Anterior Accessory Great Saphenous Vein Research Articles

The sonographic features of lymph node venous networks and flow patterns in patients with primary chronic venous disease.

Our study aims to enhance the understanding of lymph node venous networks (LNVNs) by summarising their anatomical, sonographic features, and reflux patterns. We examined 241 legs from 141 patients with primary chronic venous disease (CVD) using duplex ultrasound. The findings indicated variations in the shape, size, vascularity, and echogenicity of LNVN. The superficial inguinal lymph node with reflux appeared slightly larger, exhibiting higher velocities in the hilar artery. Regarding connections, venous flow within LNVN was predominantly drained through the saphenofemoral junction (SFJ), anterior accessory great saphenous vein (AAGSV), and great saphenous vein (GSV). A significant number of LNVNs were observed to be associated with anterolateral thigh tributaries. The study also identified valve cusps within LNVN. This study revealed a 12% prevalence of primary LNVN. Understanding the anatomical and haemodynamic features of LNVN informs treatment strategies and potentially helps prevent the recurrence of varicose veins.

Venous leg ulcers and prevalence of surgically correctable reflux disease in a national registry

BackgroundChronic venous disorders are common, with varicose veins occurring in ∼40% of the population. Venous leg ulcers affect 1% to 2% of the population, with the prevalence increasing ≤4% for those aged >65 years. Both conditions are expensive and together are responsible for ≤2% of the annual healthcare budget expenditure of Western societies. The ESCHAR (effect of surgery and compression on healing and recurrence) and EVRA (early venous reflux ablation) trials demonstrated that surgical correction of superficial venous reflux reduced ulcer recurrence, resulted in faster healing times (EVRA), and was proved cost-effective. Largescale data regarding patients with chronic venous leg ulcers presenting to venous centers with treatable superficial venous insufficiency has not been previously reported. Our study was designed to evaluate the percentage of patients with leg ulcers presenting to dedicated vein centers who were found to have surgically correctable superficial venous insufficiency. MethodsThe American Vein & Lymphatic Society Patient Reported Outcome Venous Registry began collecting data in 2014 and is one of two national registries focused on chronic venous disorders. The database was queried first for the presence of an ulcer using the CEAP (clinical, etiologic, anatomic, pathophysiologic) classification (C6 status). These de-identified data were further correlated by crossing the number of ulcers for the same limb using the revised venous clinical severity score (rVCSS). The demographics, index duplex ultrasound details, and rVCSS features for ulcer duration and compression use were analyzed. Once the presence of an ulcer had been validated by CEAP and rVCSS, the population was divided into groups according to the ultrasound-reported anatomic pathology (eg, normal, reflux, obstruction, reflux plus obstruction). The query was directed toward all patients seeking a venous evaluation at participating centers from January 2018 through January 2022. ResultsMore than 270,000 unique patient records were reviewed. Of the 270,000 records, 163,027 (60%) had had duplex ultrasound scans available, for 1794 unique patients (1879 limbs), representing 1.1% with a leg wound. Of these patients, 55.4% were men and 44.6% were women. Group S included patients with isolated superficial pathology (n = 1291; 68.7%). Group M included patients with mixed superficial and deep pathology (n = 238; 12.7%). Group D included patients with isolated deep vein pathology (n = 58; 3.1%). Finally, group N included patients with leg wounds but no venous pathology (n = 292; 15.5%). The rVCSSs for groups S and M were significantly higher than those for group N. In group S, the dominant patterns involved the great saphenous vein (GSV) above the knee (54.8%), the small saphenous vein (30.7%), and the anterior accessory GSV (14.4%). The frequency of single, double, and triple axial vein reflux identified 1.45 vessels eligible for ablation treatment per limb. In group M, the dominant patterns involved the GSV above the knee (61.7%), the small saphenous vein (26.2%), and the anterior accessory GSV (12.1%), for 1.52 axial segments per limb. Of the 84.4% of venous ulcer patients, duplex ultrasound analysis revealed that 97% of this large subset had had surgically correctable disease. ConclusionsThe American Vein & Lymphatic Society Patient Reported Outcome Venous Registry demonstrated that 85% of the leg wounds in the present study were venous in origin and 97% possessed surgically correctable disease. Our findings support early referral to dedicated vein centers with appropriate venous reflux management as a part of the multidisciplinary team caring for patients with venous leg ulcers.

