Endovenous Laser Treatment Research Articles

Endovenous laser treatment combined with transilluminated powered phlebectomy for great saphenous varicosity

Objective To analyze the clinical efficacy of endovenous laser treatment combined with transilluminated powered phlebectomy for great saphenous varicosity and summarize the experiencein order to achieve better results. Methods From January 2014 to June 2015, 45 patients (52 limbs, including 17 males and 28 females, aged 36 to 68 years) diagnosed as great saphenous varicosity received endovenous laser treatment combined with transilluminated powered phlebectomy. Thirty-eight cases was unilateral great saphenous varicose veins, 7 cases was bilateral large saphenous varicose veins. The clinical efficacy was analyzed. Results All cases were performed successfully. The mean operation time was (68.4±15.1) minutes, the average bleeding volume was (23.5±10.7) ml, the number of mean operative incision quantity was (5.8±1.9)and the average hospitalization time was (5.9±1.6) days. All patients had no serious complications. During a mean follow- up time of 22 months (12 to 30 months), only one patient recurred. Conclusions Endovenous laser treatment combined with transilluminated powered phlebectomy for great saphenous varicosity is effective and safe. It also has the advantages of shorter operation time, less bleeding, shorter hospitalization time, small trauma and better cosmetic results. Key words: Varicose veins; Saphenous vein; Lasers; Transilluminated powered phlebectomy; Treatment outcome

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.

Endovenous laser treatment of groin and popliteal varicose veins recurrence.

Objectives Recurrent varicose veins following surgery is a common, complex and costly problem in vascular surgery. Treatment for RVV is technically more difficult to perform and patient satisfaction is poorer than after primary interventions. Nevertheless, traditional vein surgery has largely been replaced by percutaneous office-based procedures, and the patients with recurrent varicose veins have not benefited from the same advantages. In this paper, we propose an endovascular laser treatment that allows reducing the invasiveness and complications in case of SFJ and SPJ reflux after ligation and stripping of the great and small saphenous vein. Methods 8 SFJ and 1 SPJ stumps were treated by endovascular laser treatment in out-patient clinic. Endovascular laser treatment was performed with a 1470 nm diode laser and a 400 µc radial slim™ fiber. Intraoperative ultrasoud was used to guide the fiber position and the delivery of tumescent anesthesia. The gravity of chronic venous disease was determined according to the CEAP classification and the severity of symptoms was scored according to the revised Venous Clinical Severity Score (VCSS). Results The average linear endovenous energy density was 237 J/cm. Patients return to daily activities after a mean of 1.9 days after. The VCSS improved drastically from a mean of 8 pre-interventional to 1 at day 30 and until one year. During the follow-up period (mean 8 months, range: 5-17 months), all the stumps except one were occluded. All patients were very satisfied or satisfied with the method. No severe complications occurred. Conclusions Office-based endovascular laser treatment of groin and popliteal recurrent varicose veins with 1470 nm diode laser and radial-slim fiber is a safe and highly effective option, with a high success rate in the early post-operative period.

Analysis of recurrence rate of great saphanous vein incompetence after endovenous laser therapy base on propensity score matching method

Objective To compare the difference in recurrence rates between the endovenous laser therapy(EVLT) combined with percutaneous continuous circumsuture(PCCS) and simplex EVLT following the treatment of great saphanous vein incompetence through the introduction of propensity score matching(PSM). Methods T the baseline data of 170 patients diagnosed with great saphanous vein incompetence who were treated in Punan Hospital in Pudong New District of Shanghai from 2009 to 2014 were retrospectively analyzed, of which underwent EVLT were 87 cases as EVLT group and EVLT combined with PCCS were 83 cases as EVLT+ PCCS group.The groups covariate were balanced based on the PSM function of SPSS software using 1: 1 nearest neighbor matching method.The recurrence rates of the two groups were estimated by Kaplan-Meier method and the differences between the two groups were evaluated by Log-rank test. Results Sixty-seven pairs of patients were successfully matched.No significant difference between the two matched groups in the basic clinical features.Before PSM, the 1, 2, and 3 year cummulative recurrence rates were 3.5%, 5.4% and 7.3% in the EVLT group, and 0.9%, 4.7% and 4.7% in the EVLT+ PCCS group, respectively, there were no statistically significant differences between the two groups by Log-rank test(P=0.491). After PSM, the 1, 2, and 3 year cummulative recurrence rates were 5.2%, 5.2% and 7.1% in the EVLT group, and 0%, 1.0% and 1.0% in the EVLT+ PCCS group, there were statistically significant differences between the two groups(P=0.031). Conclusion The PSM methods can effectively balanced the covariates of groups in non-randomised study.EVLT combined with PCCS can effectively reduce the recurrence rate after the treatment of great saphanous vein incompetence. Key words: Great saphanous vein incompetence; Endovenous laser therapy; Percutaneous continuous circumsuture; Propensity score matching; Recurrence rate

