Endovenous Laser Research Articles

A histological study of vessel wall reaction after endovenous ultrasound ablation in an animal model

Introduction. Along with the generally accepted thermal methods of saphenous varicose veins ablation, the use of non-thermal and combined methods becomes attractive. Due to the variety of mechanisms of action, low-frequency ultrasound is a promising technology for performing a wide range of minimally invasive intravascular operations, including the treatment of varicose veins. Aim. To elucidate the mechanism of action of a novel endovenous ultrasound ablation method and evaluate its effect on vein wall injury and lumen occlusion in an animal model. Materials and methods. A total of 34 central ear vein (CEV) medial ramus were treated in 17 rabbits according to the follow-up protocol. Six femoral veins from three rabbits enrolled into the acute experiment were harvested 45 min after the procedure. All treated CEV medial ramus in the follow-up experiment were divided into four treatment groups with an observation time of: (0) 30 days, control procedure; (1) 60 days, ultrasound ablation; (2) 95 days, ultrasound ablation; (3) 138 days, ultrasound ablation. Results. Occlusion was achieved in all but one CEV medial ramus (29/30; 97%) treated with ultrasound. Histologic examination of treated veins showed heat- and mechanical-induced changes in the vein wall, such as abrasion of the endothelium and fibrotic lesions in the tunica media and tunica adventitia. The occluded segments consisted mainly of cellular fibrotic material. In the acute group, histological evidence of damage to all vessel wall layers was found. Discussion. Ultrasound ablation results in homogeneous and uniform damage to the venous wall. The results of this study suggest that the ultrasound treatment leads to venous occlusion by the additive thermomechanical mechanism of damage to the vessel wall. Conclusions. Endovenous ultrasound ablation showed a similar pattern of thermal damage as endovenous laser (EVLA) and radiofrequency ablation (RFA) and damage to the endothelium as mechanochemical ablation (MOCA). Four months after ultrasound ablation, the occlusion rate was 90%.

Saphenous sparing treatments: The ASVAL Method

The ASVAL method is based on a bottom-up concept of the evolution of venous disease from the tributaries to the saphenous axes, as opposed to the traditional top-down theory where reflux, conversely, appears first on the saphenous axes and then spreads to the tributaries. The bottom-up evolution has led to a change in treatment paradigm, no longer based on effective suppression of saphenous reflux, but on reversibility of the latter by ablation of the varicose tributaries, eliminating the filling effect at the origin of the hemodynamic disturbance. As the ASVAL strategy has its limits, depending on the stage of progression of saphenous damage, it is necessary to establish the indications where it can be applied, before the saphenous vein is irreversibly damaged (diameter larger than 8 mm, multiple ectasia, extended reflux above and below knee), or the clinical staged too advanced (skin changes). Various authors have reported on these criteria for applying the ASVAL method in the right indications considering hemodynamic data (ostial reflux, extent of truncal reflux), anatomical data (saphenous diameter, reflux location, volume of varicose reservoir) and clinical data (age, nulliparity, trophic disorders, presence of symptoms). Complications and side effects are limited if the indications and principles of the miniphlebectomy technique are respected. All the cohort studies reported show that after treatment using the ASVAL method (removal of varicose tributaries and ad integrum respect for the saphenous vein), reflux abolition is achieved in between 50% and 80% of cases, depending on the patients selected. Above all, these studies show that improvement in symptoms and quality of life is systematic, whatever the result on the saphenous vein. A recent randomized controlled trial shows that endovenous laser and ASVAL are clinically equivalent, with a cost/effectiveness ratio in favor of ASVAL. In conclusion, The ASVAL method leads to an alternative concept of an ascending or multifocal evolution starting on the epifascial tributaries and enabling to set an individualized “à la carte treatment” since every patient has a different clinical and hemodynamic situation of the disease at the time of treatment, which cannot match to a “one size fits all” that represents the traditional strategy. We have now at our disposal simple tools to evaluate the patients, select the good indications and perform properly the ASVAL method by mini-phlebectomy.

Comparison of 5-year outcomes and quality of life between endovenous laser (980 nm) and microwave ablation combined with high ligation for varicose veins.

