Endovenous Treatment Research Articles

Targeted endovenous treatment of Giacomini vein insufficiency-associated varicose disease: considering the reflux patterns.

We aimed to assess the technical feasibility of targeted endovenous treatment of Giacomini vein insufficiency (GVI)-associated varicose disease and report our early results. We retrospectively screened 335 patients with varicose disease who underwent endovenous laser ablation from September 2011 to January 2013, and determined 17 patients who underwent Giacomini vein ablation. Using a targeted endovenous treatment approach considering the reflux pattern, all healthy great saphenous veins (GSV) or vein segments were preserved while all insufficient veins (Giacomini vein, perforator veins, small saphenous vein, anterior accessory GSV, major tributary veins, or incompetent segments of the GSV) were ablated. Treatment success was analysed using Doppler findings and clinical assessment scores before and after treatment. Targeted endovenous treatment was technically successful in all cases. Seven GSVs were preserved totally and three GSVs were preserved partially (10/17, 58%), with no major complications. Clinical assessment scores and Doppler findings were improved in all cases. Targeted endovenous treatment of GVI-associated varicose disease is safe and effective. In majority of GVI cases saphenous vein can be preserved using this approach.

An in vitro study to optimise treatment of varicose veins with radiofrequency-induced thermo therapy.

To develop a reproducible method of using radiofrequency-induced thermotherapy with adequate thermal spread to ablate the whole vein wall in a truncal vein but avoiding carbonisation, device sticking and high impedance "cut outs" reducing interruptions during endovenous treatments. Porcine liver was treated with radiofrequency-induced thermotherapy under glass to allow measurements, observation and video recording. Powers of 6-20 W were used at varying pullback speeds to achieve linear endovenous energy densities of 18-100 J/cm. Thermal spread, carbonisation of treated tissue and high-impedance cut outs were recorded. The currently recommended power settings of 18 and 20 W produced sub-optimal results. If pulled back at 3 s/cm to achieve linear endovenous energy densities around 60 J/cm, tissue carbonisation and high impedance cut outs occurred. When high powers and fast pullbacks of 1 s/cm were used, no carbonisation or cut outs occurred but thermal ablation of the liver model was below target due to reduced time for thermal conduction. Low powers (6-12 W) with slow pullbacks (6-12 s/cm) achieved target thermal ablation with minimal carbonisation and high impedance cut outs. Using low power (6 W) and a slow discontinuous pullback (6 s every 0.5 cm, in steps), we were able to achieve our target thermal ablation in the porcine liver model without carbonisation and high impedance cut outs. This suggests the currently recommended power levels could be reduced, reducing the need to remove the device to clean the electrodes during treatment while achieving target thermoablation of the treated tissue.

TCT-478 New Oral Anticoagulants in Cancer Patients Undergoing Percutaneous Endovenous Intervention for Lower Extremity Deep Venous Thrombosis

TCT-478 New Oral Anticoagulants in Cancer Patients Undergoing Percutaneous Endovenous Intervention for Lower Extremity Deep Venous Thrombosis

Great uncertainty regarding treatment of varicose vein recurrence

SummaryIntroduction: Although varicose vein recurrence is common and 10–30 % of all varicose vein surgery is done for recurrence of some sort, there are very few studies that can guide us to the best re-treatment option. With the introduction of minimal invasive endovenous treatments there is a variety of possible options besides traditional open surgical techniques.Method: The Scandinavian Venous Forum held a symposium at the GSP meeting in Lü-beck 2012 and this review article is based on data from the presentations at that symposium. Further data has been added regarding new knowledge that was not available a year ago, from PubMed search and article references.Results: The most common reasons for recurrence are discussed and also the discrepancy between neovascularization (NV) and recurrence due to technical failures. It is likely that NV is the most commonly duplex detected type of recurrence following open groin surgery, less common early after endovascular techniques. However, technical or tactical failures are the most common reasons for redo surgery because of symptomatic recurrence. NV seldom leads to symptomatic recurrences and thus a need for re- treatment. There is a risk that the stumps left following endovenous treatments will become a source for symptomatic recurrence after 5–10 years and indications of that have been reported in the few available 5 year RCT-reports following laser treatments. Treatment of recurrence due to stumps in the groin can be done safely within a reasonable operating time through a medial approach and the stump itself can generally not be treated with any of the endovenous alternative methods. Foam treatment can be used for most other recurrent veins but the durability is unknown. Endovascular thermal ablation can only be used for reopened or remaining saphenous veins and accessory saphenous veins while tributaries have to be treated by stab excisions or foam.Conclusion: Long term reports of results of redo surgery are limited but suggest reasonably good results from open surgical intervention and are non-existent for the endovenous techniques. So far groin recurrence seems best treated surgically by an indirect approach, preferably medial. More studies are needed to find the best treatment regime for varicose vein recurrence in general and hybrid procedures might be the way forward by combinations of different techniques.