Endovenous laser therapy (EVLT) in the treatment of short saphenous (SSV) varicose veins (VVS) – Long term follow up

Endovenous laser therapy (EVLT) in the treatment of short saphenous (SSV) varicose veins (VVS) – Long term follow up

Prevention of Complications of Endovenous Laser Treatment

Treatment of varicose vein disease should provide reliable exclusion of varicose veins from blood circulation, be minimally traumatic, ensure a satisfactory aesthetic effect as well as minimize side effects. The use of endovenous laser treatment allows achieving optimal results. Laser technology, however, may cause a number of complications, in particular segmental thrombophlebitis, ecchymosis, skin hyperpigmentation, neurological disorders, and paravasal burns. There are complications specific to laser treatment as well: during coagulation, multiple gas bubbles can be observed on the screen of the ultrasound machine, which are formed on the light guide face-end and enter the central venous system, pulmonary circulation and blood vessels of the brain through sapheno-femorale fistula. In the early postoperative period, most of the operated patients suffer from headache, dizziness, nausea, feeling of “heaviness” when breathing, and general weakness lasting for 6-7 days and affecting the normal course of the postoperative period. Thus, there has been suggested the method for preventing specific complications of endovenous laser treatment by active removal of laser coagulation products, which are formed at the working end of the light guide, in order to minimize the number of these products entering the central venous system through sapheno-femorale fistula and perforating veins (Application for an invention u201605586). The task can be achieved by draining the coagulation zone and removing the products of vaporization and carbonization from the lumen of the vein through a drainage catheter, connected to the vacuum source. The implementation of the method allows preventing complications caused by the products of vaporization and photocoagulation, which can enter the pulmonary circulation and blood vessels of the brain through the venous system.

Ozone Gas Bath Combined with Endovenous Laser Therapy for Lower Limb Venous Ulcers: A Randomized Clinical Trial

ABSTRACTBackground: Endovenous laser therapy (EVLT) is safe and effective for lower limb venous ulcers. However, severe necrosis and infection in the ulcer area are contraindications of puncture and EVLT. Local bath with ozone gas has been shown to improve the condition of ulcer areas. The aim of this study was to evaluate the clinical efficacy of ozone gas bath combined with EVLT in comparison with EVLT alone for the treatment for lower limb venous ulcers. Patients and Methods: Ninety-two patients with venous ulcers were randomized to receive ozone gas bath combined with EVLT (OEVLT group) or EVLT alone (EVLT group). In the OEVLT group, the venous ulcers were preconditioned with ozone gas bath prior to EVLT. The minimum follow-up time was 12 months. The two groups were compared in terms of complete occlusion of the treated veins, ulcer healing ratio, ratio of ulcer recurrence, patient satisfaction, complications, and side effects. Results: There was no significant difference in venous occlusion between the two groups. The ratio of ulcer healing in the OEVLT group was significantly higher than the EVLT group at 12 months follow-up. Patients in the OEVLT group showed better satisfaction and a lower recurrence ratio than the OEVLT group. No severe complications or side effects occurred in either groups. Conclusions: Ozone gas bath combined with EVLT showed improved efficacy for the treatment of lower limb venous ulcers and lower recurrence ratio comparison with EVLT alone. This procedure is a safe and technically feasible.