Our study aims to evaluateand compare the long-term results of endovenous laser (EVLA) and microwave ablation (EMA) combined with high ligation in treating varicose veins (VVs). A total of 122 patients (150 legs) underwent EMA combined with high ligation, and 127 patients (167 legs) underwent EVLA procedures (980 nm) combined with high ligation in this retrospective study. Outcomes included the Aberdeen Varicose Vein Questionnaire (AVVQ) score, the Venous Clinical Severity Score (VCSS), clinical recurrence of VVs and patient satisfaction duringthe 5-year follow-up.During the 5-year follow-up, patients who underwent the EVLA procedure showed a higher recurrence of VVs than those who underwent the EMA procedure (22.75% vs. 13.33%, P = 0.03, odds ratio (OR): 1.91, 95% confidence interval (CI): 1.06-3.45), especially at the primary site (6% vs. 14.37%, P = 0.01; OR: 2.63; 95% CI: 1.21-5.72). VV recurrence within 3 years was higher in patients who underwent EVLA than in those who underwent the EMA procedure (73.68% vs. 40%, P = 0.01; OR: 4.2; 95% CI: 1.37-12.86). Compared with those at baseline, the AVVQ score, VCSS and EQ-5D score improved significantly at 5 years for patients who underwent either procedure (P < 0.01); however, the VCSS and AVVQ score were higher for patients who underwent the EVLA procedure (P = 0.05). The patient reintervention rate was higher for EVLA than for EMA (14.79% vs. 7.33%, P = 0.033; OR: 2.19; 95% CI: 2.06-5.34). Our results confirmed that EMA and EVLA improve the QoL of patients and that EMA combined with high ligation demonstrates lower 5-year recurrence, especially at primary sites.

Evaluation of patients’ and practitionners’ satisfaction with the use of hypnosis during a thermal endovenous procedure

In the field of vascular surgery , hypnosis has been used in the creation of venous approaches but also as a complement to local anesthesia during more extensive vascular surgery, including the insertion of abdominal aortic aneurysm stents. The practice of thermal endovenous procedures seems to us to be conducive to hypnotic support in particular to reinforce hypnoanalgesia. We present a prospective and monocentric observational study at the University Hospital of Grenoble with consecutive inclusions whose objective was to evaluate the interest and the satisfaction of the patients and practionners about the practice of hypnosis during procedures of thermal endovenous treatments. Among the 31 patients treated with endovenous laser, 27 accepted the hypnosis proposal, 16 had hypnosis considered as formal and 13 conversational hypnosis and 10 conversation only. Among them, 29% of patients considered that the hypnoanalgesia technique had enormously relaxed them and 19% “very relaxed”; 42% of patients considered themselves “good”, 32% “very good” and 19% “extremely good” at the end of the procedure. Concerning the practitioners performing the endovenous procedure, more than half (51, 51%) considered that hypnoanalgesia relaxed the patient “moderately and/or a lot”. The results were as a whole point to a high level of satisfaction on the part of patients and practitioners with the practice of procedures with various levels of hypnosis induction. Despite many biases, this study has the merit of concluding that the patients were very satisfied with the apprehension of these gestures as well as the practitioners, and this without any additional time during the procedure.

Resolution of the professional community of phlebologists regarding the examination of patients before minimally invasive interventions for varicose veins of the lower extremities

To date, modern outpatient minimally invasive interventions for varicose veins, such as endovenous laser or radiofrequency ablation, microphlebectomy, sclerotherapy, non-thermal non-tumescent methods (NTNT), are widely introduced into clinical practice in the Russia. In the approved by the Ministry of Health of the Russian Federation in 2021 clinical guidelines "Varicose veins of the lower extremities" they are recommended as preferred over open surgery. At the same time, there are no federal regulations of preoperative examination of patients before these minimally invasive procedures for varicose veins. That is why the medical community is often forced to prescribe unnecessary diagnostic tests on the "just-in-case" principle, in order to protect itself for cases of complications and subsequent checks. This undoubtedly harms both the patients and the medical service, which has an additional useless and inappropriate burden. The purpose of the round table held on September 28, 2021 under the auspices of the Self-Regulatory Organization “The National College of Phlebology” together with the legal partner “The Faculty of Medical Law LLC” (Moscow), was to review the existing legislation on this issue and then to prepare a resolution regarding the justified preoperative examination of patients before minimally invasive interventions for varicose veins of the lower extremities. The prepared document consists of two parts. The first part presents the legal regulation of the diagnostic tests before interventions in phlebology. The second part contains the opinion of the professional community regarding the appropriateness or inexpediency of different pre-procedural examinations. In addition, based on the conclusions of legal analytics, a form of order of the chief physician has been developed, which regulates the diagnostic tests before the considered phlebological interventions in the clinic.

