Aberdeen Varicose Vein Questionnaire Research Articles

Predictors of Recanalization of the Great Saphenous Vein in Randomized Controlled Trials 1 Year After Endovenous Thermal Ablation

The objective was to identify predictors to develop and validate a prognostic model of recanalization of the great saphenous vein (GSV) in patients treated with endovenous thermal ablation (EVTA). The search strategy of Siribumrungwong was updated between August 2011 and August 2014 using MEDLINE, Embase, and the Cochrane register to identify randomized controlled trials (RCTs), in which patients presenting with GSV reflux were treated with radiofrequency or endovenous laser ablation. Leg level data (n=1226) of 15/23 selected RCTs were pooled. The primary outcome was recanalization of the GSV; the secondary outcome was change in health related quality of life (HRQoL) measured by the Chronic Venous Insufficiency quality of life Questionnaire or Aberdeen Varicose Vein Questionnaire 1 year post-procedure. Candidate predictors were age, sex, body mass index, clinical class, GSV diameter, saphenofemoral junction reflux, type of device, energy, and length of treated vein. At 1 year, 130 GSVs were recanalized (11%). Clinical class (odds ratio [OR] 2.1, 95% confidence interval [CI] 1.4-3.3) and diameter (OR 1.8, 95% CI 1.2-2.7) of the GSV were the strongest predictors of recanalization. Other predictors included in the final model were sex, type of device, and length of treated vein. The performance of the recanalization model was moderate, with an area under the curve above 0.717. GSV diameter, type of device, and amount of energy delivered were the only predictors of the change of HRQoL. None of the candidate predictors were included in the final HRQoL model (R(2)=.027). There are several important prognostic factors for GSV recanalization and change of HRQoL after EVTA. However, the performance of each model was unsatisfactory to allow use in clinical practice yet.

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

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. 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. 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 < 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 < 0·001, χ(2) test). 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.

Effect of sequential pneumatic compression therapy on venous blood velocity, refilling time, pain and quality of life in women with varicose veins: a randomized control study.

[Purpose] The aim of this study was to investigate the effects of sequential pneumatic compression therapy on venous blood flow, refilling time, pain level, and quality of life in women with varicose veins. [Subjects and Methods] Twenty-eight females with varicose veins were selected and randomly allocated to a control group, and experimental group. Maximum and mean venous blood velocities, the refilling time, pain by visual analog scale and quality of life by Aberdeen Varicose Veins Questionnaire were measured in all patients before and after six weeks of treatment. Both groups received lower extremity exercises; in addition, patients in the experimental group received sequential pneumatic compression therapy for 30 minutes daily, five days a week for six weeks. [Results] All measured parameters improved significantly in both groups, comparison of post treatment measurements between groups showed that the maximum and mean blood flow velocity, the pain level, and quality of life were significantly higher in the experimental group compared with the control group. On the other hand there was no significant difference between groups for refilling time. [Conclusion] Sequential pneumatic compression therapy with the applied parameters was an effective modality for increasing venous blood flow, reducing pain, and improving quality of women life with varicose veins.

Modifying a validated instrument: the Aberdeen varicose vein questionnaire

The Aberdeen Varicose Vein Questionnaire (AVVQ) is validated and frequently used as a patient-reported disease-specific quality of life (QoL) outcome in trials of varicose veins. The AVVQ comprises a manikin diagram where patients draw their varicose veins and 12 questions including pain, skin changes, use of support stockings, appearance and impact. AVVQ scores range from 0 to 100 (worst possible QoL), with the manikin diagram contributing up to 22 points, depending on the extent of the varicose veins. Our experience of using the AVVQ in the NIHR HTA funded CLASS trial comparing varicose vein treatments suggested that (i) a proportion of patients fail to complete the manikin diagram; (ii) scoring the manikin diagram was time-consuming and (iii) it was not possible to directly capture AVVQ responses from participants electronically (there was a need for a paper questionnaire). We therefore investigated the potential to use the AVVQ without the manikin diagram. Using retrospective data from CLASS, we correlated the AVVQ (scored with and without the manikin diagram) against two clinical measures of disease severity. Individuals with more severe disease had higher AVVQ scores (regardless of whether the manikin diagram component was included or not). In a prospective study of test-retest reliability involving 32 patients with varicose veins, we demonstrated good level of agreement between paired diagrams. In the same study, there was high level of agreement between two independent scorers. Our results suggest that the AVVQ could be used without the manikin diagram, which could result in cost/time savings for trials.

