Aberdeen Varicose Vein Severity Score Research Articles

Longer term follow-up of a randomized controlled trial on the role of compression after radiofrequency ablation of varicose veins

ObjectiveSeveral studies have shown that, in the short term, treatment outcomes following endothermal ablation of varicose veins without the prescription of post procedural compression are not inferior to outcomes when compression is routinely prescribed. This follow-up to our randomized controlled trial (RCT) published in 2020 explores whether the non-inferiority persists into the medium to long term. MethodsAll 94 patients from the RCT were recalled at 27 months after their initial radiofrequency ablation (RFA) procedure. The procedural details, randomization, and inclusion and exclusion criteria were described in the original RCT paper. Consent was obtained for further venous duplex ultrasound scan at 27 to 61 months after the initial procedure. The successful target vein closure at this juncture represented our primary outcome. Secondary outcomes include disease severity, measured using the Aberdeen Varicose Vein Severity Score (AVSS) and the Revised Venous Clinical Severity Score (RVCSS), post-procedural pain measured using Likert scale, and number of days taken for patients to return to work or normal activities. ResultsThirty-one of 48 patients (64.6%) in the compression group and 29 of 46 patients (63%) in the no-compression group were evaluated. The mean duration of follow-up was 43 and 42 months in the compression and no-compression group, respectively. The target vein occlusion rate evaluated at this longer-term follow up were 80.7% and 79.3% in the compression and no-compression groups, respectively. There was no significant difference between the two groups (P = .37). Secondary outcomes of quality of life and disease severity measured using AVSS and RVCSS showed no significant difference between the two groups (post-procedural AVSS mean score 5.2 in the compression group vs 8.3 in the no-compression group [95% confidence interval (CI), −7.3 to 1.1; P = .14]; post-procedural RVCSS mean score 1.5 in the compression group vs 1.8 in the no-compression group [95% CI, −1.1 to 0.7; P = .59]). Patient satisfaction was similar in both groups (mean score 6.4 in the compression group vs 5.9 in the no-compression group [95% CI, −0.22 to 1.17; P = .18]), and the number of days taken for patients to return to work were also comparable (mean of 11.9 days in the compression group vs 12.6 days in the no-compression group [95% CI, −7.7 to 6.2; P = .83]). ConclusionsThis study provided some evidence to support no additional benefit of compression use after RFA at a longer term follow-up of 3 years. However, larger, suitably powered studies would be beneficial to confirm this.

Editor's Choice – Role of Compression After Radiofrequency Ablation of Varicose Veins: A Randomised Controlled Trial☆

Post-procedure limb compression, hitherto routine following open varicose vein surgery, has been extended to endovenous procedures. However, no robust evidence exists to support this practice. Most of the previous studies have focused on the ideal duration of compression. This study evaluates the clinical and patient reported outcomes with and without post-procedure leg compression following radiofrequency ablation (RFA). This single centre, prospective, non-inferiority randomised controlled trial recruited adult patients, into two groups (A: RFA with compression stocking for two weeks, B: RFA alone). The primary outcome was ultrasound determined target vein obliteration at 12 weeks. Secondary outcome measures included a Quality of Life (QoL) score [Aberdeen Varicose Vein Severity Score (AVSS) and Revised Venous Clinical Severity Score (RVCSS)], patient satisfaction, pain score, and complications. In total, 100 consecutive patients were recruited (A: 51; B: 49) classified as clinical class C2-C6 of the Clinical-Etiological-Anatomical-Pathophysiological (CEAP) classification. At 12 weeks the occlusion rate of the target vein was similar in both groups at 98% (n=47) and 98% (n=45), respectively (p=1.0). There was no statistically significant difference in mean AVSS 6 vs. 5.0 (mean difference-1, 95% CI-2 - 3, p=.57) and mean RVCSS 3 vs. 4 (mean difference 1, 95% CI-1 - 2, p=.46) scores at 12 weeks. Comparable patient satisfaction scores were observed (p=.72) and pain score 2.0 vs. 2.0 (p=.92) were achieved in both groups. Two patients in each group developed deep vein thrombosis at two weeks follow up (p=1.0 for above the knee and p=1.0 for below the knee). The clinical and patient reported outcomes following RFA without compression are no worse than with compression. This trial supports the conclusion that the widely practised use of compression after RFA adds no clinical benefit for the patients. However, a much larger study, preferably a multicentre trial, may be required to confirm this conclusion.