Assessment, treatment and new approaches to facial veins

Patients with prominent or cosmetically embarrassing facial veins may often seek an aesthetic opinion for removal. The authors present a methodology to approach classifying facial veins by describing the veins in terms of position, colour, size and flat or bulging appearance. Tiny telangiectasia (also known as thread or spider veins) or smaller discrete blue/green or green veins are regularly treated by heat, using electrocautery, radiofrequency, intense pulsed light or extra-corporeal laser. However, the authors present the use of microphlebectomy, endovenous laser and arterial ligation for larger facial veins and arteries that are often thought to be too big or complex to treat.

Correlation of body mass index with recanalization risk after endovenous thermal ablation

ObjectiveChronic venous insufficiency (CVI) has an increased prevalence among obese individuals with body mass indices (BMI) over 30. A safe, efficacious, and evidence-based recommended treatment for CVI due to superficial venous reflux (SVR) in great saphenous veins (GSVs), small saphenous veins (SSVs), accessory saphenous veins (ASVs), and reflux in the perforator veins (PVs) is endovenous thermal ablation (EVTA). We sought to identify if BMI is an independent risk factor for recanalization after EVTA. MethodsAll patients with CVI were initially managed conservatively, and those with pathologic SVR refractory to compression therapy were offered EVTAs depending on the site of reflux. Sonographic confirmation of SVR was defined as >500 milliseconds of reflux in the GSVs, SSVs, and ASVs and a diameter >4 mm. PV reflux was confirmed as >350 milliseconds of reflux and a diameter >2.5 mm. All patients received a follow-up duplex ultrasound 1 week after the procedure, every 3 months for the first year, and every 6 months thereafter. Multivariate analysis with logistic regression was performed regarding patients' age, ablation modality (laser vs radiofrequency ablation), vein location and laterality, BMI, and recanalization. ResultsFrom 2013 to 2018, 9739 endovenous ablations were performed on 3070 patients. Endovenous laser was used in 3862 procedures and radiofrequency ablation in 5831 procedures. Veins treated with EVTA were distributed as follows: 6182 GSVs, 2509 SSVs, 597 ASVs, and 451 PVs. The mean patient age was 61.1 years (15-99, standard deviation [SD] ±15.6) with a mean BMI of 31.2 kg/m2 (13.7-69.5, SD ±7.3). A total of 68.4% patients were women and 31.4% men. The mean follow-up was 25.8 months (0-65.9, SD ±12.9). Multivariate statistical analysis with logistic regression was used to determine potential statistical significance between BMI and vein recanalization after EVTA. Overall, obese patients experienced more recanalizations than nonobese patients (P = .032), with an average BMI of 33 kg/m2 for recanalizations. PVs were statistically more likely to recanalize than any other vein (P = .0001). A secondary analysis was performed with the exclusion of PVs, due to their five times increased risk of recanalization, and showed no significant difference of recanalization across all BMI subgroups (P = .127). ConclusionsBMI does not predict recanalization risk after EVTA, except for ablations performed on PVs.

Risk factors for saphenous vein recanalization after endovenous radiofrequency ablation.

Target vein recanalization is defined as the postoperative detection of blood flow in a venous segment previously ablated. It can be occurred after thermal-tumescent procedures, as radiofrequency (RFA) and endovenous laser (EVLA) ablation techniques. Despite several papers described and analyzed incidence and consequences of recanalization, limited data are published on risk factors for this condition. The aim of this general review is to investigate clinical and instrumental risk factors for great and small saphenous veins recanalization after RFA, indicating their impact in the follow-up period. Articles were obtained through a detailed search of the scientific journal databases (PubMed, Scopus, Web of Science) for those published between January 1, 2011 to December 31, 2020. The term "radiofrequency venous ablation" was combined with "risk factors", "recanalization" and "recurrence", to obtain the first article cluster. Risk factors analysis for saphenous vein recanalization after ablation is not a well-studied problem. Although several studies have analyzed recanalization patterns and anatomical causes of ablation failure, few and disaggregate data are available regarding clinical preoperative risk factors. BMI and saphenous trunk diameter seem to be the only two recognized characteristics that may affect short and long-term recanalization rate, though CVI status, sex, target vein treatment length and others factors may be taken into account. Physicians should consider risk factors for recanalization in patient selection and treatment recommendations, but also recognize that not all "ablation failures" are of clinical relevance.

Current status of endothermal heat induced thrombosis.

