varicose veins to a tertiary referral public hospital vascular clinic between January 2011 and July 2012. Patients underwent standardized assessment with venous duplex ultrasonography, and completed questionnaires assessing quality of life (QoL) and symptoms (Aberdeen Varicose Vein Questionnaire, EuroQol Five Domain QoL assessment and EuroQol visual analogue scale). Clinical scores (Venous Clinical Severity Score (VCSS) and Clinical Etiologic Anatomic Pathophysiologic (CEAP) class) were also calculated. Regression analysis was used to investigate the relationship between QoL, symptoms and vein diameter.

Results

Some 330 patients were assessed before surgery. The median maximum vein diameter was 7·0 (i.q.r. 5·3–9·2) mm overall, 7·9 (6·0–9·8) mm for great saphenous vein and 6·0 (5·2–8·9) mm for small saphenous vein. In linear regression analysis, vein diameter was shown to have a significant association with VCSS (P = 0·041). For every 1-mm increase in vein diameter, there was a 2·75-fold increase in risk of being in CEAP class C4 compared with C2. No other QoL or symptom measures were related to vein diameter.

Conclusion

Incompetent truncal vein diameter was associated with increasing VCSS, but not a variety of other varicose vein disease-specific and generic patient-reported outcome measures.

Comparison of microbubble presence in the right heart during mechanochemical and radiofrequency ablation for varicose veins

Objective

Mechanochemical ablation is a novel technique for ablation of varicose veins utilising a rotating catheter and liquid sclerosant. Mechanochemical ablation and radiofrequency ablation have no reported neurological side-effect but the rotating mechanism of mechanochemical ablation may produce microbubbles. Air emboli have been implicated as a cause of cerebrovascular events during ultrasound-guided foam sclerotherapy and microbubbles in the heart during ultrasound-guided foam sclerotherapy have been demonstrated. This study investigated the presence of microbubbles in the right heart during varicose vein ablation by mechanochemical abaltion and radiofrequency abaltion.

Methods

Patients undergoing great saphenous vein ablation by mechanochemical abaltion or radiofrequency ablation were recruited. During the ablative procedure, the presence of microbubbles was assessed using transthoracic echocardiogram. Offline blinded image quantification was performed using International Consensus Criteria grading guidelines.

Results

From 32 recruited patients, 28 data sets were analysed. Eleven underwent mechanochemical abaltion and 17 underwent radiofrequency abaltion. There were no neurological complications. In total, 39% (11/28) of patients had grade 1 or 2 microbubbles detected. Thirty-six percent (4/11) of mechanochemical abaltion patients and 29% (5/17) of radiofrequency ablation patients had microbubbles with no significant difference between the groups ( p=0.8065).

Conclusion

A comparable prevalence of microbubbles between mechanochemical abaltion and radiofrequency ablation both of which are lower than that previously reported for ultrasound-guided foam sclerotherapy suggests that mechanochemical abaltion may not confer the same risk of neurological events as ultrasound-guided foam sclerotherapy for treatment of varicose veins.

Factors impacting on patient perception of procedural success and satisfaction following treatment for varicose veins

Background

Patient-reported outcome measures (PROMs) have been collected from patients undergoing varicose vein treatments in the National Health Service since 2009. The aim of this retrospective cohort study was to examine PROMs for varicose vein interventions, characterizing factors that might predict patient-reported perception of procedural success and satisfaction.

Methods

Centrally compiled PROMs data for varicose vein procedures carried out from 2009 to 2011 were obtained from the Hospital Episode Statistics data warehouse for England. As data were not distributed normally, non-parametric statistical tests were employed.