A Study of the Outcomes of Endovenous Laser Therapy in the Treatment of Varicose Veins

A Study of the Outcomes of Endovenous Laser Therapy in the Treatment of Varicose Veins

Perioperative quality assessment of varicose vein surgery

An estimated 350,000 varicose vein (VV) surgical procedures are performed in Germany each year, with annual treatment costs amounting to about 800 million Euro. To evaluate the outcome quality of this treatment, we examined the intraoperative and postoperative complication rates on record in the VV surgery quality assessment (QA) registry of the German Society for Vascular Surgery (GSVS). Data on 89,647 patients (27,463 men, 62,184 women; average age 52.8years, range 15-96years) collected in the GSVS varicose surgery QA registry between 2001 and 2009 were analyzed. In these patients, 95,214 surgical procedures were performed on 105,296 limbs. Complication rates were correlated with the type of VV surgical procedure, with whether surgery was performed on an inpatient or outpatient basis, and with the CEAP classification (C stage) and American Society of Anaesthesiologists' (ASA) stage at the time of surgery. Statistical analyses were performed using a chi-square test, a Cochrane-Armitage test, and an odds ratio calculation. Intraoperative and postoperative complication was low (0.18 and 0.43%, respectively), being the lowest for radiofrequency ablation (0.25%) but not differing significantly from those for endovenous laser therapy and high ligation and stripping. General complications occurred in 0.67% of outpatients and in 0.25% of inpatients, a highly significant statistical difference (p < 0.0001, chi-square test). With regard to C stage, the higher the stage, the higher the local complication rate. A clear correlation was also found between preoperative ASA stage and postoperative complication rates: for ASA stages I and II, the complication rates were 0.2 and 0.5%, respectively, increasing for ASA stage III to 1.2% and for ASA IV to 2.2%. The differences between the ASA classes were highly statistically significant (p < 0.0001, Cochrane-Armitage test) Outcome quality as reflected in the intraoperative and postoperative complication rates was very good for all patients undergoing inpatient or outpatient VV surgery. Data from the GSVS QA registry shows that VV surgery is performed with very good perioperative results in specialized centers in Germany.

Disappearance of Heat-Induced Thrombosis on the Third Day After the Endovenous Laser Treatment: A Case Report

Disappearance of Heat-Induced Thrombosis on the Third Day After the Endovenous Laser Treatment: A Case Report

Estudo comparativo da termoablação da veia safena magna na coxa, com e sem tumescência

ResumoContextoO tratamento com laser endovenoso das veias safenas oferece ao paciente um procedimento com baixos índices de complicações, proporcionando retorno precoce à atividade ocupacional.ObjetivoComparar a formação de hematoma, a presença de parestesia no trajeto da veia safena magna (VSM) e a sua taxa de obliteração em 30 dias após a termoablação ao nível da coxa, utilizando ou não a tumescência e dois tipos de fibras.MétodosEstudo prospectivo em que foram analisados três grupos de pacientes submetidos a termoablação da VSM em coxa, utilizando comprimento de onda 1470 nm. No grupo 1, utilizou-se fibra convencional e tumescência; no grupo 2, fibra convencional sem tumescência; e no grupo 3, fibra dupla radial sem tumescência. Foram comparados, no período de 30 dias, a taxa de obliteração ao eco-Doppler, a ocorrência de parestesias e hematomas.ResultadosAo se comparar 90 VSMs de coxa submetidas a termoablação, obteve-se taxas de obliterações similares entre os grupos, sem diferença estatística. Nos grupos sem tumescência, ocorreu maior número de parestesias no trajeto da VSM na coxa no sétimo dia do que no grupo com tumescência, mas somente com significância estatística na comparação com o grupo da fibra convencional. Ocorreram hematomas em todos os grupos, sendo mais frequentes no grupo 1 (73,33%).ConclusõesA realização da tumescência mostrou-se útil na prevenção de lesões neurológicas menores, mas não influenciou a ocorrência de hematomas e a taxa de oclusão da VSM na coxa em até 30 dias de sua termoablação.

