Endovenous Treatment Research Articles

Percutaneus treatment of varicose veins with bipolar radiofrequency ablation

The traditional surgical treatment of an incompetent great saphenous vein (GSV) and small saphenous vein (SSV) is challenged by endovenous techniques. Bipolar radio frequency induced thermo therapy (RFITT) is a new endovenous treatment, which occludes the vein by using the venous wall as a conductor. Linear endovenous energy densitiy (LEED) describes the amount of energy used for vein closure. Material/methods From March 2007 till April 2009, two cohorts (23 W and 20 W) were compared, respectively 280 and 178 patients. GSV and SSV were separately analyzed. Follow-up was performed at 3 weeks and 1 year post-operatively with duplex ultrasound, to assess vein closure and perioperative complaints. A visual analog scale (VAS) pain score (range 0–10) was documented. For patients operated after October 2008 follow-up was performed at least 6 months after surgery. Results 528 GSV and 76 SSV were treated. For the GSV a significant difference in LEED 40.8 17.1 in the 20 W cohort was found, resulting in higher occlusion rates 90.6% compared to 82.7% after 3 weeks. Follow-up of 1 year in the 20 W cohort showed 88.7% occlusion. Multivariate analysis showed that pullback speed (OR 3.7, CI 1.1–12.4) and CEAP classification (OR 3.1, CI 1.7–5.6) were significant predictors for vein occlusion. Despite a higher LEED, post-operative complaints were not significantly worse. Conclusion RFITT is a safe and effective method to treat incompetent saphenous veins. Slower pullback speed with higher LEED results in higher closure rates without causing more pain.

Indications to surgical treatment in varicose veins

There isn’t a consensus to the treatment of varicose veins because we don’t have randomized controlled trials [1]. Indication to the treatment is based on different criteria: etiological, clinical and diagnostic. The treatments include: conservative therapy, sclerotherapy, phlebectomy, endovenous laser therapy, radiofrequency ablation, and surgery involving saphenous ligation and stripping [2]. Short-term advantages appeared to be associated with sclerotherapy and endovenous treatments, and long-term effectiveness was more apparent following surgical intervention. Evidence suggests conservative therapy is less effective than sclerotherapy and surgery for the treatment of varicose veins. Ligation with stripping plus phlebectomy is generally regarded as the gold standard for treating primary long saphenous veins. Sclerotherapy and surgery both appear to have a place in the management of varicose veins. Sclerotherapy and phlebectomy may also be more appropriate in patients with minor superficial varicose veins not related to reflux of the saphenous system or as a post- or adjunctive treatment to other procedures, such as surgery. Current evidence suggests endovenous laser therapy and radiofrequency ablation are as safe and effective as surgery, particularly in the treatment of saphenous veins. Most importantly, the type of varicose vein should govern the intervention of choice, with no single treatment universally employed [2].

The treatment of varicose veins: an investigation of patient preferences and expectations

A number of modalities are now available for the treatment of varicose veins. The aim of the study was to investigate the factors considered important by patients when contemplating treatment of their varicose veins. Consecutive new patients referred to a vascular surgery service were invited to complete a short anonymous questionnaire prior to their consultation. The questionnaire consisted of 13 multiple choice questions relating to symptoms, potential varicose vein treatments and patient knowledge of existing therapies. Of 111 patients, there were 83 complete responses (75%). Symptoms of pain or aching were reported as moderate or severe by 77/103 (75%) of patients and significantly limited the activities of 47/101 (47%). Although the majority (89/103 [86%]) of patients were aware of surgery, only 52/103 (51%) knew of the existence of endothermal ablation (either laser or radiofrequency) and only 23/103 (22%) were aware of foam sclerotherapy. Some 58/92 (63%) were in favour of local anaesthetic treatment. Most patients (74/103, 72%) felt inadequately informed to express a preference regarding treatment type prior to their consultation, although 24/103 (23%) expressed a preference for endovenous treatment. Interestingly, 74/92 (80%) stated that the opinion of their vascular surgeon would be likely to or definitely influence their treatment decision and the majority of patients stated that what they had read in magazines (54/80, 64%) or on the Internet (51/85, 60%) would have no influence on their decision regarding treatment, respectively. Only a minority of patients referred with varicose veins were aware of endovenous treatments or felt adequately informed to express a treatment preference prior to consultation. Over half of patients expressed a preference for local anaesthetic therapy and a preference for a single visit treatment, although most would be strongly influenced by the opinion of their vascular surgeon and not influenced by media advertising.