There remain many questions regarding the pathophysiology and risk factors for endothermal heat induced thrombosis formation. Moreover, there are a paucity of data on the timing of its occurrence, and there has been no consensus regarding for its treatment. The purpose of this review was to summarize the current knowledge on the pathophysiology, risk factors and treatment strategies for endothermal heat induced thrombosis. The PubMed database was searched from 2001 to present for endothermal heat induced thrombosis, EHIT, deep vein thrombosis, chronic venous insufficiency, varicose veins, endovenous laser and radiofrequency ablation (treatment). All relevant articles identified by the authors mentioning endothermal heat induced thrombosis were included in this review. A multitude of risk factors, several pathophysiological hypotheses and different treatment strategies are described in the literature. Endothermal heat induced thrombosis is marginally understood. There remains a theoretical risk for significant venous thromboembolic complications. With the new uniform classification of EHIT (American Venous Forum), healthcare providers should continue to investigate the nature of this event.

Randomized clinical trial of mechanochemical and endovenous thermal ablation of great saphenous varicose veins.

A variety of minimally invasive techniques are available for the treatment of varicose great saphenous vein (GSVs). Non-tumescent, non-thermal ablation methods have been developed. This study compared mechanochemical ablation (MOCA), a non-tumescent, non-thermal ablation technique, with two endovenous thermal ablation methods requiring tumescence in an RCT. Patients with GSV reflux were randomized to undergo MOCA, or thermal ablation with endovenous laser (EVLA) or radiofrequency (RFA). The primary outcome measure was the occlusion rate of the GSV at 1 year. The study finally included 125 patients, of whom 117 (93·6 per cent) attended 1-year follow-up. At 1 year, the treated part of the GSV was fully occluded in all patients in the EVLA and RFA groups, and in 45 of 55 in the MOCA group (occlusion rates 100, 100 and 82 per cent respectively; P= 0·002). The preoperative GSV diameter was associated with the recanalization rate of the proximal GSV in the MOCA group. At 1 year after treatment, disease-specific life quality was similar in the three groups. The GSV occlusion rate 1 year after treatment was significantly higher after EVLA and RFA than after MOCA. Quality of life was similar between interventions. Registration number: NCT03722134 (http://www.clinicaltrials.gov).

Histopathologic differences in the endovenous laser ablation between jacketed and radial fibers, in an ex vivo dominant extrafascial tributary of the great saphenous vein in an in vitro model, using histology and immunohistochemistry

ObjectiveThe study aimed to investigate the biologic effects of the 1470-nm endovenous laser (EVL), with a jacketed fiber and a radial fiber, during EVL ablation of an ex vivo dominant extrafascial tributary of the great saphenous vein in our in vitro model by histology and immunohistochemistry. MethodsTen segments of the dominant extrafascial tributary of the great saphenous vein were harvested by a consultant vascular surgeon from patients during routine varicose vein surgery. Six segments were treated using an ex vivo model of our design by a 1470-nm EVL with a jacketed fiber. The other four segments were also treated by a 1470-nm EVL but with a radial-firing fiber. Each segment was split into five sections and treated at five different linear endovenous energy densities (LEEDs) at 10 W: 0, 20, 40, 60, and 80 J/cm. The veins were incubated and subsections collected at 6 and 24 hours after treatment. Subsections were immersed in buffered formalin and taken for histologic and immunohistochemical analysis. Histopathologic analysis was then performed. ResultsTreatment with the radial fiber led to a pattern of damage that was more homogeneous than with the jacketed fiber, with no carbonization of tissue present. Significant transmural damage and necrosis were observed at LEEDs of 60 and 80 J/cm in both treatment groups. At the same LEEDs, p53 and caspase 3 analysis showed that transmural cell wall vein death (necrosis or apoptosis) occurred by 6 hours after treatment with both fibers. ConclusionsThere was a significant difference in the effects of treatment with a jacketed fiber and a radial fiber in EVL ablation in vitro. Although both fibers caused transmural vein wall cell death at similar LEEDs, the pattern of damage with the radial fiber was more homogeneous. There was no overtreatment of tissue in terms of carbonization after treatment with the radial fiber. Treatment with the jacketed fiber showed carbonization of tissue at the same LEEDs.