Results

Data for 35 039 patient episodes (62·8 per cent women) were available for analysis. Some 23·4 per cent of patients reported a degree of anxiety or depression before treatment; a formal diagnosis of depression was present in 7·8 per cent. Quality of life, measured by generic EQ-5D-3L™ index and the Aberdeen Varicose Vein Questionnaire (AVVQ) improved after intervention by 11·7 per cent (0·77 to 0·86) and 40·1 per cent (18·95 to 11·36) respectively. No significant improvement was found in EQ-5D™ visual analogue scale scores. There was a significant improvement in self-perceived anxiety or depression after the intervention (P &lt; 0·001, McNemar–Bowker test). Both preoperative and postoperative depression or anxiety had a statistically significant relationship with self-reported success and satisfaction (both P &lt; 0·001, χ2 test).

Conclusion

This analysis of PROMs is evidence that treatment of varicose veins improves quality of life, and anxiety or depression. Preoperative and postoperative anxiety or depression scores impact on patient-perceived success and satisfaction rates.

Retrograde inversion stripping as a complication of the ClariVein mechanochemical venous ablation procedure

The endovenous revolution has accelerated the development of new techniques and devices for the treatment of varicose veins. The ClariVein mechanochemical ablation device offers tumescentless treatment with a rotating ablation tip that can theoretically become stuck in tissue. We present the first report of retrograde stripping of the small saphenous vein without anaesthesia following attempted use of the ClariVein device, without adverse sequelae.

Intra-procedural pain score in a randomised controlled trial comparing mechanochemical ablation to radiofrequency ablation: The Multicentre Venefit™ versus ClariVein® for varicose veins trial

OBJECTIVE

Endovenous techniques are, at present, the recommended choice for truncal vein treatment. However, the thermal techniques require tumescent anaesthesia, which can be uncomfortable during administration. Non-tumescent, non-thermal techniques would, therefore, have potential benefits. This randomised controlled trial is being carried out to compare the degree of pain that patients experience while receiving mechanochemical ablation or radiofrequency ablation. The early results of this randomised controlled trial are reported here.

METHODS

Patients attending for the treatment of primary varicose veins were randomised to receive mechanochemical ablation (ClariVein®) or radiofrequency ablation (Covidien® Venefit™). The most symptomatic limb was randomised. The primary outcome measure was intra-procedural pain using a validated visual analogue scale. The secondary outcome measures were change in quality of life and clinical scores, time to return to normal activities and work as well as the occlusion rate.

RESULTS

One-hundred and nineteen patients have been randomised (60 in the mechanochemical ablation group). Baseline characteristics were similar. Maximum pain score was significantly lower in the mechanochemical ablation group (19.3 mm, standard deviation ±19 mm) compared to the radiofrequency ablation group (34.5 mm ± 23 mm; p < 0.001). Average pain score was also significantly lower in the mechanochemical ablation group (13.4 mm ± 16 mm) compared to the radiofrequency ablation group (24.4 mm ± 18 mm; p = 0.001). Sixty-six percent attended follow-up at one month, and the complete or proximal occlusion rates were 92% for both groups. At one month, the clinical and quality of life scores for both groups had similar improvements.

CONCLUSION

Early results show that the mechanochemical ablation is less painful than the radiofrequency ablation procedure. Clinical and quality of life scores were similarly improved at one month. The long-term data including occlusion rates at six months and quality of life scores are being collected.

A systematic review and meta-analysis on the role of varicosity treatment in the context of truncal vein ablation

Background

With the advent of endovenous truncal ablation under local anaesthetic for the treatment of varicose veins, the fate of varicosed tributaries has become controversial, with centres offering different timings of treatment, if offered at all. This study aims to review the literature assessing delayed and simultaneous varicosity treatment during truncal ablation.

Methods

Randomised trials and cohort studies concerning varicosity treatment timing were identified through a systematic literature search. Requirements for further treatment, quality of life and rate of venous thrombotic events were assessed for meta-analysis.

Results

Four studies were identified assessing need for further varicosity procedure, with no significant difference seen between simultaneous or delayed treatment ( p = 0.339). Two studies assessed quality of life, with simultaneous treatment providing significantly improved outcomes at six weeks ( p = 0.029) but not at 12 weeks ( p = 0.283). Studies examining venous thrombotic events showed no difference in venous thromboembolism rate between simultaneous or delayed treatment approaches ( p = 0.078).