Percutaneous therapy of acute on chronic lower extremity venous occlusive disease

Venous thromboembolic disease is an underdiagnosed disease spectrum with a high mortality and morbidity. Despite significant advances in cardiovascular interventions, venous occlusive disease has not received the attention it deserves from the interventional cardiology community. We describe an 82-year-old man with massive left lower extremity DVT who underwent successful percutaneous endovenous intervention (PEVI) with rapid resolution of symptoms. We like to use this case as a call to action and raise awareness of the importance of PEVI in the treatment of extensive venous occlusive disease.

Endovenous treatments for varicose veins – over-taking or over-rated?

A variety of endovenous therapies for the treatment of superficial venous incompetence are currently available. The aim of this study was to evaluate the prevalence of endovenous techniques used by consultant vascular surgeons in the United Kingdom. An anonymous online survey of 16 multiple choice questions relating to the nature and provision of treatment for varicose veins was devised. Consultant members of the Vascular Society of Great Britain and Ireland were invited to participate by email. A total of 108/352 (31%) surgeons completed the survey. The majority offered surgery as the first-line treatment for primary great saphenous vein (GSV) and small saphenous vein (SSV) incompetence (69% and 74%, respectively). Endovenous procedures were offered as first-line treatment by 32/108 (29.6%) for GSV reflux, 36/51 (70.6%) surgeons performed these under local anaesthetic and 21/51 (41.2%) were performed as an outpatient procedure. The most important factor influencing treatment decisions was considered to be patient preference by 77/108 (71.3%) surgeons, although 48/61 (78.7%) respondents were restricted by primary care trusts with regard to endovenous treatments, and 33/108 (30.6%) offered different treatments to private patients. Traditional surgery remains the most commonly offered treatment for patients with varicose veins. The provision of endovenous therapies varies greatly, and there are significant differences in local availability regarding these treatments.

Changing practice from conventional surgery to endovenous treatments produces excellent results for both long and short saphenous varicose veins

This questionnaire study revealed a rationing of access to care of symptomatic varicose veins and that the majority of responders performed conventional surgery on the NHS. We agree with the findings of this study that endovenous treatments of superficial venous reflux are not yet widely available in NHS practice.

Heterogeneity in Randomised Clinical Trials of Endovenous Interventions for Varicose Veins

Heterogeneity in Randomised Clinical Trials of Endovenous Interventions for Varicose Veins

The Number of Instability Markers is a Significant Predictor of Outcome in Distal Radial Fractures and Can Be Used as a Guide to Devise a Standardised Management Strategy for These Fractures

The Number of Instability Markers is a Significant Predictor of Outcome in Distal Radial Fractures and Can Be Used as a Guide to Devise a Standardised Management Strategy for These Fractures

Evidence on Efficacy of Treatments of Venous Ulcers and on Prevention of Ulcer Recurrence

Venous ulcers affect almost 1 million people in the United States. Delayed healing and frequent recurrence result in pain, disability, decreased quality of life, and loss of working days for the patients. Compression therapy is the most effective treatment of ulcers, but compliance with conservative treatment is important, and recurrence must be prevented by treating the underlying ambulatory venous hypertension. Evidence from prospective randomized trials confirm that ulcer recurrence is decreased with superficial vein surgery. Evidence is also increasing about the superiority of endovenous interventions, such as laser or radiofrequency ablation, over the classic open surgical treatment of high ligation, division, and stripping of the saphenous vein. Well-conducted randomized trials are still needed to provide grade A evidence to justify treatment of incompetent perforating veins. Treatment of proximal venous occlusion is important, and venous stents have been effective and durable. Open surgery is only considered today for iliac or iliocaval venous obstruction if endovascular treatment is not possible or has already failed. Open surgery for deep venous incompetence is recommended in centers of excellence, although evidence to support its effectiveness is of low quality.