A Prospective Randomized Study Comparing Polidocanol Foam Sclerotherapy with Surgical Treatment of Patients with Primary Chronic Venous Insufficiency and Ulcer

To compare polidocanol foam sclerotherapy with surgical treatment of patients with primary chronic venous insufficiency and active ulcer treated at a single vascular center. Fifty-eight limbs of 56 patients with active ulcers were prospectively randomized to undergo either surgical treatment or foam sclerotherapy. Patients completed the Aberdeen Varicose Veins Questionnaire (AVVQ), the Venous Clinical Severity Score (VCSS), and Venous Disability Score (VDS). The follow-up was 502 ± 220 days. The ulcer healed in 100% and 91.3% of patients treated with surgery or foam sclerotherapy, respectively (P > 0.05). There were no significant differences in AVVQ, VCSS, and VDS between the 2 groups after the procedures (P = 0.45, 0.58, and 0.66, respectively; Mann-Whitney U test). Complications occurred in 14.2% and 13.0% in the surgical and foam sclerotherapy groups, respectively. Surgical treatment and foam sclerotherapy achieved high rates of ulcer healing, without a statistically significant difference. Both treatments led to significant improvements in VCSS, VDS, AVVQ scores, demonstrating improvements in clinical outcomes and quality of life.

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

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. To assess the clinical effectiveness and cost-effectiveness of foam, EVLA and surgery for the treatment of varicose veins. A parallel-group randomised controlled trial (RCT) without blinding, and economic modelling evaluation. Eleven UK specialist vascular centres. Seven hundred and ninety-eight patients with primary varicose veins (foam, n = 292; surgery, n = 294; EVLA, n = 212). Patients were randomised between all three treatment options (eight centres) or between foam and surgery (three centres). 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. 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. 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. 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. 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. Current Controlled Trials ISRCTN51995477. 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.

Quality of life in chronic venous patients who do or do not wear compressive stockings

BACKGROUND: Wearing elastic compression stockings is of considerable significance for patients with chronic venous disease (CVD), since their physiological effect is to improve venous hemodynamic parameters, making them a good treatment option that can impact on patients' quality of life. OBJECTIVE: To assess quality of life in patients with chronic venous disease who do or do not wear elastic stockings. METHODS: This was a cross-sectional observational study assessing a sample of 50 CVD patients of both sexes, divided into two groups, one who wear elastic stockings and another who do not. Primary variables were the domains of the SF-36 (Medical Outcomes Study Short-form 36) and AVVQ (Aberdeen Varicose Veins Questionnaire) and secondary variables were: age; sex; physical activity; educational level; profession; wearing elastic stockings (frequency, pressure and type); elevation of lower limbs; itching and CEAP classification. The SF-36 and AVVQ quality of life questionnaires were administered to patients. Statistical significance was set at p&lt;0.05. RESULTS: Wearing elastic stockings proved beneficial for the quality of life of people with chronic venous disease. For the AVVQ disease-specific questionnaire the greatest improvements were in overall score (p=0.0028) and the extent of varicosity domain (p=0.000). The SF-36 domains role emotional (p=0.017) and functional capacity (p=0.000) both improved. CONCLUSIONS: Wearing elastic stockings is an effective treatment for CVD that improves disease-specific quality of life and also leads to improvements in general quality of life.