Real time echo-guided endolaser for thermal ablation without perivenous tumescence

Abstract Background There is no consensus in the medical literature on the ideal procedure for endovenous laser application. Objective To assess the safety and efficacy of real time echo-guided endovenous laser for thermal ablation of great saphenous vein (GSV) incompetence, without perivenous tumescence. Methods Thirty-four limbs of patients with CEAP clinical scores of 2 to 6 and bilateral incompetence of the saphenofemoral junction (SFJ) and GSV, confirmed by Echo-Doppler, underwent endovenous laser therapy and were followed for 1 year. Laser ablation was performed using a 600 µ bare optical fiber introduced endovenously close to the malleolus along the full extent of the GSV in an anterograde direction, using a standardized echo-Doppler-guided AND? 15 watt continuous mode 980 nm diode laser with real-time monitoring of thermal ablation of the whole target vein. Adverse effects and complications were recorded. Results Hyperesthesia, cellulitis, and fibrous cord, all transitory, developed in 2.9% of the 34 limbs treated; 8.8% developed hypoesthesia in the perimalleolar region, which was transitory and had no clinical consequences; there were no cases of deep venous thrombosis. Immediate occlusion was achieved in 100% of the 34 saphenous veins that underwent photocoagulation, although one exhibited recanalization without reflux at 1-month follow-up. After 6 months and 1 year, occlusion was 100% according to echo-Doppler findings. Conclusions Real-time echo-guided 980 nm endovenous laser ablation without perivenous tumescence provided controlled thermal ablation with safe, effective, immediate and medium-term GSV occlusion and can therefore be recommended as a method for the treatment of chronic venous disease.

Volumetric optoacoustic imaging feedback during endovenous laser therapy - an ex vivo investigation.

Endovenous laser therapy (ELT) was introduced in clinical practice for treating incompetent veins about fifteen years ago. Despite the considerable clinical evidence collected so far, no rigorous guidelines are yet available regarding the optimal energy deposition protocols while incidence of recanalization, lack of vessel occlusion and collateral damage remains variable among patients. Online monitoring and feedback-based control over the lesion progression may improve clinical outcomes. Yet the currently employed monitoring tools, such as Doppler ultrasound, often do not provide sufficient contrast as well as three-dimensional imaging capacity for accurate lesion assessment during thermal treatments. Here we investigate on the utility of volumetric optoacoustic tomography for real-time monitoring of the ELT procedures. Experiments performed in subcutaneous veins of an ox foot model revealed the accurate spatio-temporal maps of the lesion progression and characteristics of the vessel wall. Optoacoustic images further correlated with the temperature elevation measured in the area adjacent to the coagulation spot and made it possible to track the position of the fiber tip during its pull back in real time and in all three dimensions. Overall, we showcase that volumetric optoacoustic tomography is a promising tool for providing online feedback during endovenous laser therapy.

Endovenous laser ablation of varicose veins

PurposeTo assess the value of endovenous laser ablation as a treatment of varicose veins. Materials and methodsStudy included 30 patients (22 females, 8 males) with a mean age of 38.4years (age range from 25 to 55years) presented with varicose vein caused by saphenofemoral junction (SFJ) incompetence with Great Saphenous Vein (GSV) reflux. Patients underwent Endovenous Laser Therapy (EVLT) with 980-nm diode laser as an outpatient procedure. Patients were re-examined one week, 1, 2 and 3months postprocedure. ResultsImmediate postoperative successful occlusion that is defined as absence of flow by duplex ultrasound, was achieved in 29 GSVs (97%). Failure occurred in one case with large vein (GSV diameter>0.8cm). The procedure was well tolerated by all patients. The mean GSV diameter measured in upright position, was 6.5mm (range from 4 to 9mm). The mean length of treated GSV was 44.2cm (range from 38 to 50cm). Ecchymosis was seen in 18 patients (72%). Indurations were observed in 2 patients (6%) and resolved within two weeks. No paresthesia, superficial burns or DVT was detected. ConclusionEndovenous laser ablation for GSV reflux is a safe, feasible and efficient outpatient technique.