Conclusion

The evidence base regarding timing of varicosity treatment is sparse; however, it does show that simultaneous treatment of varicosities leads to early gains in quality of life, with a non-significant trend for fewer further procedures but more venous thrombotic events.

Acoustic reflectors are visible in the right heart during radiofrequency ablation of varicose veins

Objective

Cerebrovascular events have been noted after foam sclerotherapy for varicose veins. One hypothesis is migration of microemboli to the brain through a cardiac septal defect. The aim of this study was to identify whether acoustic reflectors are found in the right side of the heart during radiofrequency ablation of varicose veins, as neurological events are not reported during these procedures.

Methods

Transthoracic echocardiography was performed during local anaesthetic radiofrequency ablation (VNUS ClosureFast) of the great saphenous vein in 14 patients. An apical view was captured at the start of the procedure, during each cycle of heating and at 1 min post-treatment. Patients were monitored for 1 h. Video loops were read by an independent cardiologist. The presence of acoustic reflectors was classified as: 0 = absent, 1 = occasional, 2 = stream, 3 = complete opacification.

Results

Loops were of diagnostic quality in 11/14 (79%) patients. After the second cycle of heating, acoustic reflectors moving through the right heart were seen in 5/11 (45%) patients. These were classified as grade 1 in four patients and grade 2 in one patient. No acoustic reflectors were seen in the left heart. No neurological symptoms were reported.

Conclusion

Acoustic reflectors in the right heart are a common finding during radiofrequency ablation of varicose veins. Considering the prevalence of cardiac septal defects (17%), more neurological events would be expected if these particles were indeed responsible for these events. Further work is required to elicit the mechanisms underlying neurological complications following sclerotherapy.

Impact of risk scoring on decision-making in symptomatic moderate carotid atherosclerosis

Background

Benefit from carotid endarterectomy (CEA) in symptomatic moderate (50–69 per cent) carotid stenosis remains marginal. The Fourth National Clinical Guideline for Stroke recommends use of the risk score from the European Carotid Surgery Trial (ECST) to aid decision-making in symptomatic carotid disease. It is not known whether clinicians are, in fact, influenced by it.

Methods

Using the ECST risk prediction model, three scenarios of patients with a low (less than 10 per cent), moderate (20–25 per cent) and high (40–45 per cent) 5-year risk of stroke were devised and validated. Invitations to complete an online survey were sent by e-mail to vascular surgeons and stroke physicians, with responses gathered. The questionnaire was then repeated with the addition of the ECST risk score.

Results

Two hundred and one completed surveys were analysed (21·5 per cent response rate): 107 by stroke physicians and 94 by vascular surgeons. The high-risk scenario after the introduction of the ECST risk score showed an increased use of CEA (66·7 versus 80·1 per cent; P = 0·009). The low-risk scenario after risk score analysis demonstrated a swing towards best medical therapy (23·4 versus 57·2 per cent; P &lt; 0·001). CEA was preferred in the moderate-risk scenario and this was not altered significantly by introduction of the risk score (71·6 versus 75·6 per cent; P = 0·609). Vascular surgeons exhibited a preference towards CEA compared with stroke physicians in both low- and moderate-risk scenarios (P &lt; 0·001 and P = 0·003 respectively).

Conclusion

The addition of a risk score appeared to influence clinicians in their decision-making towards CEA in high-risk patients and towards best medical therapy in low-risk patients.

The European burden of primary varicose veins

BACKGROUND

The treatment of varicose veins has been demonstrated to improve quality of life, alleviate symptoms of depression and treat the complications of venous disease. This study aims to show the studies which contain information regarding the prevalence and distribution of venous disease. Then using the population and prevalence data for venous disease, and considering the cost of treating varicose veins, this study aims to analyse the treatment of varicose veins and assess whether there is a disparity between European countries.