A randomized clinical trial of endovenous laser ablation versus conventional surgery for small saphenous varicose veins

This randomized clinical trial compared endovenous laser ablation (EVLA) and surgical ligation with attempted stripping in the treatment of small saphenous vein (SSV) insufficiency. The early results demonstrated that EVLA was more likely to eradicate axial reflux and was also associated with a faster recovery, lower periprocedural pain, and fewer sensory complications. The aim of this 2-year follow-up was to establish whether these benefits remained stable over time and whether these improved technical outcomes were associated with less clinical recurrence. Patients with primary saphenopopliteal junction and SSV reflux were randomized to EVLA or saphenopopliteal junction ligation and attempted stripping/excision. Outcomes assessed at 2 years included the presence of residual or recurrent reflux, clinical recurrence, sensory complications, the need for secondary intervention, and patient-reported quality of life on the Aberdeen Varicose Veins Questionnaire, SF-36, and EuroQol. Of 106 patients who were equally randomized and successfully treated according to the protocol, 88 (83%) were successfully assessed at 2 years. The groups were comparable at baseline. At 2 years, EVLA remained superior to surgery in eradicating axial reflux in 36 patients (81.2%) compared with 29 (65.9%) in the surgery group (P = .002). There was no significant difference in clinical recurrence (EVLA: seven of 44 [16%] vs surgery: 10 of 44 [23%]; P = .736), sensory disturbance (EVLA: one [2.4%] vs surgery vs three [6.8%]; P = 1.000) or any quality of life domain. The results of treatment of SSV insufficiency with EVLA appear durable up until 2 years. The study does not appear to suggest that the improved abolition of reflux after EVLA compared with surgery is associated with superior outcomes than those seen after surgery by this time point, because equal effect was shown in both groups. The sensory disturbance associated with surgery appears to settle over this time frame. EVLA is therefore superior in the short-term and not inferior by 2 years.

Health-related quality-of-life scales specific for chronic venous disorders of the lower limbs.

We conducted a systematic review of the literature about quality-of-life (QOL) scales in chronic venous disorders (CVDs) comprising leg ulcers to identify the respective advantages and deficits of existing tools. A research protocol was built following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and the PICO (population, intervention, comparator, and outcome) criteria. The following databases were screened: MEDLINE, SCOPUS, EMBASE, CINHAL, and Cochrane. Psychometric and linguistic validation studies in English were included, as were clinical trials that have used QOL scales in CVDs. The data search was up to date as of October 31, 2013. Inclusion criteria were met in 103 of the 511 recorded references, in which 10 scales were identified: two for the full spectrum of CVDs, three for patients with CVDs without leg ulceration, four for leg ulcers, and one exclusively for patients with varicose veins. Among them, the ChronIc Venous Insufficiency Questionnaire (CIVIQ), Aberdeen Varicose Vein Questionnaire (AVVQ), and VEnous INsufficiency Epidemiological and Economic Study on Quality of Life (VEINES-QOL) scales were the most highly used according to the literature, and CIVIQ and VEINES-QOL were the most extensively validated scales and had the longest iterative validation process. A total of 31 psychometric and linguistic validations of the 10 QOL scales and 66 clinical trials that have used these scales were identified. The validation studies were based on acceptability, content validity, construct validity, reliability, and responsiveness. The clinical trials were composed of 25 randomized controlled trials and 41 observational studies. Only the randomized controlled trials are considered in the present article. This systematic review confirmed that CVDs have an important effect on QOL. The majority of the studies addressed the application rather than the validation of the 10 identified scales. Two scales, CIVIQ and VEINES-QOL, emerged as being thoroughly validated instruments, although factorial stability was not demonstrated for the VEINES-QOL. Our findings confirm a paucity of validation studies.

Positive Outcomes of Varicose Vein Surgery: The Patient Perspective.