Retrograde mechanochemical ablation of the small saphenous vein for the treatment of a venous ulcer

We present the first case of retrograde ablation of the small saphenous vein to treat active venous ulceration. A 73-year-old gentleman with complicated varicose veins of the left leg and a non-healing venous ulcer despite previous successful endovenous treatment to his left great saphenous vein underwent mechanochemical ablation of his small saphenous vein with the ClariVein® system, under local anaesthetic, using a retrograde cannulation technique. Post-operatively the patient had improved symptomatically and the ulcer size had reduced. This report highlights that patients with small saphenous vein incompetence and active ulceration can be treated successfully with retrograde mechanochemical ablation.

The Durability of Polidocanol Endovenous Microfoam Treatment Effect on Varicose Vein Symptoms and Appearance in Patients with Saphenofemoral Junction Incompetence: One-Year Results from the VANISH-2 Study.

The Durability of Polidocanol Endovenous Microfoam Treatment Effect on Varicose Vein Symptoms and Appearance in Patients with Saphenofemoral Junction Incompetence: One-Year Results from the VANISH-2 Study.

Penile Mondor’s Syndrome after endovenous treatment of the great saphenous vein with 1470 nm diode laser

We report a penile Mondor's disease after endovenous laser ablation with a 1470 nm diode laser of the great saphenous vein with additional foam sclerotherapy of distal tributaries. We administered body-weight adjusted full dose of low-molecular weight heparin (enoxaparin) in a therapeutic dosage for 10 days. In addition, anti-inflammatory therapy with diclofenac-sodium 75 mg twice a day for the following five days was initiated. One month later, the patient reported no further discomfort or pain and the thrombophlebitis of the superficial dorsal penile vein had sonographically disappeared completely.

Clinical aspects and indications for endovenous treatments for varicose veins

Endovenous laser treatment has been around for more than a decade. A brief history of circumstances that have made this treatment modality possible is provided.

TCT-517 Reduction of Hospitalization and Duration of Anticoagulation for Deep Venous Thrombosis in Patients Undergoing Percutaneous Endovenous Intervention and Receiving Novel Anticoagulants

TCT-517 Reduction of Hospitalization and Duration of Anticoagulation for Deep Venous Thrombosis in Patients Undergoing Percutaneous Endovenous Intervention and Receiving Novel Anticoagulants

The state of the art of endothermal ablation

Complaints relating to reflux in the venous system can be addressed by conservative, surgical, or interventional treatment options. The aim of the treatment is to prevent complications and progression of venous disease and to improve patients' quality of life. Endovenous thermal ablation therapies have become the most frequently used type of therapy for saphenous varicose veins. The available endovenous thermal techniques are endovenous laser ablation, radiofrequency ablation, and endovenous steam ablation. In this review, the procedures, indications, and treatment parameters of the three endovenous thermal ablation treatments are discussed as well as their advantages and disadvantages.

Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy, and surgical stripping for great saphenous varicose veins with 3-year follow-up.

This study compares the outcome 3 years after treatment of varicose veins by endovenous laser ablation (EVLA), radiofrequency ablation, ultrasound-guided foam sclerotherapy (UGFS), or surgery by assessing recurrence, Venous Clinical Severity Score (VCSS), and quality of life (QOL). A total of 500 patients (580 legs) were randomized to one of the three endovenous treatments or high ligation and stripping of the great saphenous vein (GSV). Follow-up included clinical and duplex ultrasound examinations and VCSS and QOL questionnaires. Kaplan-Meier (KM) life-table analysis was used. P values below .05 were considered statistically significant. At 3 years, eight (KM estimate, 7%), eight (KM estimate, 6.8%), 31 (KM estimate, 26.4%), and eight (KM estimate, 6.5%) of GSVs recanalized or had a failed stripping procedure (more than 10 cm open refluxing part of the treated GSV; CLF, EVLA, UGFS, and stripping, respectively; P<.01). Seventeen (KM estimate, 14.9%), 24 (KM estimate, 20%), 20 (KM estimate, 19.1%), and 22 (KM estimate, 20.2%) legs developed recurrent varicose veins (P= NS). The patterns of reflux and location ofrecurrent varicose veins were not different between the groups. Within 3 years after treatment, 12 (KM estimate, 11.1%), 14 (KMestimate, 12.5%), 37 (KM estimate, 31.6%), and 18 (KM estimate, 15.5%) legs were retreated in the CLF, EVLA,UGFS, and stripping groups, respectively (P< .01). VCSS, SF-36, and Aberdeen QOL scores improved significantly in all the groups with no difference between the groups. All treatment modalities were efficacious and resulted in a similar improvement in VCSS and QOL. However,more recanalization and reoperations were seen after UGFS.