The significance of minimally invasive treatment methods in the single-stage elimination of varicose vein disease of the great and small saphenous veins of the lower limbs and their branches

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.

Varicose Veins of the Lower Extremity: Doppler US Evaluation Protocols, Patterns, and Pitfalls.

Venous insufficiency is a cause of substantial morbidity and medical expenditures. Diagnostic US evaluation of venous insufficiency requires a thorough understanding of the venous anatomy, including the deep, superficial, and perforator veins. The highly variable venous anatomy requires that operators use sound judgment to expand on protocol images and thus avoid missing important sources of reflux. The US examination requires specific patient positioning and use of provocative maneuvers. A basic understanding of the pathophysiology of venous insufficiency and the various treatment methods helps to identify key observations so that ineffective treatment methods are not pursued. The examination reports should have greater detail than those for the more common lower extremity deep venous thrombosis evaluation, requiring numeric and narrative descriptions of deep and superficial venous patency, reflux, diameter, and pathways. Potential pitfalls include not recognizing or detecting deep venous reflux, misidentifying common femoral vein reflux as deep venous reflux when the reflux is isolated or related to saphenofemoral insufficiency, not recognizing anterior accessory great saphenous vein (AAGSV) involvement in saphenofemoral insufficiency, not recognizing or reporting great saphenous vein or AAGSV superficialization, not suspecting central venous obstruction, and not realizing when provocative maneuvers were ineffective. With knowledge of the lower extremity venous anatomy, venous insufficiency pathophysiology, basic treatment strategies, protocol best practices, patterns of observation, and diagnostic pitfalls, those who interpret venous insufficiency US studies can perform examinations and deliver reports that help patients receive appropriate treatment. Online supplemental material is available for this article. ©RSNA, 2022.

Anterior accessory great saphenous vein as a cause of postoperative recurrence of veins after radiofrequency ablation.

There are problems of postoperative relapse of veins after radiofrequency ablation (RFA). The study aims to analyze the causes of postoperative recurrence of veins after RFA. 928 patients with varicose veins of the lower extremities, clinical classes C2-C4 according to the CEAP classification, were treated in the ambulatory surgery centers using RFA. The causes of varicose recurrence showed that it was caused by: a) high fusion of the anterior accessory great saphenous vein (AAGSV) with great saphenous vein (GSV) directly in the saphenofemoral junction (SFJ), which was not revealed by preoperative ultrasound (1.7%); a long stump of the GSV after the RFA (7.8%); progression of varicose disease with the small saphenous vein (SSV) and formation of new reflux associated with insufficiency of the saphenopopliteal junction (SPJ) (4.7%); d) insufficiency of perforating veins of the tibioperoneal group (Sherman, Boyd), as well as Gunter (3.8%); e) neovascularization with dilation of small vessels in the area of the saphenofemoral junction (0.97%). A comparative assessment of the quality of life (QL) after different surgery methods 3 years after implementation was carried out. Thus, QL in all patients who underwent surgery significantly improved than before surgery. However, after the RFA GSV+AAGSV, the patients had better QL by all scales than those who underwent only RFA GSV. Operations performed simultaneously on GSV and AAGSV have better functionality than GSV-only RFA.

Technical success and safety of peripherally inserted central catheters in the great saphenous and anterior accessory great saphenous veins.

Peripherally inserted central catheters (PICC) are occasionally placed in the great saphenous vein (GSV) and anterior accessory great saphenous vein (AAGSV) in patients with inadequate upper extremity veins or contraindications to upper extremity placement. Outcomes on the placement of PICCs in these veins are limited. This study aimed to determine technical success and safety of GSV/AAGSV PICCs. This is a retrospective study that reviewed all GSV/AAGSV PICC placements between January 2011 and December 2019. A total of 29 PICC placements procedures were identified. The electronic medical record was queried for demographic, procedural, and complication data. Technical success was defined by whether the vein could be accessed and a PICC could be placed. Catheter-associated infections, dislodgement or migration, malfunction, and PICC-associated thrombosis were recorded. Technical success of placement was 100%. Twenty-one (72%) catheters were placed in the GSV in the mid to upper thigh and eight (28%) were placed in the AAGSV. The median PICC dwell time was 13 days with a range of 3-155 days. PICC-associated complications occurred after 11 (37.9%) placements. Line associated infection was the most common complication (17.2%). Due to a high complication rate, GSV/AAGSV PICC placement should be considered only when upper extremity or cervical PICC placement is not feasible or contraindicated.