Patient-reported outcomes are increasingly recognized as important to understanding outcomes of medical interventions such as varicose vein surgery (VVS). Our aim was to compare positive outcomes of VVS as defined by several patient-reported measures, and to identify baseline characteristics associated with positive outcomes of VVS. A secondary analysis of the UK Patient-Reported Outcome Measures database was conducted on patients undergoing VVS, in the period 2009-2011 who completed the generic EQ-5D (index and visual analog scale [VAS] summary scores) and disease-specific Aberdeen varicose vein questionnaire (AVVQ). Surgical outcome was defined as positive if pre/post change scores exceeded half a standard deviation of mean baseline scores. Logistic regression models were used to identify significant predictors of positive outcomes, including age, gender, and baseline health. Of 9,113 patients analyzed (71% females, 57% aged >50 years), positive outcomes were identified in 62% using the AVVQ, 43% based on EQ-5D index scores, and 24% according to EQ-VAS; 10% improved on all three measures. Patients with poorer baseline functioning (AVVQ scores ≥ 11) were more likely to have a positive outcome based on the EQ-5D index (odds ratio [OR] 1.23, 95% confidence interval [CI] 1.11-1.36) and EQ-VAS (OR 1.30, 95% CI 1.14-1.47). Defining surgery as successful will clearly depend on how health-related quality of life (HRQL) is operationalized and the criteria used to identify meaningful change. Across a range of criteria, a consistently greater proportion of patients had positive outcomes in terms of VV-related functioning (via AVVQ) compared with those who improved in terms of generic health (via EQ-index), or self-rated health (EQ-VAS).

An overview of the most commonly used venous quality of life and clinical outcome measurements.

Modern medicine should no longer rely solely on technical success to evaluate treatments. The treatment of venous disease has seen many new developments, insights, and treatment modalities. Combining clinical scores with quality of life (QoL) outcome measurements is becoming the new norm for evaluation of treatments. Many different outcome assessment instruments are currently available, indicating a lack of consensus. We set out to find the most reliable and comprehensive scoring instrument for clinical and QoL measurement in venous disease. In this review, we focus on the eight most widely used instruments. For clinical assessment, these are the Clinical, Etiologic, Anatomic, and Pathologic (CEAP) classification, Villalta scale, and Venous Clinical Severity Score (VCSS); for generic QoL, the 36-Item Short Form Health Survey (SF-36) and EQ-5D questionnaires; and for disease-specific QoL, the Aberdeen Varicose Vein Questionnaire (AVVQ), Chronic Venous Insufficiency Questionnaire (CIVIQ), and VEnous INsufficiency Epidemiological and Economic Study on Quality of Life/Symptoms (VEINES-QOL/Sym) questionnaire. Each instrument is reviewed. For the accurate evaluation of treatment outcomes, socioeconomic, QoL, and clinical aspects must be assessed. None of the available disease-specific instruments is suited to use in uniform outcome measurement for the whole spectrum of venous disease. A new combined QoL and clinical instrument is needed to validly assess and compare the outcomes of venous treatments. The VEINES-QOL/Sym is currently the most valid instrument to assess disease-specific QoL.

The European multicenter cohort study on cyanoacrylate embolization of refluxing great saphenous veins.

Cyanoacrylate (CA) embolization of refluxing great saphenous veins (GSVs) has been previously described. The outcomes from a multicenter study are still lacking. A prospective multicenter study was conducted in seven centers in four European countries to abolish GSV reflux by endovenous CA embolization. Neither tumescent anesthesia nor postinterventional compression stockings were used. Varicose tributaries remained untreated until at least 3 months after the index treatment. Clinical examination, quality of life assessment, and duplex ultrasound evaluation were performed at 2 days and after 1, 3, 6, and 12 months. In 70 patients, of whom 68 (97.1%) were available for 12-month follow-up, 70 GSVs were treated. Two-day follow-up showed one proximal and one distal partial recanalization. Three additional proximal recanalizations were observed at 3-month (n = 2) and 6-month (n = 1) follow-up. Cumulative 12-month survival free from recanalization was 92.9% (95% confidence interval, 87.0%-99.1%). Mean (standard deviation) Venous Clinical Severity Score improved from 4.3 ± 2.3 at baseline to 1.1 ± 1.3 at 12 months. Aberdeen Varicose Vein Questionnaire score showed an improvement from 16.3 at baseline to 6.7 at 12 months (P < .0001). Side effects were generally mild; a phlebitic reaction occurred in eight cases (11.4%) with a median duration of 6.5 days (range, 2-12 days). Pain without a phlebitic reaction was observed in five patients (8.6%) for a median duration of 1 day (range, 0 -12 days). No serious adverse event occurred. Paresthesia was not observed. Endovenous CA embolization of refluxing GSVs is safe and effective without the use of tumescent anesthesia or compression stockings.