The effects of the Brazilian ant Dinoponera quadriceps venom on chemically induced seizure models

Arthropod venoms are potential sources of neuroactive substances, providing new tools for the design of drugs. The aim of this study was to evaluate the effects of Dinoponera quadriceps venom (DqV) on seizure models in mice induced by pentylenetetrazole (PTZ), pilocarpine, and strychnine. In the PTZ model, intraperitoneal treatment with DqV (0.5mg/kg) increased the time until the first seizure and the percentage of survival (155.4±27.7s/12.5%, p<0.05) compared to the control group (79.75±3.97s/0%), whereas endovenous treatment (0.1 and 0.5mg/kg) decreased the time until the first seizure (0.1mg/kg: 77.83±5.3s versus 101.0±3.3s in the control group; 0.5mg/kg: 74.43±3.9s versus 101.0±3.3s for the control group, p<0.05). We did not observe significant changes in the pilocarpine- and strychnine-induced seizure models. In assays that measured oxidative parameters in the PTZ model, intraperitoneal treatment with DqV (0.5 and 2.0mg/kg) only decreased the levels of MDA and nitrite in the cortex. However, endovenous treatment with DqV (0.1 and 0.5mg/kg) increased the levels of MDA in the cortex and hippocampus and at a dose of 0.5mg/kg in the striatum. Moreover, increased in nitrite content was observed in all three of the brain regions analyzed. Taken together, the D. quadriceps venom caused both neuroprotective and neurotoxic effects in a PTZ-induced seizure model, and this effect was dependent on the route of administration used.

Cost-effectiveness in varicose vein treatment

Methods used in cost calculation have a profound effect on cost-effectiveness analyses, thereby influencing UK healthcare decision-making. The aim of this study was to quantify the impact of different cost assessments using data obtained alongside a recent randomised clinical trial (RCT) on endovenous treatments for varicose veins. National reimbursement data from payment by results (PbR) were compared to the service line report (SLR) and RCT micro-costing data. There were 18 laser and 205 foam treated patients from the 2010–2011 day-case activity SLR. There were 100 RCT patients which were separated for costing into session treatments (2 laser, 3 tumescent foam or 5 standard foam treatments per 3.5 hour session) as well as individually-timed treatments. Reimbursement was £1098, irrespective of treatment type. Using SLR derived data the cost of laser, tumescent foam and standard foam per patient was £1059, £603 and £551, respectively. This decreased to £812, £239 and £124 using session calculations and decreased further to a median (inter-quartile range) of £721 (677–774), £195 (176–209) and £100 (93–109) using individually timed treatments (P &lt; 0.0005, Kruskal-Wallis). Cost differences between laser and foam increase significantly using micro-costing. Several costing approaches may be required for representative cost-effectiveness comparisons.

Thrombus formation using endovenous lasers: an in vitro experiment

The purpose of these experiments was to simulate thrombus formation during endovenous laser closure by measuring coagulum formation of in vitro laser exposures in porcine blood and investigate the role of procedures and equipment in thrombus formation. Continuous wave 810, 940, 980, 1310 and 1470 nm lasers and microsecond pulsed wave 1064 nm Nd:YAG (neodymium-doped yttrium aluminium garnet), 1320 nm Nd:YAG and 2100 nm THC:YAG (thulium holmium chromium-doped yttrium aluminium garnet) lasers were tested with standard fibres with diameters of 365, 550 and 600 μm as well as two prototype modified tip fibres. The results show that pulsed lasers with high-peak power densities form less coagulum. Fibre specifications were found not to influence coagulum formation, and prototype modified tip fibres designed to prevent contact between the fibre tip and the vein wall did not eliminate coagulum formation. Microsecond-pulsed wave lasers with high-peak power densities may be a better choice to minimize soft thrombus formation during endovenous laser ablation treatments.

Which treatments are cost-effective in the management of varicose veins?