Feasibility and technique of endovenous laser ablation (EVLA) of recurrent varicose veins deriving from the sapheno-femoral junction-A case series of 35 consecutive procedures.

To assess the feasibility and technical success of endovenous laser ablation (EVLA) of recurrent varicose veins arising from the former sapheno-femoral junction (SFJ). We retrospectively analyzed all EVLA procedures treated in our institution by one surgeon between March 2019 and April 2020 and selected all consecutive cases with SFJ recurrence occuring after surgical high ligation and stripping or endovenous thermal ablation for incompetence of the great saphenous vein (GSV) in superficial venous insufficiency. The feasibility, technical success as determined by duplex ultrasound on the postoperative visit, complications and rate of endothermal heat-induced thrombosis (EHIT) were recorded. A subgroup definition was performed based on sonographic morphology of the recurrence and resulting strategy of ablation. Thirty-five limbs with SFJ recurrence in 34 patients were treated with EVLA in order to shut down the highest refluxing point. In 22 interventions, it was required to switch off a short stump or a neovascularization by direct puncture (Subgroup 1). In 13 treatments, the presence of residual GSV segments, or persistent, varicose transformed major tributaries like the anterior accessory great saphenous vein, enabled cannulation and advancing the laser fiber from distal to the former SFJ (Subgroup 2). The EVLA procedures could be successfully carried out in all 35 cases. There were no major complications, no thromboembolism or EHIT, and no local groin complications. In one case, the patient developed a phlebitic response that required temporary medication. Technical success was achieved with 34/35 treatments (97.1%). When comparing the subgroups, the morphological pattern of the SFJ recurrence and the resulting technique of puncture, cannulation and ablation did not influence the result. The results of this case series suggest that SFJ recurrences can also be successfully treated in situations where there are tortuous or short stumps that require direct puncture and ablation.

A Single-Center Experience of Anterior Accessory Great Saphenous Vein Endothermal Ablation Demonstrates Safety and Efficacy

Endothermal ablation is well-established for the treatment of the great saphenous and small saphenous veins. The data for treatment of the anterior accessory great saphenous vein (AAGSV) are lacking. The purpose of this study is to evaluate the safety and efficacy of AAGSV treatment using endothermal ablation.

The clinical relevance of anterior accessory great saphenous vein reflux

BackgroundInsurance approval for saphenous vein ablation is generally limited to junctional reflux involving the great saphenous vein (GSV) or small saphenous vein. This study was designed to investigate prevalence and disease severity of anterior accessory GSV (AAGSV) compared with GSV disease in patients presenting to dedicated outpatient vein centers. MethodsDeidentified data were pulled from the American Vein & Lymphatic Society PRO Venous Registry for first and second patient encounters. Variables included age, sex, and body mass index (BMI); clinical class of Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) classification; revised Venous Clinical Severity Score (rVCSS); and duplex ultrasound values for each limb. Data were further scrutinized according to duplex ultrasound findings. Patients with normal findings on duplex ultrasound examination or evidence of acute or chronic thrombosis were excluded. Patients were further characterized into two groups. The primary group had no prior vein treatment vs the progressive group, in which patients have had a superficial venous intervention at some point in the past. ResultsThere were 6836 unique patients with duplex ultrasound patterns of either AAGSV or GSV above the knee or both AAGSV and GSV in either group. This pool contained 2604 patients with recorded CEAP class and rVCSS, representing 2664 patient limbs in the final data set. In comparison to limbs in the progressive group, AAGSV reflux was more common in the primary group (78/563 vs 209/2101; P < .01). Demographic features of the groups demonstrated no significant difference. The primary group demonstrated a significantly higher rVCSS (6.95 vs 6.10; P < .01) than the progressive group. Patients in the primary group also demonstrated a significantly higher incidence of more advanced disease (CEAP class C4 and above; 43.1% vs 24.8%; P < .0001) than those in the progressive group. The primary group demonstrated no significant differences in age, sex proportions, or mean BMI. The mean rVCSS for GSV of these patients (7.22) was significantly higher than that of AAGSV patients (5.63; P < .01). The incidence of superficial vein thrombosis for the AAGSV patients (6.41%) was significantly higher than that of the GSV patients (2.17%; P < .05) in the progressive group. Patients in the progressive group demonstrated no significant difference in age, sex proportions, mean BMI, or average rVCSS. The proportion of AAGSV limbs with superficial thrombosis events (37/287 [12.9%]) was significantly higher than that for GSV (59/2214 [2.7%]; P < .01). ConclusionsAAGSV reflux is common and carries similar morbidity to GSV reflux. It is manifested with an alarming presence of superficial vein thrombosis.

