Comparative effectiveness of endovenous laser coagulation techniques in preventing recurrences of varicose vein disease in the lower extremities

Introduction. This article presents a clinical case of successful and single-stage endovenous laser coagulation combined with miniphlebectomy in a patient with extensive and combined varicose lesion of all major subcutaneous veins of the lower limbs with significant symptoms of chronic venous insufficiency.Aim. To determine the possibilities of simultaneous elimination of all main subcutaneous veins and their varicose tributaries on both lower limbs using minimally invasive methods.Materials and methods. A 44-year-old female patient complained of gastrocnemius muscle cramps, swollen shins, feeling of heaviness at the end of the working day and the presence of varicose veins in both lower extremities. The severity of the chronic vein disease before the intervention according to the VCSS (Venous clinical Severity Score) was 8. As a result, patency of deep veins and condition of their valve apparatus, insufficiency of valves of the sapheno-femoral and sapheno-popliteal annexes on both sides with reflux through large and small saphenous veins and anterior accessory large saphenous vein on the right, insufficiency of perforating veins of both tibias were determined. Endovenous laser coagulation of the great and small saphenous veins on both sides and the right anterior accessory great saphenous vein, miniphlebectomy of dilated tributaries within both lower limbs was performed. The symptoms of chronic venous insufficiency decreased markedly. Swelling of the lower legs and cramps in the gastrocnemiu muscles have almost completely disappeared, and the feeling of heaviness in the legs after static loads has significantly decreased.Conclusion. Endovenous laser coagulation with miniphlebectomy should be given preference in varicose vein disease with combined affection of all great saphenous veins of both lower limbs. Their application provides an opportunity to eliminate simultaneously incompetence of all target veins and to remove varicose dilated tributaries, providing good therapeutic and cosmetic effect without hospitalization and detachment of the patient from his or her work activity.

Nowadays endovenous laser coagulation is the priority method of treatment of lower limb varicose vein disease. However, there are a number of specific complications that reduce efficiency of its usage.The objective of the research was to decrease specific postoperative complications after endovenous laser coagulation due to the introduction of its mathematical design.Materials and methods. The study included 168 patients with lower limb varicose vein disease. Prior to surgery the mathematical calculation of the basic parameters of laser coagulation such as density of laser irradiation and rate of reverse movement of the light pipe depending on the diameter of varicose veins was made. The control group consisted of 146 patients with varicose vein disease; the aforementioned parameters were established according to the instruction of using a laser device.Results. The analysis of complications such as induration of skin over coagulase great or small saphenous vein, phlebitis in the projection of the great or small saphenous vein, ecchymosis or dermatomelasma in the early postoperative period, pain syndrome showed the reduction in the number of complications while applying the mathematical model of calculation of linear density of laser radiation and the speed of reverse traction of the light pipe with its transfer to the graphic image.Conclusions. The application of the mathematical model of calculation of linear density of laser radiation and the speed of reverse traction of the light pipe with its transfer to the graphic image allows us to improve the results of endovenous laser coagulation for varicose veins due to the reduction in specific complications.

The aim of the work is to analyze the effectiveness and safety of thermal methods (endovenous laser coagulation (EVLC) and radiofrequency ablation (RFA)) for the treatment of varicose veins of the lower extremities and the impact on the quality of patient life. Materials and methods. An open, prospective study of the comparative efficacy of EVLC (124 patients) and RFA (112 patients) for the treatment of patients with varicose vein disease was conducted. Both groups were compared by age, sex, body mass index, clinical manifestations of the venous pathology severity and assessed the risk of potential complications. Determination of quality of life criteria was performed using the AVVQ questionnaire. Results. The average number of cycles performed for the RFA procedure was 13.8 (7; 14), and the energy was 60.1 (8; 80) J/cm for EVLC. The average value of the VAS during the first 14 days after treatment in the EVLC group was 2.2 (sd 1.9), RFA – 0.8 (sd 0.9), P > 0.05. The majority of patients who underwent EVLC used painkillers – 82 (66.1 %), RFA – 48 (42.9 %), P < 0.001. The results of duplex monitoring in the first 48 hours recorded 100 % occlusion of the treated segments of the great saphenous vein in both study groups; after 1 and 12 months – in 98.4 % (96.0 %) of patients after EVLC and in 100.0 % (98.2 %) – after RFA, respectively. One or more adverse events during the first 2 weeks after treatment were reported by 86 patients (69.4 %) in EVLC group, 52 (46.4 %) – in RFA group. The differences between EVLC and RFA were statistically significant (P < 0.001). VCSS and AVVQ values were significantly decreased one month after treatment, continuing the positive trend for up to 12 months. However, no significant difference between ablation methods was observed (P > 0.05). Conclusions. Endovenous laser coagulation and radiofrequency ablation are safe and effective thermal treatments for varicose veins of the lower extremities, which lead to a statistically significant improvement in the quality of patient life. Radiofrequency ablation has the advantage of a lower risk of developing general complications.