A Comparison of the Effectiveness of Treating Those With and Without the Complications of Superficial Venous Insufficiency

To test the hypothesis that patients with soft tissue changes related to superficial venous insufficiency (SVI) have greater benefits from treatment than those with only symptomatic varicose veins. A commonly held view is that SVI is only a minor ailment, yet randomized clinical trials (RCTs) show that treatment improves quality of life (QoL) and is cost-effective. In an effort to curb the treatment costs of this common disorder, rationing is applied in many health care systems, often limiting the reimbursement of treatment to those with soft tissue changes. This cohort study draws its data from an interventional RCT. After informed consent, consecutive patients with symptomatic unilateral SVI were randomized to receive surgical ligation and stripping or endovenous laser ablation. This analysis differentially studies the outcomes of patients with simple varicose veins (C2: n = 191) and soft tissue complications (C3-4: n = 76). Effectiveness outcomes measured up to 1 year included the following: Qol [short form 36 (SF36), EuroQol, and the Aberdeen Varicose Veins Questionnaire], clinical recurrence, and the need for secondary procedures. Multivariable regression analysis was used to control for potential confounding factors. Both groups saw significant improvements in QoL. All improvements were equal between groups apart from the SF36 domain of Bodily Pain, where C2 saw an improvement of 12.8 [95% confidence interval (CI): 4.8-20.8] points over C3-4 participants (P = 0.002), who also suffered more recurrence [odds ratio (OR) = 2.7, 95% CI: 1.2-6.1, P = 0.022] and required more secondary procedures (OR = 4.4, 95% CI: 1.2-16.3, P = 0.028). This study suggests that rationing by clinical severity contradicts the evidence. Delaying treatment until the development of skin damage leads to a degree of irreversible morbidity and greater recurrence. NCT00759434 Clinicaltrials.gov.

Clinical outcomes and quality of life 5 years after a randomized trial of concomitant or sequential phlebectomy following endovenous laser ablation for varicose veins.

Endovenous laser ablation (EVLA) is a popular treatment for superficial venous insufficiency. Debate continues regarding the optimal management of symptomatic varicose tributaries following ablation of the main saphenous trunk. This randomized trial compared the 5-year outcomes of endovenous laser therapy with ambulatory phlebectomy (EVLTAP) with concomitant ambulatory phlebectomy, and EVLA alone with sequential treatment if required following a delay of at least 6 weeks. Patients undergoing EVLA for great saphenous vein insufficiency were randomized to receive EVLTAP or EVLA alone with sequential phlebectomy, if required. Outcomes included disease-specific quality of life (QoL) (Aberdeen Varicose Vein Questionnaire; AVVQ), requirement for secondary procedures, clinical severity (Venous Clinical Severity Score; VCSS), residual and recurrent varicose tributaries, and generic QoL. Patients were followed up for 5 years. Fifty patients were randomized equally into two parallel groups. The EVLTAP group had lower VCSS scores at 12 weeks (median 0 (i.q.r. 0-1) versus 2 (0-2); P <0·001), and lower AVVQ scores at 6 weeks (median 7·9 (i.q.r. 4·1-10·7) versus 13·5 (10·9-18·1); P < 0·001) and 12 weeks (2·0 (0·4-7·7) versus 9·6 (2·2-13·8); P = 0·015). VCSS and AVVQ scores were equivalent by 1 year, but only after 16 of 24 patients in the EVLA group, compared with one of 25 in the EVLTAP group (P < 0·001), had received a secondary intervention. From 1 to 5 years both groups had equivalent outcomes. EVLA with either concomitant or sequential management of tributaries is acceptable treatment for symptomatic varicose veins, with both treatments achieving excellent results at 5 years. Concomitant treatment of varicosities is associated with optimal improvement in both clinical disease severity and QoL.