Clinical and Duplex-Sonographic Outcomes of 1,320-nm Endovenous Laser Treatment for Saphenous Vein Incompetence

Endovenous laser treatment (EVLT) can be performed using different wavelengths with different absorption rates and characteristics, but limited data are available regarding wavelength-related side effects and efficacy. To evaluate the safety and efficacy of 1,320-nm EVLT for treating saphenous vein incompetence. A 1-year retrospective study was performed using clinical and Duplex-sonographic follow-up data from patients treated using an 810-nm or 1,320-nm laser. The difference in clinical improvement after EVLT between the two groups was statistically significant. Improvement in venous clinical severity score (VCSS) was greater in the 1,320-nm group than in the 810-nm group, but improvement in Aberdeen Varicose Vein Severity Score was not statistically significantly different between the two groups. Ultrasonography-proven recanalization rates 1year after surgery were 11.1% for the 810-nm group and 6.5% for the 1,320nm group (p<.05). EVLT using a 1,320-nm laser had better clinical outcomes and lower recurrence and recanalization rates than EVLT with an 810-nm laser.

Validation of a New Duplex Derived Haemodynamic Effectiveness Score, the Saphenous Treatment Score, in Quantifying Varicose Vein Treatments

ObjectivesTo evaluate a duplex-derived score for varicose vein treatments using numerical values of haemodynamic effectiveness. DesignThe saphenous treatment score (STS) was developed prospectively to compare the effect of endovenous treatments on reflux within saphenous segments. PatientsSixty-six patients were randomised to endovenous laser ablation (EVLA) or ultrasound-guided foam sclerotherapy (UGFS) to the great saphenous vein (GSV). MethodsAssessments included the Aberdeen varicose vein severity score (AVVSS), the venous clinical severity score (VCSS), the venous filling index (VFI) and the STS. ResultsA mean STS of 5.70 decreased to 3.30, P < .0005, post-treatment. The median (IQR) AVVSS, VCSS and VFI (ml/sec) decreased from 21.52(15.48) to 18.86(11.27), P = .14, from 6(4) to 3(4), P < .0005 and from 7.1(6.9) to 1.9(.9) P < .0005, respectively. In 15 patients requiring additional UGFS the mean STS values decreased from 5.8 to 4.13 and then to 2.6 P < .0005, respectively. The individual above and below knee mean treatment differences in STS on 38 EVLA and 28 UGFS patients were 1.92 and .87 (EVLA) compared to 1.57and .29 (UGFS) P = .001, respectively. ConclusionsThe STS has been shown to grade the haemodynamic effects of different treatments as well as ongoing treatments on the GSV.

Five-year results of a randomized clinical trial comparing endovenous laser ablation with cryostripping for great saphenous varicose veins

This was the long-term follow-up of a previously reported randomized clinical trial comparing endovenous laser ablation (EVLA) with cryostripping for great saphenous varicose veins. A total of 120 patients with great saphenous varicose veins were randomized 1:1 to EVLA or cryostripping. Principal outcome measures were freedom from incompetence or neovascularization on duplex imaging, and improvement in Venous Clinical Severity Score (VCSS) and Aberdeen Varicose Vein Severity Score (AVVSS) 5 years after treatment. Life-table analysis showed freedom from duplex-derived incompetence and neovascularization at 5 years in 62 (95 per cent confidence interval 50 to 76) per cent after EVLA and in 51 (39 to 66) per cent after cryostripping (P = 0.246). Neovascularization was more common after cryostripping, but incompetent tributaries were more common after EVLA. VCSS and AVVSS values improved significantly after treatment in both groups, and were maintained for 5 years, but with no significant difference between the groups. In this study, no significant difference was demonstrated in late outcome after EVLA or cryostripping in patients with great saphenous varicose veins.