Introduction. Relapses is an important criterion that is used to determine the effectiveness of any treatments of varicose veins of the lower extremity (VVLE). However, only a few studies in the literature are devoted to the distant outcomes of endovenous laser coagulation (EVLC) using the 1470 nm laser.Aim. To identify anatomical variants of VVLE relapses after EVLC using the 1470 nm laser, study the frequency of relapses, and determine the factors affecting the risk of relapses.Materials and methods. A total of 358 EVLC with 78 sonographic recurrences were performed during a 5-year observation period. EVLC was performed using the 1470 nm laser system, and radial light guides with a 400-μm-diameter. At 1, 3, 6, 12, 24, 36, 48, 60 months after EVLC, a follow-up ultrasound examination was carried out. A visual detection of varicose vein was classified as a clinical recurrence. Patients without visually detected varicose tributaries and trunk, but with recanalized sections of the great saphenous vein (GSV) trunk, an incompetent GSV trunk in the lower leg, tributaries and perforators of the operated extremity were considered to be sonographic recurrences. Statistical analysis was performed with IBM SPSS 22 statistic software package (USA). The analysis of variance test (ANOVA) was used to determine the statistical significance of observed differences in mean value, and Pearson's chi-squared (χ2) test in Fisher's exact solution to determine frequencies. Differences were considered statistically significant at p < 0.005.Results. The main anatomical variants of sonographic recurrences included incompetent ostial tributaries (n = 20), segmental recanalization of femoral perforator GSV trunk (n = 21), perforators in the upper third leg (n = 10), perforators in the middle and lower third leg (n = 22).Discussion. Endovascular laser obliteration of the intact anterior accessory great saphenous vein (AAGSV) needs further studies. It is not recommended to ligate perforators with a diameter < 3.5 mm, while coagulation of perforators that have direct drainage to the great or small saphenous vein trunk with a high energy flow needs further studies.Conclusion. The most of sonographic VVLE recurrences occur within 1 to 4 years after endovascular laser treatment and are associated with the development of valve insufficiency in previously intact saphenous and/or perforator veins followed by segmental recanalization of the obliterated GSV trunk.

The factors contributing to superficial vein thrombosis (SVT) in patients with varicose vein disease are unclear. Differences in vein wall apoptotic activity could be associated with the pathogenesis of SVT. The aim of the study is to address the role of the programmed cell death in the vein wall by comparing varicose veins with history of SVT to uncomplicated varicose veins. Vein segments from the proximal part of the great saphenous vein (GSV), the distal part of the vein and from a varicose tributary, from 16 patients with varicose vein disease and one episode of SVT, were evaluated for the immunohistochemical expression of pro-apoptotic (Bax, p53, Caspase 3, BCL-6, BCL-xs), anti-apoptotic (BCL-xl and BCL-2) and proliferation (Ki-67) markers. The results of this study were compared to the results from the evaluation of 19 patients suffering from uncomplicated varicose vein disease and 10 healthy GSVs as controls. Overall, there was increased apoptosis in the distal part of GSV compared to the proximal part documented by increased expression of Bax (p < 0.01), Caspase 3 (p = 0.01), BCL-xs (p < 0.01). The comparisons of the markers' expression between patients with varicose veins and patients with a history of SVT showed significant differences among the three different anatomic locations. In the proximal GSV, only BCL-xs was higher in patients with SVT (p = 0.029). In the tributaries, Bax, BCL-xl and Ki-67 were higher in patients with SVT (p < 0.01). In the distal GSV, increased Bax, BCL-xs, BCL-xl and Ki-67 staining was observed in the thrombosis group compared to uncomplicated veins (p < 0.01). The vein wall in SVT shows increased pro-apoptotic activity compared to uncomplicated disease and normal veins. Whether increased vein wall cell apoptosis is a causative factor for SVT in varicose veins disease or a repairing mechanism of the thrombosis itself needs further research.