Role of compression stockings after endovenous laser therapy for primary varicosis.

The objective of this prospective, randomized trial was to evaluate the effect of compression stockings after endovenous laser therapy (EVLT) for insufficiency of the great saphenous vein. Effect evaluation was focused on differences in postoperative pain within 6weeks. The study randomized 111 patients undergoing EVLT for duplex ultrasound-confirmed great saphenous vein insufficiency (C2-4EPASPR) to receive either 2weeks of elastic stockings (class II, thigh length) or no elastic stockings after an initial 24-hour period of wearing bandages. Patients registered pain scores (primary outcome) and use of analgesics in a diary on a visual analog scale. At 2days, 14days, and 6weeks after the procedure, leg circumferences, Aberdeen Varicose Vein Questionnaire scores, RAND 36-Item Health Survey scores, patient satisfaction (5-point scale), time before returning to work, and adverse events (secondary outcomes) were evaluated. In the 79 patients (15 men and 64 women; mean age, 52years) who completed the treatment and follow-up, small but significant differences in pain scores were observed during the first week after laser surgery, with more favorable scores in the group wearing stockings. Patients not wearing stockings used more analgesics than did patients wearing stockings (P< .05). Patients wearing stockings reported a statistically significantly higher score of satisfaction at 2days (4.44 vs 4.15) and 6weeks (4.59 vs 4.18), although the absolute differences were small. No significant differences were found regarding time to return to work, Aberdeen Varicose Vein Questionnaire scores, RAND 36-Item Health Survey scores, leg circumference measurements, and risk of complications. Wearing of postoperative stockings for 2weeks after an initial 24-hour period of wearing bandages results in a small but significant reduction of postoperative pain and use of analgesics compared with not wearing compression stockings after EVLT for great saphenous vein insufficiency.

The effect of single phlebectomies of a large varicose tributary on great saphenous vein reflux.

Phlebectomy of varicose tributaries is usually considered an additional treatment after or during saphenous ablation. As phlebectomies alone affect the hemodynamics of the venous system, this treatment can be effective as primary intervention in selected patients. The objective of this study was to analyze hemodynamic, clinical, and patient-reported outcomes after phlebectomies in a prospective multicenter study to determine predictors for treatment success, that is, restoration of great saphenous vein (GSV) competence. Patients with symptomatic GSV and tributary incompetence (reflux > 0.5second) at the level of the thigh were included. Duplex ultrasound (DUS) was used to assess GSV and tributary characteristics, and a reflux elimination test was performed. Three and 12months after phlebectomy of the tributary, reflux and GSV diameter were evaluated with DUS. Clinical outcome measures were C class of the Clinical, Etiologic, Anatomic, and Pathologic (CEAP) classification and Venous Clinical Severity Score; patients' reported outcome was determined by the Aberdeen Varicose Vein Questionnaire. To evaluate differences between the success and failure groups, baseline DUS characteristics, Venous Clinical Severity Score, CEAP class, and Aberdeen Varicose Vein Questionnaire score were compared. Multivariable logistic regression including allclinically relevant variables following a backward variable elimination process was used to determine predictors for success. The model was internally validated by 1000 bootstrap samples. The study included 94 patients (65 women, 29 men) with a mean age of 53years. The majority had C2 or C3 disease. One year after treatment, GSV reflux had disappeared in 50% of patients (P< .01), and GSV diameter had decreased significantly (P< .01). Clinical outcome and Aberdeen Varicose Vein Questionnaire score improved significantly (P< .01) and symptoms had disappeared in 66%. Of 47 patients with persisting GSV incompetence, 15 did not receive additional treatment because they were asymptomatic. Independent predictors for success were low C class of the CEAP classification, low number of refluxing GSV segments, small diameter of the GSV above the tributary, and positive reflux elimination test result (P< .0001). The reflux elimination test appeared to be an important independent predictor, with >65% chance of success when the result was positive. At 1-year follow-up, treatment with single phlebectomies of a large tributary was effective to abolish GSV reflux in 50% of patients and to free 66% of patients from symptoms. Patients with limited disease progression and mildDUS alterations are most likely to benefit from this approach.