Four-year Duplex Ultrasound Follow-up of Trunk Incompetent Saphenous Veins Treated with High Ligation and Reversed Catheter-directed Foam Sclerotherapy

Introduction: Ultrasound-guided foam sclerotherapy (UGFS) is an alternative and supplementary method for endovenous thermal ablation (EVTA) to treat incompetent saphenous reflux (ISR) and branch varicose veins (BVV).[1] The long-term result is not as satisfactory as EVTA, even while administered by catheter-directed method with or without tumescent local anesthesia.[2,3,4] Combined high ligation(HS) of sapheno-femoral junction(SFJ)/ sapheno-popliteal junction (SPJ) and reversed catheter-directed foam sclerotherapy (rCDFS) to treat ISR is an idea to assure SFJ/SPJ closure, avoid foam leaking into deep vein and enhance foam-endothelium interaction to improve safety and surgical results in less invasive and lower cost way. Midterm sonographic changes of target saphenous veins (TSV), clinical severity improvement and re-intervention rate are our concerns. Methods: From Jan. 2015 to Nov. 2018, 37 patients, 38 limbs treated with HS+rCDFS were retrospectively reviewed. The TSVs, CEAP severity, life quality scores, presence of venous leg ulcers (VLU), previous procedures for ISR or BVV, ongoing surgical procedures and following procedures were recorded. All enrolled patients were called back for re-evaluation of CEAP severity, life quality scores and VLU healing. The sonographic changes of TSV and BVV were focused. Results: 37 patients, 70.3% female, aged 29-85(mean 62.4), received HS+rCDFS because of unsatisfactory results of previous interventions (UGFS 21%, others 22.2%) or reluctant to EVTA. The severity above C4a was 76.3% (figure 1), including 26.3% with VLU. The TSVs included 30 great saphenous veins(GSV), 1 anterior accessory great saphenous vein (AAGSV) and 7 small saphenous veins (SSV). 71.1% surgeries were proceeded under local anesthesia. 23.7% surgeries combined with miniphlebectomy and 28.9% with sclerotherapy to BVV and 10.5% with sclerotherapy to reticular/spider veins. 63.2% patients needed following sclerotherapy, 18.4% needed following miniphlebectomy. 70.3% patients were followed from 57 to 1316 (mean 248) days. 76.9% TSVs were fibrotic or sealed. There were 4 small caliber recanalization, 1 large caliber recanalization(LCR), 1 neovasculization and 1 collateralization.(table 1) The VLU healing rate was 100%. The mean AVVQ and VCSS were 2.4, 1.9 respectively. There was one re-intervention for LCR with 1% polidocanol microfoam, Varithena. Conclusion: The severity of this series of patients was high but HS+rCDFS still permitted satisfactory midterm results to treat de novo or relapsed ISR and BVV and achieved 100% VLU healing, not inferior to EVTA or open saphenous vein stripping. The follow-up sonographic findings were surprisingly well without evident neovasculization as expected. Only 4% significant collateralization or LCR might need re-intervention. Disclosure: Nothing to disclose

Endovascular Treatment of Klippel-Trenaunay Syndrome

Endovascular Treatment of Klippel-Trenaunay Syndrome

Incidence and distribution of lower extremity reflux in patients with pelvic venous insufficiency.