Expanding the Role of Endovenous Laser Therapy: Results in Large Diameter Saphenous, Small Saphenous, and Anterior Accessory Veins

Minimaly invasive and pathogenetically based methods are currently prevalent in phlebology, as they are in other fields of surgery. CHIVA (Сure conservatrice et hemodynamiу que de l’insuffisance veineuse en ambulatoire) hemodynamic surgery is one of these popular minimally invasive surgical procedures. The execution technique relies on the findings of a duplex ultrasound scan that is used to analyse the hemodynamics of the superficial venous network. The CHIVA strategy aims to preserve the venous material while also restoring normal distal venous pressure and venous function. However, this technique has a number of disadvantages, including the possibility of vein recanalisation and relapses, as well as the fact that the immediate cosmetic outcome is not always satisfactory. Objective — to compare the outcomes of lower extremity varicose vein treatment based on the employed method: the CHIVA method executed via open surgery versus the CHIVA method combined with other minimally invasive methods (sclerotherapy, endovenous laser coagulation (EVLC)). Materials and methods. A randomised prospective study was conducted on 52 patients with varicose veins of the lower extremities categorised as C1‑C3 according to the CEAR classification. The patients were divided into 2 groups of 26 patients each, with one group undergoing the CHIVA procedure using the classic open technique, and the other group receiving a combination of CHIVA with EVLC and sclerotherapy. To evaluate the results, we used Hobb’s criteria, measured the diameter of the great saphenous vein via ultrasound, analysed alterations in the Venous Clinical Severity Scoring (VCSS) , studied data from the Chronic Venous Insufficiency Quality of Life Questionnaire (CIVIQ 20), and determined the incidence of relapses. Results. After CHIVA and CHIVA + EVLC + sclerotherapy, the normalisation of hemodynamics and interruption of the venous shunt led to a substantial reduction in the diameter of the great saphenous vein within 6 months after the operation (p&lt;0.01). Both groups had an improvement in VCSS 6 months after surgery. No statistical difference was observed between the treatment groups. All methods had a positive impact on the quality of life of patients, as shown by the CIVIQ 20 questionnaire. Of the 52 operated patients, there were 4 relapses (7.7%). No relapses were noted in the group receiving CHIVA with EVLC and sclerotherapy (p=0.039). As evaluated by Hobb’s criteria, patients exhibited greater satisfaction with the outcomes of hemodynamic surgery combined with EVLC and sclerotherapy due to its better and faster aesthetic outcomes (р=0.012 and 0.05). Conclusions. All 52 patients exhibited favourable treatment outcomes, demonstrating a reduction in CVI symptoms during a comprehensive clinical assessment using ultrasound within 6 months and 1 year. The combination of CHIVA with EVLC and sclerotherapy showed distinct advantages in the treatment of varicose veins, yielding the most favourable cosmetic outcomes according to Hobb’s criteria and achieving a reccurence rate of 0%.