Saphenofemoral Junction Ligation and Disconnection for Varicose Veins—A Longitudinal Study of Cosmesis and Function

Saphenofemoral junction ligation and disconnection (SFJLD) can be performed without exceeding the safe limits of local anesthetic if stripping of the long saphenous vein is not routine. We studied the early cosmetic and functional outcome of this procedure to identify the optimum time gap from SFJLD to multiple stab avulsions for varicose veins (VV). A series of patients with primary VV underwent SFJLD under local anesthetic as day case procedures. The volume of VV was quantified with a cartograph wheel, whereas the extent and severity of VV was assessed with four validated questionnaires: (a) Clinical Etiology Anatomy Pathology Score, (b) Venous Clinical Severity Score, (c) Aberdeen Varicose Vein Severity Score, and (d) Short Form 36. Patients were assessed preoperatively, and at 1, 3, and 6 months postoperatively. The analysis of variance for repeated measures test was used; a p value <0.05 was found to be significant. There were 48 patients (15 men; mean age: 54 years; 95% CI: 29-79). In all, 91% (n = 44) of patients had cosmetic and symptomatic improvement. The volume of VV reduced significantly over the three postoperative time points when compared with preoperatively (112 [95% CI: 88-136] vs. 75 [95% CI: 55-97] vs. 65 [95% CI: 43-87] vs. 58 [95% CI: 31-86], p = 0.001). Using the Clinical Etiology Anatomy Pathology, Venous Clinical Severity Score, and Aberdeen Varicose Vein Severity Score questionnaires, severity of VV improved postoperatively when compared withpreoperatively (p = 0.001 respectively). Improvements in quality of life were also noted postoperatively with the Short Form 36 questionnaire (p = 0.032). At maximum follow-up of 3 years, 13% (n = 6) had recurrent VV. SFJLD confers cosmetic and symptomatic improvement at 1 month. Improvement is sustained on early follow-up, thereby allowing multiple stab avulsions to be performed as a staged procedure within 6 months. The rates of recurrent VV are acceptable on short-term follow-up.

Randomized Clinical Trial of Different Bandage Regimens after Foam Sclerotherapy for Varicose Veins

Conclusion: There are no differences between sclerotherapy results in patients treated for truncal varices with foam sclerotherapy regardless of whether compression therapy after the procedure is used for 1 or 5 days. Summary: There are no data on the optimal bandaging regimen after foam sclerotherapy for truncal varices. In Great Britain, 80% of the members of the Vascular Society of Great Britain and Ireland responding to a questionnaire, and who treated patients with sclerotherapy, indicated they used compression bandages, and 90% subsequently used compression stockings after compression bandaging. Duration of treatment ranged from 1 to 7 days for initial bandages, with compression stockings used for 7 to 14 days, with some surgeons recommending compression stockings for up to 3 months. The authors sought to determine whether duration of bandaging could be reduced after foam sclerotherapy for truncal varices. Patients with primary uncomplicated varicose veins were randomized after foam sclerotherapy treatment to wearing compression bandaging for 24 hours or 5 days. In each case after compression bandages were removed, thromboembolism deterrent (TED) stockings then used for a total of 14 days of compression after foam sclerotherapy. The primary end point of the study was the 6-week Aberdeen Varicose Vein Severity Score (AVVSS) and Buford pain score. The study randomized 124 legs, of which 61 were randomized to 24 hours of compression bandaging and 63 to 5 days of compression bandaging. Venous occlusion rates at 6 weeks were 90% and 89%, respectfully (P = .842). There were no differences in phlebitis after 2 weeks (P = .445), skin discoloration after 6 weeks (46% vs 40%; P = .546). There were no differences between groups in the AVVSS from baseline to 2 weeks (–0.29 vs –0.80; P = .717) or to 6 weeks (–5.89 vs –5.14; 95% confidence interval [CI] for the difference, –3.29 to 1.8; P = .563). There were also no differences between groups in changes in the Buford pain score from baseline to 2 weeks (–9.04 vs –2.80, P = .248) or to 6 weeks (–17.32 vs –8.46; 95% CI for the difference, –19.06 to 1.33; P = .088). Finally, the two groups also did not demonstrate any differences in changes in the Short Form-36 score from baseline to 6 weeks (2.02 vs. 1.74; P = .903). Comment: Foam sclerotherapy is replacing liquid sclerotherapy as the preferred method of sclerotherapy for patients with truncal varicosities. Compression after treatment is essential to optimal results. However, as the authors point out with respect to foam sclerotherapy, the optimal duration of compression after treatment has not been adequately studied. This study is good news for patients. Compression bandages are not comfortable, and the results indicate that 24 hours of compressive bandaging, followed by a TED stocking for a total of 2 weeks, is just as efficacious as 5 days of compressive bandaging, followed by a TED stocking for a total of 2 weeks. The study provides practical guidance for post-therapy bandaging of patients undergoing foam sclerotherapy.