METHODS

Relevant papers regarding the prevalence or incidence of venous disease were identified through searches of PubMed (1966 to October 2010). The search terms 'prevalence OR incidence' AND 'varicose veins or venous disease' were used. Population data, prevalence data and the number of varicose vein procedures performed in each country was obtained for 2010.

RESULTS

Four studies were included. From calculated values comparing the predicted and actual number of patients requiring treatment for venous disease, the UK, Finland and Sweden are potentially not treating all patients with C2 disease. In contrast to this, all other European countries represented are treating more patients, suggesting that they may be treating additional patients. There was up to a four-fold difference in the numbers of procedures per million population that were performed for varicose veins in different European countries.

CONCLUSION

There is a marked disparity across Europe between the predicted number of patients with varicose veins requiring treatment and the actual care given. The factors influencing this need more detailed investigation.

Patterns of short saphenous vein incompetence

The significance of short saphenous vein (SSV) reflux is an under-explored territory in chronic venous disease (CVD). We have examined the origin and significance of SSV reflux in primary and secondary CVD. While the natural history of SSV incompetence remains uncertain, its prevalence has been shown to approximate 3.5%, rising with progressing clinical venous insufficiency, and bears an association with lateral malleolar venous ulceration. The most common pattern of reflux extends throughout the SSV Patterns of incompetence in recurrent disease are highly variable, but SSV reflux may itself pose a risk for recurrence, in part due to the complex anatomy of the saphenopopliteal system. Further studies are required to delineate the impact of SSV reflux in secondary venous disease and deep venous incompetence.

Short-term gain for long-term pain? Which patients should be treated and should we ration?

Objectives:

Treatments of common conditions which do not affect mortality often become sidelined in the drive to improve efficiency and reduce costs. The rationing of patients is a divisive but crucial component to universal health care. How should this be accomplished?

Methods and Results:

In this article we examine the outcomes of various rationing methods in varicose veins.

Conclusions:

No method is perfect and treatment of symptoms and complications should remain the target for all physicians.

Management of chronic venous disease by primary care

Objective:

To assess the patterns of referral for chronic venous disease (CVD).

Method:

General practitioners (GPs) were invited by an email to complete a validated online survey evaluating the referral and community management of CVD.

Results:

A total of 138 participants were recruited. Most GPs (85%) saw fewer than 50 patients with CVD a year. Thirty-one percent were aware of National Institute for Clinical Excellence referral guidelines for CVD and 36% were aware of and agreed with local referral guidelines. Eleven percent were aware of clinical venous scoring systems. Sixty-three percent believed mild CVD would progress and 84% believed treatment would improve the quality of life. Sixteen referred C3 disease, 43% C4, 37% C5 and 65% C6 disease. Forty-one percent would refer on request. Pain symptoms increased referral in C2 disease. Endothermal ablation was believed available to 33% and traditional stripping to 62% and 27% were unaware of the treatment options. Forty-five percent were happy to provide postoperative care.

Conclusions:

Despite national guidelines, the management of CVD in the UK is variable.

Management of uncomplicated varicose veins - a case vignette for a clinical decision proposal

Venous disorder is common in the general population. Uncomplicated varicose veins represent a significant proportion of the disease burden, and can impact considerably on quality of life, producing a wide spectrum of symptoms. Little is known about the natural course of the disease at this stage and the treatment strategy employed is often not based on robust scientific evidence. The aim of this article is to elucidate the options to manage uncomplicated varicose veins. There are likely to be significant geographic differences in the treatment strategy employed, and it is hoped that we will arouse discussion among physicians regarding the management of this very common medical condition. The reader will be asked for their preferred treatment choice for a given clinical case vignette.