Endovenous laser treatment in patients with advanced CVI

As a result of the trophic changes in the distal third of their shank, patients in Advanced CVI stages are not suitable for conventional stripping. Incisions in areas with disrupted trophics should not be performed because of the risk of slow wound healing. This paper is based on the results of the endovenous laser treatment (EVLT) of 23 patients with advanced disease with trophic changes in the distal third of the shank. In all of these patients incompetent valves of GSV in the shank segment as well as insufficiency of the perforant veins have been detected preoperatively. This gave us the opportunity to follow the proximal laser ablation of the thigh segment of GSV to perform through the same access point laser ablation of the shank segment in the distal retrograde direction. In all of these patients GSV has been exteriorized proximally over the trophic changes and ante- and retrograde laser ablation has been performed with great results. Retrograde laser ablation has been successful in all cases due to the incompetent GSV valves in its shank segment. Thus, without access to an area of disturbed trophicity, the low vein-venous reflux is effectively stopped.

Comparative Study of Cryostripping and Endovenous Laser Therapy for Varicose Veins: Mid-Term Results.

BackgroundConventional stripping is considered to be the standard procedure for great saphenous vein (GSV) varicosities, but many other alternative treatments such as cryostripping, endovenous laser therapy (EVLT), radio-frequency ablation, and ultrasound-guided foam sclerotherapy have been developed. Among them, both cryostripping and laser therapy have been reported to be less traumatic, with lower rates of complications and recurrences when compared to conventional stripping. To compare the efficacy of these treatments, we have analyzed and compared the mid-term clinical outcomes of cryostripping and EVLT.MethodsPatients diagnosed with varicose veins of the GSV and treated with cryostripping or laser therapy between September 2008 and April 2013 were enrolled in this study. Duplex ultrasonography was used for the diagnosis and evaluation of varicosity and reflux, and the clinical-etiology-anatomy-pathophysiology classification was used to measure the clinical severity. The symptoms, Venous Clinical Severity Score (VCSS), recurrence rates, and complication rates of the cryostripping and laser therapy groups were analyzed and compared.ResultsA total of 68 patients were enrolled in this study. 32 patients were treated with cryostripping, and 36 patients were treated with laser therapy. The median follow-up period was 29.6 months. Recurrence was noted in three patients from the cryostripping group and in two patients from the EVLT group. There was no difference in the VCSS score, operative time, duration of hospital stay, and complication rate between the cryostripping group and the EVLT group.ConclusionThe mid-term clinical outcomes of cryostripping were not inferior to those of EVLT. Further, considering its cost-effectiveness, cryostripping seems to be a safe and feasible method for the treatment of varicose veins.

Endovenous Laser Ablation in Patients with Venous Ulcers: Long Term Results and Risk Factors for Non-healing or Recurrence

Introduction: The ESCHAR study showed that superficial venous surgery reduced the recurrence rate compared with compression therapy only. Ulcer recurrence rates after endovenous laser (EVL) treatment for superficial venous insufficiency seem comparable, but so far only small groups and shorter follow up times have been reported. The aim of this study was to investigate long term treatment outcomes of patients with venous ulcers treated with EVL in a larger population, in ordinary clinical practice without dedicated ulcer care. Methods: One hundred and ninety seven consecutive patients previously treated with EVL for a healed or open venous ulcer were invited to follow up including clinical examination, quality of life score using EQ5D, Duplex, ankle brachial index, venous refilling time (RT) and pump volume measured with PPG. Risk factors for non-healing and/or recurrence were calculated using chi-square to compare proportions and logistic regression. Results: 197 patients have been examined after a mean follow up time of 41 months. After EVL further ulcer treatment and compression was carried out mostly in primary care. Details of post-operative treatment were not possible to retrieve. 165 patients had healed ulcers (Group 1) without recurrence during follow up, 32 patients never healed or had a recurrence after EVL (Group 2). The mean age was 62.7 years for group 1 and 64,2 for group 2 (NS). The number of women/men was 99/66 in group 1 and 14/18 in group 2 (NS). Significant risk factors for non-healing and or recurrence were reduced ankle mobility (p = .009), perforating vein insufficiency (PVI) in the ulcer area (p = .007), popliteal and crural vein insufficiency (p = .016 and .000 respectively) and shortened RT (p = .016). There was a greater proportion in group 2 with previous deep venous thrombosis, diabetes, remnant varicose veins (VV) in ulcer area, and they had lower QoL, but no significance was reached. Other non-significant risk factors were cardiovascular disease, previous VV surgery, smoking, C5 or C6 at EVL, skin disease and remnant VV outside ulcer area. Conclusion: Endovenous laser ablation treating patients with venous ulcers in ordinary clinical practice confers long-term healing in a majority. Non-healing and recurrence was associated with reduced ankle mobility, deep and perforating vein insufficiency and shortened RT. It may be speculated that healing rates can be further improved with a more dedicated ulcer care and follow up post-operatively.