Randomized clinical trial of different bandage regimens after foam sclerotherapy for varicose veins

This trial compared outcomes after foam sclerotherapy in patients wearing compression bandaging for 24 h or 5 days after treatment. Consecutive patients with primary uncomplicated varicose veins were randomized after foam sclerotherapy treatment. The primary endpoint was 6-week Aberdeen Varicose Vein Severity Score (AVVSS) and Burford pain score. Some 124 legs were randomized, 61 to 24 h and 63 to 5 days of bandaging. Target vein occlusion rates at 6-week duplex imaging were 90 and 89 per cent respectively (P = 0.842). There was no significant difference in phlebitis after 2 weeks (P = 0.445) or skin discoloration after 6 weeks (46 versus 40 per cent; P = 0.546). There was no significant difference in the change in AVVSS from baseline to 2 weeks (-0.29 versus -0.80; P = 0.717) or to 6 weeks (-5.89 versus -5.14; 95 per cent confidence interval (c.i.) for the difference -3.29 to 1.80; P = 0.563), or in change in Burford pain score from baseline to 2 weeks (-9.04 versus -2.80; P = 0.248) or to 6 weeks (-17.32 versus -8.46; 95 per cent c.i. for the difference -19.06 to 1.33; P = 0.088), or in change in Short Form 36 score from baseline to 6 weeks (2.02 versus 1.74; P = 0.903). There was no advantage to compression bandaging for more than 24 h when thromboembolus deterrent stockings were worn for the remainder of 14 days. NCT00991497 (http://www.clinicaltrials.gov).

Randomised Clinical Trial Comparing Endovenous Laser Ablation with Stripping of the Great Saphenous Vein: Clinical Outcome and Recurrence After 2 Years

Objective This study aims to compare the outcome 2 years after treatment of varicose veins by endovenous laser ablation (EVLA) or surgery by assessing recurrence, venous clinical severity score (VCSS) and quality of life. Methods A total of 121 patients (137 legs) were randomised to either EVLA or saphenofemoral ligation and stripping of the great saphenous vein (GSV). Follow-up included clinical and duplex ultrasound examinations, VCSS and quality of life questionnaires. Results A total of 18 (26%) and 25 patients (37%) in the EVLA and surgery group, respectively, developed recurrent varicose veins (not significant (NS) between groups). The source of reflux was not significantly different between the groups. Technical failure occurred in three EVLA and two surgery patients, reflux in the anterior accessory GSV, the groin, thigh and calf perforators was found in six, two, four, and three EVLA patients, and in three, three, nine and six surgery patients. VCSS, Aberdeen Varicose Vein Severity Score and several domains of the Medical Outcomes Study Short Form 36 (SF36) quality of life score improved significantly in both groups. Conclusions No significant differences in clinical or ultrasound recurrences were found between EVLA and surgery groups. Our study also shows that similar improvements in clinical severity scores and quality of life were gained in both treatments.