In the current economic climate, the cost-effectiveness of health-care interventions is under great scrutiny. In this article, the evidence for cost-effectiveness of treatments for varicose veins is summarized. The majority of studies evaluating treatments for varicose veins have not assessed health economic outcomes, but have focused on clinical and anatomical measures. The cost-effectiveness of treating varicose veins (compared with conservative management) was demonstrated in the REACTIV trial. Other in-trial economic analyses suggested that endovenous interventions are likely to be cost-effective and a decision tree analysis demonstrated that the greatest cost-effectiveness may be present for procedures performed under local or tumescent anaesthesia in the office or outpatient setting. However, the treatment modality that offers the greatest cost-effectiveness remains unclear. In conclusion, endovenous treatment performed in the outpatient setting under local anaesthesia is likely to be the most cost-effective treatment strategy for varicose veins. Better quality health economic analyses are needed to refine this conclusion.

Reflux time estimation on air-plethysmography may stratify patients with early superficial venous insufficiency

It has been suggested that quantification of haemodynamic parameters of venous disease may complement clinical assessment and may help identify a group of patients with severe venous disease or alternatively patients with early venous disease. However, there has been very little work to prove this hypothesis. The venous filling index (VFI) of air-plethysmography (APG) can quantify severity and treatment effect but has limited discriminatory value. However, the components of the VFI, total venous volume (VV) and time to reach 90% of VV (VFT90), have never been fully studied. The aim was to investigate the contribution of VV and VFT90 to an elevated VFI and determine their relationship to great saphenous vein (GSV) diameter and clinical severity scoring. Ninety-three consecutive patients/legs (22-78 years) with primary GSV reflux (>0.5 seconds) awaiting endovenous treatment were recruited. CEAP (clinical, aetiological, anatomical and pathological elements) assessments were: 33 (35.5%) C₂, 14 (15.0%) C₃, 29 (31.2%) C4a, 5 (5.4%) C4b, 7 (7.5%) C₅ and 5 (5.4%) C₆. The median venous clinical severity score (VCSS) was 6 (2-20) and the averaged GSV diameter at three sites was 7.5 mm (4-12). The VFI, VV and VFT90 were recorded using APG. There was no correlation between the VV and the VFT90 (r = -0.103, P = 0.324). The VFI, VV and VFT90 significantly correlated (P < 0.0005, Spearman) with the GSV diameter: r = 0.623, r = 0.567, r = -0.432, respectively, and the C of CEAP (P < 0.05): r = 0.4, r = 0.225, r = -0.343, respectively. None of the 25 (26.9%) patients with a VFT90 > 25 seconds were among the 17 (18.3%) patients in categories C4b-6 or with a VCSS > 9 (P = 0.005, Fisher's exact test, corrected odds ratio: 17.3). The VFT90 complements the VFI as a marker of severe superficial venous insufficiency. However, in contrast to the VFI, it may have discriminatory value in stratifying patients with early disease into two groups based on the severity of haemodynamic impairment.

Histology of saphenous veins after treatment with the ClariVein® device – an ex‐vivo experiment

Endovenous treatment modalities are used increasingly to treat varicose veins. The ClariVein® catheter is a new endoluminal mechanico-chemical obliteration technique which can be used without tumescent anesthesia. It is still unclear what changes the mechanical tip of the catheter has on the walls of the vein. Five great saphenous vein specimens were obtained atraumatically by crossectomy. Then the veins were treated ex vivo with the ClariVein® catheter without sclerotherapy. The activated catheter rotating tip (3 500 U/min) was steadily withdrawn at 1-2 mm per second. Subsequently, histological and immunohistochemical investigations of treated (cv) and untreated specimens (plain) were performed. A 4-point score was calculated to compare the results. The mechanical part of the catheter caused a subtle incomplete destruction of the endothelium (endothelium cv: 2.2 vs. plain: 1, p = 0.04). Changes in the media or adventitia were not seen. Immunohistochemical presentation of the endothelium of the intima was demonstrated with antibodies against CD31 (cv: 3.4 vs. plain: 2.8), CD34 (cv: 3.8 vs. plain: 3.2) and factor VIII (cv: 2.2 vs. plain: 1, p = 0,004). The mechanical part of the ClariVein® catheter caused a subtle incomplete destruction of endothelium, which was confirmed histologically and immunohistochemically. The reduced expression of factor VIII in the treated vein could be caused by the release of preformed factor VIII granules due to the minimal mechanical irritation.