Suitability of Varicose Veins for Endovenous Treatments

The aim of the study was to assess the suitability of radiofrequency ablation (RFA), endovenous laser ablation (EVLA), and foam sclerotherapy (FS) for patients with symptomatic varicose veins (VVs). The study comprised 403 consecutive patients with symptomatic VVs. Data on 577 legs from 403 consecutive patients with symptomatic VVs were collected for the year 2006. Median patient age was 55 years (interquartile range 45-66), and 62% patients were women. A set of criteria based on duplex ultrasonography was used to select patients for each procedure. Great saphenous vein (GSV) reflux was present in 77% (446 of 577) of legs. Overall, 328 (73%) of the legs were suitable for at least one of the endovenous options. Of the 114 legs with recurrent GSV reflux disease, 83 (73%) were suitable to receive endovenous therapy. Patients with increasing age were less likely to be suitable for endovenous therapy (P = 0.03). Seventy-three percent of patients with VVs caused by GSV incompetence are suitable for endovenous therapy.

Endovenous therapy of varicose veins: A better outcome than standard surgery?

In the UK approximately one million people are affected with varicose veins. Nearly half a million patients seek advice from their GPs about lower limb varicose veins related symptoms every year. Therefore, they constitute an important part of the elective operations and waiting lists in NHS hospitals. About 40,000 operations for varicose veins were performed in the NHS in 2001. The majority (60-70%) of those patients had an incompetent saphenofemoral junction (SFJ) and great saphenous vein (GSV) reflux. The traditional and most common approach for treating SFJ incompetence and GSV reflux is saphenofemoral disconnection and GSV stripping to the knee. Despite being considered a minor surgical procedure, complications are not uncommon. The minimally invasive endovenous treatment of lower limb's varicose veins has been used over the last few years in many centres across the world. It would appear to be equal to, if not superior to, traditional surgery. It has also been proven to be safe with few serious complications. The most common treatments are endovenous laser ablation and endovenous radiofrequency ablation and chemical sclerotherapy. The case for minimally invasive strategies appears to have been accepted by many patients already and it would appear in trials that they are 'voting with their feet'. Rigorous scientific evidence remains elusive and not yet conclusive. As in all other branches of surgery new technology should be embraced but cautiously, with all results collected and disseminated to finally prove the utility or otherwise of this technique.

Radiofrequency ablation for uncomplicated varicose veins

In recent years, minimally invasive endovenous treatments have gained popularity in the treatment of superficial venous reflux. The perceived advantages of endovenous therapy include reduced pain, high vein occlusion rates, and early return to work and normal activities. Endovenous radiofrequency ablation (RFA) involves the delivery of thermal energy from a bipolar catheter to the venous segment to be treated. This technique has been available since 1998 and numerous devices and catheters are now produced. Numerous prospective and randomized studies have compared the effectiveness of RFA with traditional and endovenous procedures. In this article, the available evidence for clinical effectiveness, quality of life and cost gains following endovenous RFA is summarized. The scientific principles behind RFA and technical procedural considerations are discussed and standards of care for the delivery of endovenous RFA are proposed.