Erectile function improvement after endovenous varicosis therapy of the great saphenous vein

SummaryThere are no cases reported about endovascular varicosis therapy having an impact on the erectile function of the man. This case reports’ patient had a stronger erection in the area of the glans penis after he underwent endovenous lasertherapy of the great saphenous vein.This effect could also be explained with the anatomy of the veins because some of the blood of the penis is drained by the external pudendal vein which leads into the saphenofemoral junction. If there is a manipulation on the veins of the saphenofemoral junction it might have an impact on the drainage of the penis.

Less Painful Tumescent Solution for Patients Undergoing Endovenous Laser Ablation of the Saphenous Vein

This study aims to investigate the efficacy of lidocaine, prilocaine, and bupivacaine used in tumescent solution during endovenous laser treatment (EVLT) on intraoperative and postoperative pain. This prospective randomized study included 90 patients. The patients were divided into 3 groups including 30 patients in each group, according to the content of local anesthetics in tumescent solution. All patients received EVLT treatment with lidocaine in group 1, prilocaine in group 2, and bupivacaine in group 3. Visual analog scale was used for the evaluation of intraoperative and postoperative pain. The mean intraoperative pain score was 2.27 ± 1.53 in group 1, 1.97 ± 1.54 in group 2, and 3.05 ± 0.73 in group 3. On the first day postoperatively, the mean pain score was 2.57 ± 1.7 in group 1, 3.27 ± 1.23 in group 2, and 1.13 ± 0.94 in group 3 (P = 0.0001). Intraoperative and postoperative mean pain scores during first day follow-up were significantly lower in group 3. Tumescent anesthesia is the most critical component of EVLT to improve comfort by reducing the pain. Therefore, we conclude that bupivacaine is an optimal alternative to lidocaine and prilocaine in tumescent anesthesia and can be used safely.

Leg Ulcers: Diagnosis and Management (3rd edn)

The title, Leg Ulcers: Diagnosis and Management, gives the impression that this text book has been restricted to the subject of leg ulcers. However, one soon discovers that it is a comprehensive text book of lower limb venous diseases. Leg ulcers, particularly those of venous aetiology, constitute a major health problem in most Western countries. A significant proportion of the venous leg ulcer patients are relatively young, resulting in economic losses not only from the cost of treatment but also from the wastage of productive man-hours. As highlighted in the text book, the principal health personnel who manage venous leg ulcers vary between countries. In the UK, for example, the majority are initially seen and managed by nurses in community leg ulcer centres. This, notwithstanding the high profile given to venous diseases in general and leg ulcers in particular by the editors, is highly commendable since for most vascular units venous disease would contribute to at least 30% of their workload. A detailed examination of normal anatomy and physiology of lower limb veins and a thorough discussion of pathology, pathological anatomy, pathophysiology, epidemiology and clinical presentation of all aspects of lower limb venous diseases have been systematically reviewed. Venous leg ulcers have been didactically presented with the specialist in mind. Extensive discussion of conventional and the more controversial views on pathophysiology have been appropriately discussed in a balanced format without the authors' personal bias influencing the quality of materials presented. The basis for the accepted methods of investigation and treatment of venous leg ulcers, including compression, therapy and surgery are well presented. Unproven methods of treatment like pharmacotherapy, topical treatment and more modern methods including foam sclerotherapy, echosclerotherapy and endovenous laser treatment have also been adequately covered. There is also a very good chapter on ‘The Differential Diagnosis of Leg Ulcers’. The text is illustrated using excellent line diagrams, black-and-white as well as colour photographs. Each chapter has been very well researched with a comprehensive list of references. Perhaps my only criticisms of the text book are the several instances of repetition and a few typographical errors. On the whole, however, it is a good specialist text book of lower limb venous diseases which any vascular surgeon with a special interest in this field would find quite useful.