Women with pelvic venous insufficiency often present with lower extremity symptoms and manifestations of chronic venous disorders. The purpose of this investigation was to determine the incidence of lower extremity chronic venous disorders and the types and distribution of lower extremity veins involved in patients with a known diagnosis of pelvic venous insufficiency. Between January 2012 and December 2015, we retrospectively reviewed the charts of 227 women with pelvic venous insufficiency as well as their lower extremity venous duplex investigations. Presenting symptoms, Clinical, Etiology, Anatomy, Pathophysiology (CEAP) class, initial revised Venous Clinical Severity Score (rVCSS) and the types of lower extremity veins with reflux and their locations were noted. Patients were also subcategorized according to their primary pelvic disorder as follows: Entire cohort (PVI), Ovarian vein reflux (OVR), Iliac vein stenosis (IVS) or both (OVR + IVS). The study group consisted of 227 women (454 limbs) with documented pelvic venous insufficiency. The average age was 44.71 ± 10.2 years. In decreasing order, patients presented with the following lower extremity symptoms: pain (66%), swelling (32%), heaviness (26%), limb fatigue (13%), itching (13%), leg cramps (10%), skin changes or Superficial Venous Thrombosis (SVT) (2%) and ulceration or bleeding (0.08%). Table 1 outlines the CEAP class for 215 of the 227 patients. For the entire cohort, 48% of right and 50% of left limbs demonstrated C0 or C1 disease. The incidence and type of symptomatic lower extremity veins were as follows: any axial vein, 32%; great saphenous vein (GSV), 21%; small saphenous vein (SSV), 11%; GSV and SSV, 5%; non-saphenous tributaries, 15%; saphenous tributaries, 12%; posterior or postero-lateral thigh distribution, 5%; vulvar distribution, 4%; perforators, 4%; deep veins, 2%; and anterior accessory saphenous veins, 1%. For the GSV and SSV, the following patterns of reflux were observed: entire GSV, 4%; entire above knee GSV, 2%; entire below knee GSV, 2%; above knee segmental GSV, 20%; below knee segmental GSV, 21%; above and below knee GSV segmental disease, 1%; entire SSV, 4%; and SSV segmental disease, 12%. The incidence of reflux in any axial vein, the GSV and anterior accessory GSV was greater in the OVR group compared to IVS or OVR + IVS (p ≤ 0.03). In addition, 64 of 227 (28%) patients had a history of prior lower extremity venous ablations: OVR (10/39, 26%), IVS (15/50, 30%) and OVR + IVS (39/127, 9%). The number of ablations per patient was as follows-OVR: 1.48 ± 0.5, IVS: 1.7 ± 0.7 and OVR + IVS: 1.65 ± 0.7. At least 50% of patients with pelvic venous insufficiency present with lower extremity venous disease. The incidence of reflux in any axial vein is greatest in the OVR group suggesting a correlation with hormonal fluctuations and pregnancy. The majority of symptomatic patients present with segmental axial GSV or SSV disease. Although vulvar and gluteal escape veins are highly associated with pelvic venous insufficiency, they are infrequently observed. In patients who experience residual or persistent symptoms after treatment for chronic venous disorders, a pelvic venous ultrasound should be performed to assess the presence of pelvic venous insufficiency.

Use of Polidocanol Endovenous Microfoam to Improve Hemodynamics and Symptomology in Patients with Challenging Clinical Presentations: A Case Series

Chronic venous insufficiency (CVI) is a widely prevalent condition. Saphenous venous reflux is the most common underlying pathology that leads to CVI. Endovenous thermal ablations (ETA) are the current gold standard. However, some patients present with some unique challenges making ETA less ideal. Nonthermal nontumescent therapies could be considered as alternative therapy in these patients. We performed a retrospective review of treatment effects with United States Food and Drug Administration-approved polidocanol endovenous microfoam (PEM; Varithena® 1%) on venous symptomology in 10 (n=10) C3-C6 patients with CVI and concomitant complex disease/pathology that limited the use of ETA. The pathology included risk of bruising or bleeding, severe lipodermatosclerosis, hidradenitis suppurativa, chronic fibrosis of the vein from prior superficial thrombosis, risk for nerve injury, and failed prior ETA. Before treatment, all patients underwent a venous incompetence study by duplex ultrasound (DUS). Preprocedure pain, symptoms, and Venous Clinical Severity Scores (VCSSs) were recorded. Clinical assessments and DUS were performed 4 days, 6 weeks, 6 months, and 1 year after treatment. DUS demonstrated reflux in the great saphenous vein (GSV), anterior accessory GSV, and/or the small saphenous vein. Pain scores and VCSS were reduced 4days and 6weeks after treatment. These lower scores were maintained for up to 1year after treatment. PEM use in C3-C6 patients resulted in successful improvement in VCSS, CVI symptoms, and wound healing among patients in whom ETA was not considered to be the optimal therapy.