Treatment of varicose veins

Varicose veins (VVs) are the most common manifestation of chronic venous insufficiency, affecting 25% of women and 15% of men. Reticular veins and telangiectasias (spider veins) are found in more than 80% of the general population. VVs produce symptoms of pain, swelling, heaviness, fatigue, and pruritus and predispose patients to complications including bleeding, superficial thrombophlebitis, and ulcerations that interfere with activities of daily living and result in lost time from work. Current treatments for VVs include conservative measures, and when these are unsuccessful, more invasive surgical and endovenous interventions primarily aimed at reducing venous hypertension and preventing progression to chronic inflammation and ulcerations. Surgical procedures including saphenous vein stripping, ligation of the saphenofemoral junction, and ambulatory phlebectomy are effective in the treatment of VVs but are associated with a high complication rate and recovery time. Emerging endovenous therapies, including endovenous laser therapy, radiofrequency ablation, and endovenous foam sclerotherapy, have shown similar efficacy in the treatment of VVs compared with more invasive surgical procedures, with lower complication rates and less time lost from work.

Leg ulcer treatment

Venous ulcers continue to cause problems for patients and health care systems. These are painful and unpleasant for the patient and expensive for health care providers to treat. This brief review highlights effective methods of management. There is level 1 evidence of the efficacy of compression (bandaging or stockings) in healing ulcers as well as maintaining healing. Patients with superficial saphenous reflux, with or without perforating and deep vein incompetence, benefit from superficial venous surgery. This does not speed ulcer healing but is effective at preventing recurrence after healing with compression. Minimally invasive methods of managing incompetence of superficial saphenous trunks, including endovenous laser ablation, radiofrequency ablation, and foam sclerotherapy are probably also effective in treating patients with venous leg ulcers. Perforating vein ligation is commonly combined with superficial venous surgery for leg ulcer patients, but no systematic data are available to define the role of this treatment. Some centers use deep vein reconstruction to restore competence to deep vein valves. Insufficient data have been published to allow any general recommendation to be made for this treatment. A limited number of drugs have efficacy in promoting leg ulcer healing. They may be used in combination with compression treatment in patients with ulcers refractory to other methods of management. No particular ulcer dressing has been shown to be effective in speeding ulcer healing.

REVAT (Recurrent Varices After Treatment)

SummaryThe term “recurrent varicose veins” covers various entities. In the first instance, recurrent varicose veins may be the progression of the underlying disease, as there is a hereditary disposition to the condition, but we also find the phenomenon of neovascularisation, and lastly we repeatedly see recurrent varices as a result of technical or strategic surgical errors and the failure of endovenous procedures. No differentiation between these different types of recurrent varicose veins has previously been made in the literature, so that the numbers given vary between 6% and 60%. Up to the present time, few data on the progression of the underlying disease are to be found in the literature. Our own studies, on average 36 months postoperatively, demonstrated new varicose side branches that could be interpreted as progression of the underlying disease in 56.8% of the patients followed up.Several recent publications demonstrate neovascularisation as a cause of recurrence. While some authors give a figure of 24% for recurrence due to neovascularisation in patients who have had surgery, other publications regard neovascularisation as the main cause of postoperative recurrence.The data on technical or strategic surgical errors and recanalisation after endovenous procedures are also very varied. Numbers for technical errors as the cause of recurrent varicose veins following surgery range from 10.7% to more than 70%. Published recanalisation rates after endovenous laser therapy vary between 0% and 36%; the average recanalisation rate in the available prospective randomised studies on radiofrequency obliteration was 12.9%. Foam sclerotherapy has recanalisation rates between 69% and 86%, with a mean follow-up of 32.2 months.Given the different possible causes, it is extremely important, that recurrent varicose veins should be classified. The authors have developed a simple classification that can be used in routine daily practice. Recurrent varicose veins are given the acronym REVAT (recurrent varices after treatment). Generally speaking, on the one hand there is progression of the underlying disease (progression of disease = PD) and, on the other hand, varicosities after treatment as a result of technical error or failure of the method used (recurrence after treatment = RT). Progression of the underlying disease can be further subdivided into neovascularisation at the saphenofemoral or popliteal junction (progression of disease at the junction = PD-J) and new varices arising in the treated vascular territory (progression of disease at the limb = PD-L).In the case of recurrent varices after treatment we distinguish between a persisting or a new reflux at the saphenofemoral or the popliteal junction (recurrence after treatment at the junction = RT-J), untreated segments of the great or small saphenous veins or recanalisation of the trunk (recurrence after treatment at the trunk = RT-T) and untreated side branches or perforating veins (recurrence after treatment at side branches = RT-S). With the help of these abbreviations a simple formula can be generated to describe the recurrent varices, e.g. recanalisation of the left great saphenous vein (GSV) after endovenous treatment and a new varicosis in the vascular territory of the left great saphenous vein resulting from progression of the underlying disease: vascular territory left great saphenous vein = GSV-L, technical or tactical error due to recanalisation of the GSV = RT-T, progression of the underlying disease in the vascular territory of the GSV = PD-L. This generates the formula: GSV-L : RT-T, PD-L.Since there are no exact figures on the incidence of the individual causes of recurrent varicosis, a classification of recurrent varicosis is indispensable to ensure clarity in the future.