Total preservation of patency and valve function after percutaneous pharmacomechanical thrombolysis using the Trellis®-8 system for an acute, extensive deep venous thrombosis

Pharmacomechanical thrombolysis is being used increasingly for the treatment of deep vein thrombosis (DVT) and aims to reduce the severity of post-thrombotic syndrome. We report the case of a 60-year-old woman with extensive lower limb DVT that was treated using pharmacomechanical thrombolysis leading to complete recovery of her deep venous system. The prompt use of pharmacomechanical thrombolysis for the acute management of extensive DVT should be considered when treating patients with extensive DVT in order to facilitate return of normal function.

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.

Complications of Radiofrequency Ablation of Varicose Veins

Radiofrequency ablation (RFA) has become a valued weapon in the phlebologist's armoury. It offers ease of use and reproducibility with good outcomes. However, as with all interventions, complications arise. In this review we examine the complications inherent with RFA and their relative risk, with their avoidance measures if available. Overall, we find that RFA offers a very safe procedure with rare severe complications.

The burden of depression in patients with symptomatic varicose veins

OBJECTIVE

To evaluate the burden and impact of depression in patients with symptomatic varicose veins.

METHODS

Patients with varicose veins referred to the vascular surgeons for further management, were invited to complete a validated questionnaire relating to quality of life, using the Aberdeen Varicose Veins Questionnaire (AVVQ), EuroQol-5D questionnaire (EQ-5D) and the EuroQol-Visual Analogue Score (EQ-VAS); and depressive symptoms, using the Centre of Epidemiological Studies Depression Scale (CES-D). Social, demographic, clinical (CEAP classification, venous clinical severity score (VCSS)) and venous disability score (VDS) data was also collected.

RESULTS

One hundred patients, mean age 52.7 years (63 females; 37 males) were recruited. Twenty-nine per cent of patients with varicose veins had depression scores suggestive of depression; no patient had previously been diagnosed or was on treatment. Depression scores were not influenced by age (p = 0.30) or gender (p = 0.60); and there was no correlation between depression scores and VCSS (p = 0.07, r2 = 0.034), or between VDS groups 1, 2 or 3 (p = 0.75). There was a weak correlation between depression scores and AVVQ (p = 0.0009, r2 = 0.12) and depression scores and EQ-5D (p < 0.0001, r2 = 0.32) and EQ-VAS (p < 0.0001, r2 = 0.25).

CONCLUSION

Depression is prevalent in patients with symptomatic varicose veins, where it is commonly undiagnosed and untreated. A more holistic approach to patients with venous disease is therefore advocated.

Internal jugular thrombosis post venoplasty for chronic cerebrospinal venous insufficiency

Chronic cerebrospinal venous insufficiency (CCSVI) is a hypothesis through which cerebral venous drainage abnormalities contribute towards the pathogenesis of multiple sclerosis. CCSVI venoplasty is already practised worldwide. We report the case of a 33-year-old lady with multiple sclerosis who underwent left internal jugular venoplasty resulting in iatrogenic jugular thrombosis requiring open thrombectomy for symptom relief. This occurred without insertion of a stent and while fully anticoagulated. Clinicians should be aware that endovenous treatment of CCSVI could cause paradoxical deterioration of cerebral venous drainage. Patients with complications post venoplasty are now presenting to geographically distant vascular units.

Superficial venous disease treatment--is there still a role for open surgery in 2011?

The treatment of superficial venous disease (commonly described as varicose veins by the general public) has remained relatively constant over the past 100 years until the refinements of endovenous treatments such as sclerotherapy and more recently, the development of endovenous ablation. This has radically changed the treatment profile of this disease with treatments easily administered and well tolerated even in those patients who would not be considered fit for open surgery previously. With the advent of day surgery and improved general and local anaesthetic techniques, venous surgery has forged a path towards the end goal of outpatient treatment with no requirement for inpatient stay. The end goal of all superficial venous surgery is an improvement in quality of life, and with such new treatments reducing the impact of the actual intervention, such gains are easier to make. This review assesses and presents the current literature describing superficial venous disease treatments covering all treatment modalities. With endovenous treatment, true ambulatory treatment is available, providing high quality treatment at speed and convenience for patients.