Operative and postoperative risks of combined interventions by phlebectomy and foam sclerotherapy

SummaryBackground: Insufficiency of anterior accessory great saphenous vein (AASV) with a competent great saphenous vein (GSV) is frequently encountered in patients referred for phlebological evaluation. The classic therapeutic approach to treat AASV insufficiency consists of crossectomy and stripping of GSV and all tributaries. In isolated AASV insufficiency, stripping of the AASV combined with foam sclerotherapy of the proximal AASV section is a useful alternative to preserve the GSV. Historically, the combination of phlebectomy and sclerotherapy in a single session was avoided given the perceived and reported risk of complicationsAim: A retrospective analysis of the side effects and complications following phlebectomy of the AASV combined with foam sclerotherapy in one session.Patients and method: Case records of all patients with isolated AASV insufficiency, who underwent a combined procedure (phlebectomy of the AASV and foam sclerotherapy) between 01.01.2013 and 30.11.2016, were evaluated.Results: 28 patients (29 legs) were included. There were no severe side effects or complications in any case. Complete occlusion of the proximal AASV could be demonstrated sono-graphically.Conclusion: The combination of phlebectomy and foam sclerotherapy in one session is an effective and safe treatment option in cases of isolated AASV insufficiency.

Anterior accessory great saphenous vein treated with endovenous laser

Introduction Endovenous laser ablation of great saphenous vein (GSV) represents well established technique of radical therapy of varicose veins of lower extremities with excellent long-term results. However, the laser ablation of anterior accessory GSV (AAGSV) remains infrequent in everyday surgical practice. This study assesses the efficacy of this unusual procedure. Material and methods From April 2003 to June 2014, we performed endovenous laser ablation of AAGSV in 147 patients (31 men and 116 women). In total, 173 AAGSV procedures were done. Before surgery, all patients were assessed with colour flow duplex ultrasonography and reflux pattern and diameter of the truncal vein (3.5 to 22.8 mm) were recorded. The endovenous procedures were performed using 980 nm diode or 1320 nm Nd:YAG lasers combined with 600 microns bare fiber. In the follow-up (1 month to 10 years postop), patients were asssessed clinically and with duplex ultrasound. Results No deep venous thrombosis, nor pulmonary embolism were recorded. In majority of patients, we found bruising and/or indurations along the treated veins which resolved within 2 to 3 weeks. Twice, the neovascularisation was found in the groin and the total occlusion rate was 92%. Conclusion Even technically more difficult and delicate, endovenous laser therapy of AAGSV can be performed safely and finally with excellent results comparable to well established ablation of GSV.

Clinical Results of a New Strategy (Modified CHIVA) for Surgical Treatment of Anterior Accessory Great Saphenous Varicose Veins

IntroductionTraditionally, anterior accessory great saphenous vein insufficiency was managed by crossectomy and resection of varicose veins. The aim of this paper is to show the safety and efficacy of a new therapeutic strategy for anterior accessory great saphenous varicose veins. MethodsThis non-randomised prospective study included 65 patients with varicose veins from the anterior accessory great saphenous vein. The novelty of the technique is to avoid the great saphenous vein crossectomy and perform just flebectomy of the visible veins. Venous duplex studies were performed preoperatively, a month and a year postoperatively. The clinical assessment was done by the Fligelstone scale. ResultsThe baseline CEAP clinical classification was: 58% C2, 26% C3 and 15% C4–6. The new strategy was applied to all cases. Complications: 3 haematomas, 7 cases of asymptomatic partial anterior saphenous thrombosis. Reduction of the initial average diameter was from 6.4mm anterior saphenous to 3.4mm by one year (P<.001). At twelve months a forward flow is maintained in 82% of cases. Recurrence of varicose veins was 8%. All patients improved their clinical status based on the Fligelstone scale. Cases with saphenous diameter bigger than 7.5mm and obesity were identified as predictors of worse clinical and haemodynamic outcome. ConclusionsThis modified surgical strategy for anterior saphenous varicose veins results in better clinical outcomes at one year postoperatively.

Resultados clínicos de una nueva estrategia quirúrgica (CHIVA modificado) en el tratamiento de las varices dependientes de la vena safena magna accesoria anterior