The Aberdeen Varicose Vein Questionnaire May be the Preferred Method of Rationing Patients for Varicose Vein Surgery

Rationing treatment of varicose veins (VVs) is of importance in countries with a public health service and limited funds. This study examines why and how the Aberdeen varicose vein questionnaire (AVVQ) can be used in achieving rationing. Baseline assessments prior to endovenous treatment included the venous clinical severity score (VCSS), venous filling index (VFI), and the refluxing great saphenous vein (GSV) diameter. Absolute change in the AVVQ defined improvement. There was no significant correlation in AVVQ improvement compared to baseline VCSS, VFI, GSV diameter or when patients were divided into mild and severe disease (C2,3 vs C4-6) or laser ablation versus foam sclerotherapy. However, AVVQ improvement significantly correlated at 3 weeks (n = 84) and 3 months (n = 70) with their baseline values (r = .5 and r = .585), P < .0005 (Spearman). In conclusion, patients with an initial poor quality of life may benefit most from endovenous treatment, irrespective of other baseline severity assessments.

Hemodynamic Changes in the Femoral Vein with Increasing Outflow Resistance.

In postthrombotic or May-Thurner syndrome, iliac veins may be scarred, compressed, or obstructed. Obesity and increased intra-abdominal pressure may also hamper the venous return. Therefore, measurement of outflow resistance (OR) impeding venous return may be helpful: clinically to assess the effect of intervention and diagnostically to determine whether OR contributes to venous disease. A proof-of-concept study is presented in healthy volunteers where OR is quantified using duplex assessment of the femoral vein (FV) at mid-thigh following increasing high-thigh tourniquet pressure. Twenty-two consecutive subjects (15 male), without evidence of venous disease, were studied. Two male exclusions were due to bifid FVs. Median (range) baseline characteristics were age = 30 (24-57) years, height = 173 (158-197) cm, weight = 72 (50-97) kg, body mass index = 24 (19-30), and FV diameter = 11.2 (6.8-14.8) mm. Subjects were examined standing with the test leg resting gently on the floor. A 26 cm wide calf-cuff was attached to an intermittent pneumatic compression device (ArtAssist®) that delivered three compressions per minute, at 120 mm Hg. A high thigh-cuff, 12 cm wide, was inflated before each calf compression in incremental steps of 20 mm Hg, from 0 to 120 mm Hg, to provide a standard OR (VenaPulse®). FV waveform parameters were recorded using duplex at mid-thigh with each thigh-cuff inflation pressure and repeated three times. Means were used in the calculations. OR was calculated using Pressure(P)/Flow(Q). Pressure was 120 mm Hg minus the additional height to the duplex transducer. Flow was time-averaged mean velocity (TAMV) x pi x diameter (d) squared/4. A 15% FV diameter reduction was assumed with each 20 mm Hg rise in thigh-cuff pressure. Peak velocity, total TAMV, and TAMV from initial to peak (Fig) all decreased significantly (P < .0005, Friedman) with increasing thigh-cuff pressure with P < .0005 correlations (Spearman) of r = .842, r = .488, and r = .744, respectively. Furthermore, increasing thigh-cuff pressure at 0, 20, 40, 60, 80, 100, and 120 mm Hg also caused a gradual and significant increase in mean (+/-SD) OR at 3.8 (2.3), 5.2 (3.2), 7.4 (3.9), 13.5 (8.5), 27.2 (14.2), 84.2 (43),and 715 (414) resistance units, respectively (P < .0005, Friedman and r = .921, Spearman). Hemodynamic velocity parameters measured using duplex attenuate progressively with increasing venous obstruction. OR can be quantified using duplex. Standardization of these measurements may allow future research on individual patients to determine the extent OR improves after endovenous intervention.

Können Schaumverödung und Thermoablation das chirurgische Venenstripping ersetzen?

Minimally invasive treatments of varicosis are increasingly establishing. Short and intermediate-term outcomes of endovenous treatments are satisfying: success rates are comparable with conventional surgery, whereas recovery is faster and complication rates are lower. Success rates are highest for endovenous laser ablation (EVLA). However, endovenous radiofrequency ablation (RFA) has advanced. Its short term outcomes are now comparable to EVLA, but with less side-effects. Ultrasound guided foam sclerotherapy (UGFS) replaced other forms of liquid sclerotherapy. In principle, this treatment can be combined with every other treatment for varicosis, but it loses its position as a monotherapy, due to poorer intermediate-term outcomes compared with EVLA and RFA. More prospective randomized controlled trials are needed in order to state an evidence based hierarchy of treatments for varicosis. With the minimally invasive treatments it is possible to treat patients on an outpatient basis. It will have to be assessed whether this will lead to higher cost-effectiveness.