Five-Year Results of a Randomised Clinical Trial Comparing Concomitant and Sequential Phlebectomy Following Endovenous Laser Ablation.

Concomitant ambulatory phlebectomy with endovenous laser ablation (EVLA) for great saphenous vein (GSV) incompetence has been shown to reduce secondary procedures and improve quality of life (QoL) when compared with EVLA alone at 1 year. This study aims to assess the 5-year outcomes of EVLA with concomitant or sequential ambulatory phlebectomy. Patients undergoing EVLA for primary sapheno-femoral junction incompetence with GSV reflux were randomized to receive EVLA alone (EVLA) or EVLA with concomitant phlebectomies (EVLA-AP). EVLA was performed as a day-case procedure under tumescent anesthesia and duplex ultrasound. Follow-up assessments were performed at 1, 6, 12, 52, 104, and 260 weeks. Outcome measures were: secondary procedures; clinical outcomes (recurrence, CEAP, VCSS), duplex GSV reflux; and disease-specific QoL using the Aberdeen Varicose Vein Questionnaire (AVVQ). Fifty patients were equally randomised to receive EVLA or EVLA-AP. One patient withdrew from the EVLA group. EVLA (n = 24; 20 female, 4 male; mean age, 52.5 ± 15.6 years; median VCSS (interquartile range [IQR]), 4 (2-5); median CEAP (IQR), 2 (2-2); EVLA-AP (n = 25; 8 male, 17 female; mean age, 51.1 ± 14.3 years; median VCSS (IQR), 4 (2.25-5); median CEAP (IQR), 2 (2-3.75). All patients successfully underwent their allocated procedure. Follow-up at 5 years for EVLT-AP was 84% (n = 21) and for EVLT was 75% (n = 18). There was no significant difference after 1 year in the requirement for secondary procedures (EVLA, 7 vs EVLA-AP, 5 secondary procedures; P = .520). Intragroup analysis demonstrated significant clinical improvement in both groups over the 5 years; however, there was no significant intergroup differences in clinical recurrence rates (P = .725), CEAP grades (P = .661), VCSS (P = .581), or AVVQ (P = .835). Five-year follow-up demonstrates that the initial benefits of performing concomitant ambulatory phlebectomy are not sustained into the long term. There is no significant difference between clinical or QoL outcomes. This evidence may suggest that phlebectomies can be performed as per patient and surgeon preference.

The Aberdeen Varicose Vein Questionnaire, Patient Factors and Referral for Treatment

It has been suggested that the Aberdeen Varicose Vein Questionnaire (AVVQ) could be used to help inform a patient pathway for referral and treatment of varicose veins. We aimed to determine 1) which patient and vein characteristics affected the AVVQ score, and 2) whether scores differed between those who were and were not offered treatment. Patients completed the AVVQ at the clinic prior to being seen. Treatment was offered to patients with symptoms, and duplex detected truncal incompetence by surgeons blinded to the score. A total of 228 consecutive patients completed the AVVQ: 199 were valid questionnaires. On multivariate analysis, factors associated with a worse quality of life were female gender (p=.034, 3.14 mean unit increase in AVVQ), and bilateral varicose veins (10.25 unit increase, p<.001). For patients with C2 disease, only the presence of bilateral veins was significant. Overall, the AVVQ score was higher in those patients offered treatment than in those who were not (mean 20.3 [SD=9.9] vs. 17.3 [SD=10.3], p=.023), which equates to a 2.74 unit increase. This was not significant in patients with C2 disease. It is unlikely that a threshold AVVQ score could be used to aid referral of patients with C2 disease. The distribution of veins (unilateral vs. bilateral) must be adjusted for when reporting AVVQ scores.

Endovenous laser ablation versus conventional surgery in the treatment of small saphenous vein incompetence.