Randomized clinical trial comparing endovenous laser with cryostripping for great saphenous varicose veins

The aim of this randomized single-centre trial was to compare the 2-year results of endovenous laser ablation (EVLA) and cryostripping for varicose veins. A total of 120 patients with uncomplicated great saphenous varicose veins were randomized equally to one of the two treatments. Principal outcomes measures were: freedom from recurrent varicose veins on duplex imaging, and improvement in Venous Clinical Severity Score (VCSS) and Aberdeen Varicose Vein Severity Score (AVVSS) 6, 12 and 24 months after treatment. Life-table analysis showed overall freedom from recurrent incompetence at 2 years in 77 (95 per cent confidence interval (c.i.) 72 to 78) per cent of patients after EVLA and in 66 (95 per cent c.i. 60 to 67) per cent after cryostripping (P = 0.253). VCSS and AVVSS values improved significantly after treatment, but the differences between the treatments were not significant. EVLA provided significantly more favourable results than cryostripping with respect to duration of operation, postprocedural pain, induration and resumption of normal activity. EVLA and cryostripping were similarly effective in patients with varicose veins, but patients favoured EVLA because of less pain and postoperative morbidity, and quicker return to normal activity. ISRCTN33832691 (http://www.controlled-trials.com).

Initial Experience in Endovenous Laser Ablation (EVLA) of Varicose Veins Due to Small Saphenous Vein Reflux

Objective Conventional surgery for varicose veins due to small saphenous reflux is associated with high recurrence rates (up to 50%), many resulting from inadequate surgery. This prospective audit examines the safety and efficacy of EVLA in the treatment of this. Method 65 patients (68 limbs) with varicosities due to primary or recurrent sapheno-popliteal junction (SPJ) and small saphenous vein (SSV) reflux underwent out-patient EVLA (810 nm diode laser). The SSV was ablated from mid-calf to the SPJ. Symptomatic improvement (Aberdeen Varicose Vein Severity Score [AVVSS]), time to return to normal activity, post-EVLA analgesic requirements, and complications were recorded. Results Duplex ultrasound follow-up (median 6-months) confirmed abolition of SPJ/SSV reflux in all limbs following a median total laser energy delivery of 1131J (IQR 928-1364) at an energy density of 66.3 Joules/cm (IQR 54.2–71.6). AVVSS improved from 15.4 (IQR 11.8–19.7) to 4.6 (IQR 3.2–6.7) at three months (p<0.001). Median analgesia requirement was 3 days (23% [15/65] patients required none) and the median time to normal activity was 0 (0–4) days (65% [42/65] returning to normal daily activity immediately). There were no instances of skin burns or DVT but 3 patients (4.4%) developed transient cutaneous numbness (sural nerve). 98% (64/65) patients would undergo EVLT again. Conclusions EVLA abolished SPJ/SSV reflux in all limbs. This is likely to be more effective than conventional surgery, although long-term follow up is required. Data from a randomised control trial would be desirable.

Endovenous Laser Ablation (EVLA) of Great Saphenous Vein to Abolish “Paradoxical Reflux” in the Giacomini Vein: A Short Report

Reflux in the GSV due to sapheno-popliteal incompetence associated with ascending (paradoxical) reflux in the Giacomini vein is a rare but well described pattern of reflux. Treatment of this type of reflux is controversial and only surgical treatment has been described. We describe 2 patients in whom this type of reflux was successfully abolished following endovenous laser ablation (EVLA) of the GSV with the SPJ and Giacomini vein regaining competency. Paradoxical reflux in the Giacomini vein and SPJ is secondary to GSV incompetence which exerts a syphon effect. EVLA of the refluxing segment of GSV interrupts this effect and prevents the paradoxical reflux at the SPJ.

Initial Experience in Endovenous Laser Ablation (EVLA) of Varicose Veins Due to Small Saphenous Vein Reflux