Anatomical Patterns of the Above Knee Great Saphenous Vein and its Tributaries: Implications for Endovenous Treatment Strategy

Objective: The aim of the present study was to analyse the anatomical patterns of the above knee great saphenous vein (GSV) and its tributaries in limbs with varicose veins in view of potential suitability for endovenous treatment. Methods: Limbs of a consecutive series of new patients with varicose veins presenting at the phlebologic clinic during a 4 month period were studied. In 73 limbs of 56 patients with varicose veins and both saphenofemoral junction and GSV reflux, anatomical patterns of the above knee GSV were defined as :-‘complete’ GSV: main trunk visualised within the saphenous compartment from the groin to the knee-‘incomplete’ GSV: main trunk partially visualised from the groin to mid thigh with a non-refluxing mostly hypoplastic distal GSV and a superficial tributary vein (STV) parallel to the GSV.Results: 51 limbs (70 %) had a ‘complete’ GSV. In 4 of these 51 limbs reflux passed from the main GSV trunk to a STV at mid thigh level leaving a non-refluxing part of the GSV from mid thigh to the knee.Conclusion: In only 64% of limbs with varicose veins the entire above knee GSV was involved in the disease. This may have implications for endovenous treatment strategy.

ABSCESO EPIDURAL LUMBAR POST HERNIA DISCAL TRAUMÁTICA: CASO CLÍNICO

Se presenta el caso de un hombre de 42 anos con historia de trauma y compresion axial de la columna lumbar que origino una hernia de nucleo pulposo a nivel lumbar, demostrada mediante resonancia magnetica. Al cuarto dta de evolucion aparece fiebre y alteraciones de laboratorio concordantes con infeccion, sin signos de compromiso neurologico. El hemocultivo resulta positivo para staphylococcus aureus. La resonancia magnetica demuestra presencia de absceso espinal lumbar, que impresiona secundario a hematoma epidural infectado. El paciente es tratado medicamente, con antibioticoterapia que incluye inicial mente ceftriaxona/ metronidazol/ gentamicina y posteriormente cloxacilina/cefazotina, con buena evolucion, completando 6 semanas por vta endovenosa y 4 vta oral. Su evolucion fue favorable, siendo dado de alta en buenas condiciones y sin deficit neurologico.