In this multicenter, randomized controlled trial, endovenous laser ablation (EVLA) is compared with conventional surgery for the treatment of varicose veins based on incompetence of the small saphenous vein and the saphenopopliteal junction (SPJ). In two Dutch hospitals, 189 patients were enrolled and randomized to receive EVLA (810-nm laser) or ligation of the SPJ. End points were success rate measured with duplex ultrasound (6 weeks post-treatment), perioperative pain, quality of life, duration of surgery, difficulty of surgery, complications, cosmetic results, and number of days to resume work and normal activities. Pain was measured on a visual analog scale (VAS). Quality of life was assessed using the Aberdeen Varicose Vein Questionnaire (AVVQ) and Euro Qol-5D. The follow-up duration in this article is 6 weeks. One hundred seventy-five patients have been treated and analyzed. One hundred eighteen patients (67%) underwent EVLA, and 57 patients (33%) underwent ligation of the SPJ. The patient characteristics were similar in both groups. In the surgery group, 21% residual incompetence of the SPJ was seen after 6 weeks, compared with 0.9% in the laser group. Both treatment modalities reduced pain after 6 weeks. One week post-treatment, patients in the EVLA group temporarily experienced more pain compared with the surgery group (31 vs 18 on a VAS from 0 to 100). There were no significant differences between the two groups with respect to quality of life. Both treatments did show improvement in quality of life. Also with regard to the cosmetics, there were no differences, aside from the fact that patients rated their scar as more beautiful after EVLA. After EVLA, patients could return to work more quickly. The operation time was longer in the surgery group. After 2 weeks, there were significantly more neurological complications in the surgery group: 18 (31%) vs 16 (17%) patients in the EVLA group. Ten percent of patients in the surgery group developed a surgical site infection vs 0% in the EVLA group. EVLA provides an excellent alternative to conventional surgery in the treatment of symptomatic varicose veins due to an incompetent small saphenous vein with SPJ. EVLA has a superior immediate success rate, is easier and faster, and has fewer complications.

Comparison of disease-specific quality of life tools in patients with chronic venous disease

This work was presented as a poster in the American Venous Forum 25th Annual Meeting; 28 February 2013; Phoenix, Arizona, USA. Quality of life (QoL) is an important outcome measure in the treatment for chronic venous disease. The Aberdeen Varicose Vein Questionnaire (AVVQ) and the ChronIc Venous Insufficiency quality of life Questionnaire (CIVIQ-14) are two validated disease-specific QoL questionnaires in current use. The aim of this study is to evaluate the relationship between the AVVQ and the CIVIQ-14 to enable better comparison between studies and to compare these disease-specific QoL tools with generic QoL and clinician-driven tools. Adults attending our institution for management of their varicose veins completed the AVVQ, CIVIQ-14 and EuroQol-5D (EQ-5D). Clinical data, CEAP classification and the Venous Clinical Severity Score (VCSS) were collected. The relationship between the AVVQ and CIVIQ-14 scores was analysed using Spearman's correlation. The AVVQ and CIVIQ-14 scores were also analysed with a generic QoL tool (EQ-5D) and a clinician-driven tool, the VCSS. One hundred patients, mean age 57.5 (44 males; 56 females), participated in the study. The median AVVQ score was 21.9 (range 0-74) and the median CIVIQ-14 score was 30 (range 0-89). A strong correlation was demonstrated between the AVVQ and CIVIQ-14 scores (r = 0.8; p < 0.0001). Strong correlation was maintained for patients with C1-3 disease (r = 0.7; p < 0.0001) and C4-6 disease (r = 0.8; p < 0.0001). The VCSS correlated strongly with the AVVQ and CIVIQ-14 scores (r = 0.7; p < 0.0001 and r = 0.7; p < 0.0001, respectively). Both the AVVQ and CIVIQ-14 scores correlated well with the EQ-5D score (r = -0.5; p < 0.0001 and r = -0.7; p < 0.0001, respectively). This study demonstrates that there is good correlation between two widely used varicose vein specific QoL tools (AVVQ and CIVIQ-14) across the whole spectrum of disease severity. Strong correlation exists between these disease-specific QoL tools and generic and clinician-driven tools. Our findings confirm valid comparisons between studies using either disease-specific QoL tool.