Elevated sex steroid hormones in great saphenous veins in men

Background: The great saphenous vein (GSV) has long been recognized as the best conduit for vascular bypass procedures. Concomitant varicose veins disease may be a reason for GSV unavailability either due to dilatation and tortuosity of the vein or due to its destruction during invasive venous treatment. Objectives-to assess the rate of varicose vein patients with concomitant lower extremity arterial disease (LEAD) who have previously lost their GSV due to venous ablation. Material and Methods: A total of 285 patients (76 F, 209 M) with LEAD were consecutively enrolled. A total of 111 patients (222 limbs) underwent a detailed duplex ultrasound of the lower extremity veins for assessing suitability of the GSV as a conduit. We registered presence of varicose veins (VVs), type of previous invasive procedure and availability of saphenous veins as possible grafts. Results: The mean age of screened patients was 70.5 ± 9.1.62 (21.75%) patients had varicose veins or were operated on before due to varicose veins. A total of 42 patients with varicose veins had C2 disease, 10 had C3, 9 had C4 and 1 had C6 according to CEAP classification. A total of 222 lower extremities were examined by duplex ultrasound of which 51 limbs had VVs. Despite the presence of varicose tributaries, the GSV was suitable for bypass in 9 of those lower extremities. The GSV was not available as a conduit in 34 (19.9%) ipsilateral lower extremities in the LEAD with no VVs group and in 42 (82.6%) ipsilateral lower extremities in the LEAD with VVs group (p = 0.0001). Varicose vein disease was associated with a higher frequency of the GSV unavailability (odds ratio 18.8, 95% confidence interval 8.35-42.35). On the 11 ipsilateral limbs (5% of LEAD patients and 21.6% of LEAD with VVs patients), the GSV was unavailable due to previous venous interventions. Conclusions: Almost 20% of patients may have both LEAD and VVs. Among those with VVs, most have the ipsilateral GSV unavailable as a potential conduit. Additionally, one fifth of limbs with VVs had GSVs destroyed previously due to saphenous ablative procedures.

Case of the disappearing heat-induced thrombus causing pulmonary embolism during ultrasound evaluation

Introduction. Sclerobliteration of varicose veins of the lower extremities is one of the most common methods of treating patients with varicose veins. However, the main disadvantage of echosclerobedation of the trunks of the great and small saphenous veins is the possibility of recanalization of sclerosed veins. In this regard, it is of interest to compare the results of using radiofrequency vein obliteration and endovenous laser coagulation in these patients. Aim. To study the effectiveness, advantages and disadvantages of the use of radiofrequency vein obliteration and endovenous laser photocoagulation of recanalized varicose veins in patients undergoing sclerobliteration. Materials and methods. 44 patients aged 18 to 62 years underwent radiofrequency obliteration and endovenous laser coagulation of varicose veins after previous sclerobliteration. A comparative assessment of the duration of the operation, technical success, intensity of the pain syndrome, the level of postoperative complications and relapses of the disease after the use of these methods of recanalized saphenous veins after previous sclerotherapy was made. Results and discussion. The technical success of endovenous laser coagulation of reknalizirovanny varicose veins was 100%, radiofrequency obliteration of veins – 90.9%. The intensity of postoperative pain on the 7th day from the moment of radio wave exposure was 12.1% lower than after the use of endovenous laser coagulation, the average duration of laser thermolysis was 32 ± 0.6 minutes, radio wave – 39 ± 0.7 minutes. Conclusion. Laser coagulation compared to radiofrequency is a more reliable and feasible operation, but is accompanied by a higher level of postoperative pain and side effects.

Selection of Saphenous Vein Conduit in Varicose Vein Disease

Background and objectives: Radiofrequency ablation (RFA) is a recent modality of treatment of the affected varicose vein. In the present study, the outcome of great saphenous varicose vein disease treated by radiofrequency ablation technique was analyzed.&#x0D; Methods: Patients with varicosities of the lower limb affecting mainly the great saphenous vein were (GSV) included. The procedures were carried out under spinal anesthesia. The target varicose vein was accessed by Seldinger technique and the RFA catheter advanced 2 to 3 cm below sapheno-femoral junction under ultrasonography (USG) guidance. A tumescent anesthetic infiltration was given in a solution of normal saline and sodium bicarbonate before the vein being ablated.&#x0D; Results: The success rate of RFA was 97.5 % (39 out of 40). One patient showed episodic recanalisation of vein at one year duplex colour scan. Though the complications related to procedure were negligible, one patient developed endovenous heat induced thrombosis (EHIT) and non-fatal pulmonary thromboembolism (PTE) which was managed adequately.&#x0D; Conclusion: Endovenous RFA is a useful treatment modality for varicose vein disease primarily due to great saphenous insufficiency with marked symptomatic improvement and least recurrence. Although the complications are minimal, EHIT is a potential and serious complication of heat ablation.&#x0D; Ibrahim Med. Coll. J. 2021; 15(1): 37-40