IntroductionTraditionally, anterior accessory great saphenous vein insufficiency was managed by crossectomy and resection of varicose veins. The aim of this paper is to show the safety and efficacy of a new therapeutic strategy for anterior accessory great saphenous varicose veins. MethodsThis non-randomised prospective study included 65 patients with varicose veins from the anterior accessory great saphenous vein. The novelty of the technique is to avoid the great saphenous vein crossectomy and perform just flebectomy of the visible veins. Venous duplex studies were performed preoperatively, a month and a year postoperatively. The clinical assessment was done by the Fligelstone scale. ResultsThe baseline CEAP clinical classification was: 58% C2, 26% C3 and 15% C4-6. The new strategy was applied to all cases. Complications: 3 haematomas, 7 cases of asymptomatic partial anterior saphenous thrombosis. Reduction of the initial average diameter was from 6.4 mm anterior saphenous to 3.4 mm by one year (p <0.001). At twelve months a forward flow is maintained in 82% of cases. Recurrence of varicose veins was 8%. All patients improved their clinical status based on the Fligelstone scale. Cases with saphenous diameter bigger than 7.5 mm and obesity were identified as predictors of worse clinical and hemodynamic outcome. ConclusionsThis modified surgical strategy for anterior saphenous varicose veins results in better clinical outcomes at one year postoperatively.

Anatomy of the lymph node venous networks of the groin and their investigation by ultrasonography.

To describe the anatomy of the lymph node venous networks of the groin and their assessment by ultrasonography. Anatomical dissection of 400 limbs in 200 fresh cadavers following latex injection as well as analysis of 100 CT venograms. Routine ultrasound examinations were done in patients with chronic venous disease. Lymph node venous networks were found in either normal subjects or chronic venous disease patients with no history of operation. These networks have three main characteristics: they cross the nodes, are connected to the femoral vein by direct perforators, and join the great saphenous vein and/or anterior accessory great saphenous vein. After groin surgery, lymph node venous networks are commonly seen as a dilated and refluxing network with a dystrophic aspect. We found dilated lymph node venous networks in about 15% of the dissected cadavers. It is likely that lymph node venous networks represent remodeling and dystrophic changes of a normal pre-existing network rather than neovessels related to angiogenic factors that occur as a result of an inflammatory response to surgery. The so-called neovascularization after surgery could, in a number of cases, actually be the onset of dystrophic lymph node venous networks.Lymph node venous networks are an ever-present anatomical finding in the groin area. Their dilatation as well as the presence of reflux should be ruled out by US examination of the venous system as they represent a contraindication to a groin approach, particularly in recurrent varicose veins after surgery patients. A refluxing lymph node venous network should be treated by echo-guided foam injection.

Factors Associated with Recurrence of Varicose Veins after Thermal Ablation: Results of The Recurrent Veins after Thermal Ablation Study

Background. The goal of this retrospective cohort study (REVATA) was to determine the site, source, and contributory factors of varicose vein recurrence after radiofrequency (RF) and laser ablation. Methods. Seven centers enrolled patients into the study over a 1-year period. All patients underwent previous thermal ablation of the great saphenous vein (GSV), small saphenous vein (SSV), or anterior accessory great saphenous vein (AAGSV). From a specific designed study tool, the etiology of recurrence was identified. Results. 2,380 patients were evaluated during this time frame. A total of 164 patients had varicose vein recurrence at a median of 3 years. GSV ablation was the initial treatment in 159 patients (RF: 33, laser: 126, 52 of these patients had either SSV or AAGSV ablation concurrently). Total or partial GSV recanalization occurred in 47 patients. New AAGSV reflux occurred in 40 patients, and new SSV reflux occurred in 24 patients. Perforator pathology was present in 64% of patients. Conclusion. Recurrence of varicose veins occurred at a median of 3 years after procedure. The four most important factors associated with recurrent veins included perforating veins, recanalized GSV, new AAGSV reflux, and new SSV reflux in decreasing frequency. Patients who underwent RF treatment had a statistically higher rate of recanalization than those treated with laser.

Endovenous Radiofrequency Thermal Ablation and Ultrasound-Guided Foam Sclerotherapy in Treatment of Klippel-Trenaunay Syndrome

Klippel-Trenaunay syndrome is composed of port-wine stain, limb hypertrophy and varicose veins. The two patients with Klippel-Trenaunay syndrome treated by endovenous radiofrequency thermal ablation and ultrasound-guided foam sclerotherapy of the abnormal veins was conducted. Radiofrequency thermal ablation resulted in successful occlusion of the incompetent anterior accessory great saphenous vein. Moreover, ultrasound-guided foam sclerotherapy showed complete occlusion of the residual veins. At 6 month follow-up, both patients markedly decreased leg symptoms including pain, cramping, limb swelling, and bulging of veins. Radiofrequency thermal ablation combined with foam sclerotherapy is a minimally invasive procedure alternative to the standard invasive surgery and can be the option for saphenous ablation in Klippel-Trenaunay syndrome patients.