Colouterine fistula complicating diverticulitis in elderly women

Dear Editor: Diverticulosis is a very common colonic pathology occurring in more than 65% of the population by the age of 80. The inflammatory process involving diverticulosis arises with an inflammatory response that may require surgery for hemorrhage, abscess, perforation, or fistula formation. The pathophysiology of colouterine fistulas includes destruction of two serosas of two epithelialized surfaces in close proximity. We describe the case of an elderly 76-year-old patient who presented within a period of 6 months with two episodes of acute diverticulitis that required endovenous treatment. The patient had already presented with fecal incontinence. At this time, the patient was taken to the emergency room because of the presence of a foul-smelling vaginal discharge with fecaloid flow. Abdominal examination revealed a low tenderness in the left lower quadrant, without palpable mass. The patient had no fever. Laboratory tests did not show any alteration in biological values. Antibiotic treatment was initiated and the patient was studied. A CT scan was performed that showed the presence of a uterus full of air and fecal content. Also, an inflammatory sigmoid colon with the presence of diverticles and a thick sigmoid wall could be seen. An image of malignancy could not be excluded. All these data confirmed the presence of a colouterine fistula. No colonoscopy had been yet performed because of the wish of the patient and their family. Surgery was performed and, at laparotomy, a chronic inflammatory mass was observed. This mass included the whole sigmoid colon and the posterior uterine wall. An en bloc resection was performed with a Hartman’s procedure. Colouterine fistulas were first reported by Lejemtel in 1909. At that time, three main etiologies were described: first, trauma or spontaneous rupture of a gravid uterus in which an intestinal loop impacted on the tear and a subsequent necrosis developed after constricting contractions of the myometrium; second, the presence of abscess rupture into the bowel and the uterus; third, a uterine or sigmoid carcinoma. In later years, radiotherapy has also been involved in colouterine fistula formation. Hawkes described obstetric trauma including curettage of the uterus with simultaneous perforation of the uterus and the colon. The first report of colouterine fistulas related to diverticulitis was by Noecker in 1929. This diagnosis is rare and even rarer is to observe colouterine fistulas related to diverticulitis. Among causes other than diverticulitis, endometriosis, gynecological cancer, and also apex abscesses have been described. Many reasons have been provided in order to explain colouterine fistula formation. Owing to the great thickness of the uterine wall, colouterine fistulas are very rare. The development of diverticulitis episodes may lead to a fistula formation, because of repeated inflammatory response in the tissues, such as in our patient. Repeated acute episodes of diverticulitis may lead to adhesions, local inflammation, with subsequent necrosis and fistula formation. It is usually the fundus of the uterus and the sigmoid colon that are linked. Also, a perforated sigmoid colon in the presence of an abscess may be the cause of the fistula formation, which was the case with our patient. Int J Colorectal Dis (2009) 24:599–600 DOI 10.1007/s00384-008-0630-x

Systematic Review of Treatments for Varicose Veins

This systematic review compares the safety and efficacy of varicose vein treatments, including conservative therapy, sclerotherapy, phlebectomy, endovenous laser therapy, radiofrequency ablation, and surgery involving saphenous ligation and stripping. Systematic searches of medical bibliographic databases were conducted in February 2008 to identify suitable studies published from January 1988 onward. Articles were considered eligible for inclusion through the application of a predetermined protocol. Safety and effectiveness data from the comparison of two or more varicose vein procedures were extracted and analyzed. Seventeen studies, published between 2003 and 2007, were included in this review. Serious adverse events were rare. Minor adverse events were more common but generally self-limiting. All treatments displayed levels of effectiveness depending on the extent of the vein in question. Short-term advantages appeared to be associated with sclerotherapy and endovenous treatments, and long-term effectiveness was more apparent following surgical intervention. Evidence suggests conservative therapy is less effective than sclerotherapy and surgery for the treatment of varicose veins. Ligation with stripping plus phlebectomy is generally regarded as the "gold standard" for treating primary long saphenous veins. Sclerotherapy and surgery both appear to have a place in the management of varicose veins. Sclerotherapy and phlebectomy may also be more appropriate in patients with minor superficial varicose veins not related to reflux of the saphenous system or as a post- or adjunctive treatment to other procedures, such as surgery. Current evidence suggests endovenous laser therapy and radiofrequency ablation are as safe and effective as surgery, particularly in the treatment of saphenous veins. Most importantly, the type of varicose vein should govern the intervention of choice, with no single treatment universally employed.

Varicose Veins

Varicose veins are common and often asymptomatic. A variety of treatment methods are available for those who develop symptoms or complications. The traditional open surgical treatment still forms the mainstay of treatment. Endovenous treatment methods offer a new alternative but have their own limitations. Foam sclerotherapy holds much promise as it can be done in an outpatient setting under local anesthesia, but it needs to be tested over a longer time period.