Objective To explore the feasibility of reserveing great saphenous varicose veins lap in varicosity operation. Methods Sixty cases with great saphenous vein varices from August 2013 to October 2014 were enrolled and evenly divided into two groups. Thirty cases of different clinical stages in trial group underwent surgical high stripping and ligation with preserving great saphenous varicose veins line. The control group were given routine traditional great saphenous vein high ligation+ stripping. The two groups were followed-up for prognosis and data analysis. Results The trial group had statistically significant differences in pain score, operation time, blood loss, hospital stay, and indexes of hematoma than the control group (t=3.268, 4.325, 5.670, 5.931, χ2=3.547, P<0.01), and deep vein thrombosis, phlebitis, recurrence rate, vascular endothelial growth factor (VEGF), interleukin-1 (IL-1) showed no significant differences. The trial group showed slower post-operative blood flow velocity (t=10.87, P<0.01), while its diameter, patency rate, valve function, and concurrent blood clots had no significant difference compared with preoperative ones. Conclusions Keeping great saphenous vein lap backbone shows no statistically significant differences in the incidence of postoperative complications. Because of retaining the great saphenous vein trunk, it provides the choice of diversity for the great saphenous varicose veins on preserving blood vessel bank. Key words: Varicose veins; Ligation; Venous thrombosis; Phlebitis; Postoperative complications

Objective. To improve the results of standard treatment of varicose veins of the lower extremities, to evaluate the effectiveness of sclerosurgical and surgical interventions in the long-term postoperative period. Materials and methods. The results of the examination and treatment of 228 patients with varicose veins of the lower extremities in the surgical clinic of the Transcarpathian Regional Clinical Hospital named after Andriy Novak from 2012 to 2015 were analyzed. The study included patients with varicose veins of classes C2-C6 according to the CEAP classification, in whom sclerotherapy was used as surgical treatment - 153 (67.1%) patients (group 1) or classical phlebectomy - 75 (32.9%) patients (group 2). Results. On the basis of duplex angioscopy of the operated limbs (189 in group 1 and 96 in group 2), technical and tactical errors of surgical intervention were revealed: pathologic stump of the great saphenous vein with varicose transformation of the near-octopus tributaries in 8 (4.2%) limbs in group 1 and 6 (6.3%) limbs in group 2; "additional" mistakenly left trunk of the great saphenous vein - in 5 (2.6%) and 11 (11.5%) limbs, respectively; varicose transformation of the anterior accessory vein of the thigh on 42 (22.2%) and 25 (26.0%) limbs, respectively; partial and complete recanalization of the trunk of the great saphenous vein on 54 (28.6%) and 30 (15.9%) limbs, respectively, in group 1; "lateral" varicose veins on 5 (2.6%) limbs in group 1 and 18 (18.8%) limbs in group 2. Partial and complete recanalization of the trunk of the great saphenous vein, in our opinion, was associated with poor compression after sclerotherapy and a failed femoral vein on 18 (9.5%) limbs. Conclusions. A comparative analysis of the dynamics of varicose veins and the results of treatment of patients in the long-term postoperative period confirmed the higher effectiveness of phlebectomy, after which good results were recorded statistically significantly (p&lt;0.05) more often than after surgery. The total frequency of good and satisfactory (positive) treatment results demonstrated comparable efficacy of phlebectomy and scleroscopic intervention - 85.4 and 89.9%, respectively.