Conventional surgery for varicose veins due to small saphenous reflux is associated with high recurrence rates (up to 50%), many resulting from inadequate surgery. This prospective audit examines the safety and efficacy of EVLA in the treatment of this. 65 patients (68 limbs) with varicosities due to primary or recurrent sapheno-popliteal junction (SPJ) and small saphenous vein (SSV) reflux underwent out-patient EVLA (810 nm diode laser). The SSV was ablated from mid-calf to the SPJ. Symptomatic improvement (Aberdeen Varicose Vein Severity Score [AVVSS]), time to return to normal activity, post-EVLA analgesic requirements, and complications were recorded. Duplex ultrasound follow-up (median 6-months) confirmed abolition of SPJ/SSV reflux in all limbs following a median total laser energy delivery of 1131J (IQR 928-1364) at an energy density of 66.3 Joules/cm (IQR 54.2-71.6). AVVSS improved from 15.4 (IQR 11.8-19.7) to 4.6 (IQR 3.2-6.7) at three months (p<0.001). Median analgesia requirement was 3 days (23% [15/65] patients required none) and the median time to normal activity was 0 (0-4) days (65% [42/65] returning to normal daily activity immediately). There were no instances of skin burns or DVT but 3 patients (4.4%) developed transient cutaneous numbness (sural nerve). 98% (64/65) patients would undergo EVLT again. EVLA abolished SPJ/SSV reflux in all limbs. This is likely to be more effective than conventional surgery, although long-term follow up is required. Data from a randomised control trial would be desirable.

The outcome of recurrent varicose vein surgery: the patients' perspective

Objectives: This study was performed to assess the patient's perception of the outcome of recurrent varicose vein surgery. Methods: Patients who underwent surgery for recurrent varicose veins between 1 January 1995 and 31 December 1998 were sent a questionnaire and Aberdeen Varicose Vein Severity Score (AVVSS) in September 2003. Results: A total of 48 questionnaires were distributed and 40 responses (83%) were received. The mean length of follow-up was 81.78 months. Outcome was 'excellent' (no varicose veins) for four patients, 'satisfactory' for 22 (small, asymptomatic recurrence), 'unsatisfactory' for 10 (symptomatic recurrence) and 'worse' for four patients; 65% thought that the outcome was successful (excellent or satisfactory) and 35% a failure. The median AVVSS in the success group was 11.50 (IQR 7.94–19.69) compared with 29.63 (IQR 18.46–40.31) in the failure group ( P = 0.0009, Wilcoxon). Conclusions: Two-thirds of patients undergoing surgery for recurrent varicose veins are satisfied with the outcome, nearly seven years after surgery. One-third will regard surgery as having failed. Patients should be advised of these potential outcomes prior to surgery.

The effect of long saphenous vein stripping on quality of life.

Long saphenous vein (LSV) stripping in the treatment of varicose veins may reduce the recurrence of varices but may also increase morbidity rates. The effect of stripping on health-related quality of life (HRQoL) is unknown. The aim of this study was to examine the effect of LSV surgery, with and without successful stripping, on HRQoL. This prospective study comprises 102 consecutive patients who underwent varicose vein surgery that included attempted stripping of the LSV to the knee. HRQoL was assessed before surgery and at 4 weeks, 6 months, and 2 years after surgery with the Aberdeen varicose vein severity score (AVSS; disease-specific) and the Short-Form 36 (SF-36; generic). Patients defined as stripped were those in whom complete thigh stripping to the knee was confirmed with postoperative duplex scanning at 2 years. Patients defined as incompletely stripped were those in whom any LSV remnant was found in the thigh after surgery. Deep venous reflux (DVR) was defined as reflux of 0.5 seconds or more in at least the popliteal vein. Sixty-six of 102 patients (65%) provided complete HRQoL data at all four time points. At baseline, there was no significant difference between patients who were stripped (n = 25) and incompletely stripped (n = 41) in terms of AVSS, SF-36, age, gender, DVR, or CEAP grade. Significantly more patients in the incompletely stripped group underwent surgery for recurrent disease (29/41, 71%, versus 8/25, 32%; P =.002, with chi(2) test). Both groups gained significant improvements in AVSS scores for as much as 2 years. After adjustment for recurrent disease, stripping conferred additional benefit in terms of AVSS at 6 months (median [interquartile range]) (9 [4 to 16] versus 15 [9 to 24]; P =.031) and 2 years (7 [2 to 10] versus 9 [5 to 15]; P =.014), which was statistically significant in patients without preoperative DVR but not significant in patients with preoperative DVR. SF-36 scores were not affected by stripping. LSV surgery leads to a significant improvement in disease-specific HRQoL for as much as 2 years. In patients without DVR, stripping to the knee confers additional benefit.