Invited commentary

Carlie Chaplin once said that simplicity is not a simple thing. We seem to forget this when treating patients with varicose veins. Population studies showed that only one-third of these patients has saphenous reflux, yet elimination of saphenous reflux when it is present is believed to be curative, and removal of the saphenous vein from the circulation remains the mainstream intervention. Excellent short-term results of high ligation with or without stripping of the saphenous vein convinced many surgeons that recurrences result from the errors in surgical technique. Over time, however, it became clear that other factors play an important, if not the major, role in development of recurrent varicose veins and recurrent saphenous reflux. Surgical trauma induces inflammation and angiogenesis. Along with hemodynamic forces, these processes lead to reconnection of remaining distal saphenous vein and other superficial veins to the deep venous system. It is especially demonstrative in cases of high ligation without stripping, when neoveins form large collaterals around the ligated segment, sometimes indistinguishable in appearance from the saphenous vein itself. Histopathologic differences in the endovenous laser ablation between jacketed and radial fibers, in an ex vivo dominant extrafascial tributary of the great saphenous vein in an in vitro model, using histology and immunohistochemistryJournal of Vascular Surgery: Venous and Lymphatic DisordersVol. 7Issue 2PreviewThe study aimed to investigate the biologic effects of the 1470-nm endovenous laser (EVL), with a jacketed fiber and a radial fiber, during EVL ablation of an ex vivo dominant extrafascial tributary of the great saphenous vein in our in vitro model by histology and immunohistochemistry. Full-Text PDF

Anesthesia in outpatient phlebology practice

Tumescent and/or conductive anaesthesia is the most frequently performed procedure to anesthetize the thermal types of surgical interventions, mini-phlebectomy and stripping of subcutaneous veins in outpatient settings. These interventions have become a common outpatient procedure almost everywhere, which made the issue of local anaesthesia more sensitive over the past 5 years in Russia. The aim is to compare the efficacy, safety and comfort when injecting various anaesthetic solutions to relieve pain during endovenous laser obliteration/radio frequency catheter ablation, stripping of the subcutaneous veins and mini-phlebectomy. Searching method. We searched for original articles in PubMed, in the archives of «Phlebology» and «Angiology and Vascular Surgery» journals issued for the period between 2001 and November 2018 and the search for official instructions in the state register of medicinal products. Selection criteria. We included all comparative studies: randomized and non-randomized, in which pain was assessed both during injection of a tumescent solution before EVLO and/or mini-phlebectomy and during surgery, as well as systematic reviews and monographs. Data analysis. In total, we identified 9 studies: 7 randomized and 2 non-randomized, one systematic review and two monographs. The advantage of a buffered solution over unbuffered one in terms of reducing pain during injection is revealed in three randomized, one simple comparative study and on the basis of systematic review data. A great efficacy of combining tumescent anaesthesia with a femoral nerve blockade, which was equivalent to spinal anaesthesia, was found in 4 randomized trials, two of which were double-blind, and one non-randomized. In addition, a smaller degree of motor block was reported after blocking the femoral nerve in comparison with spinal anaesthesia. In one randomized trial in which pain was assessed using cold and warm solutions, no significant differences in pain were observed either during or after surgery. In order to prepare a tumescent solution, lidocaine, prilocaine and mepivacaine were used at concentrations ranging from 0.028% to 0.2%; the advantages of higher concentrations over the lower ones have not been revealed. No adverse reactions and complications of anaesthesia have been reported in the studies, except for one where methaemoglobinemia of mild degree was detected in a small number of patients when using 0.2% prilocaine. The conclusion. Local anaesthesia, namely, conductive and tumescent anaesthesia, is an effective and safe anaesthesia method in outpatient surgery. Even very low concentrations of anaesthetic solutions are effective for tumescent anaesthesia. The use of buffered solutions increases significantly patient comfort during the injection. The combination of tumescent anaesthesia and femoral nerve block increases the effectiveness of anaesthesia. The femoral nerve block has significant advantages in comparison with spinal anaesthesia in terms of safety.

Re: "Histological and Immunofluorescent Analysis of the Large Tributary of the Great Saphenous Vein Treated With a 1920 nm Endovenous Laser: Preliminary Findings".

The last issue of EJVES Short Reports (2018; 39: 7–11) included the report “Histological and immunofluorescent analysis of the large tributary of the great saphenous vein treated with a 1,920 nm endovenous laser: preliminary findings” by Ashpitel et al.1Ashpitel H.F. Dabbs E.B. Nemchand J.L. La Ragione R.M. Salguero F.J. Whiteley M.S. Histological and immunofluorescent analysis of a large tributary of the great saphenous vein treated with a 1920 nm endovenous laser: preliminary findings.EJVES Short Rep. 2018; 39: 7-11Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar We have read it with great interest. Similar to the authors, we are involved in research focused on endovascular treatment of vein diseases. Therefore, we would like to raise several issues, which for us are the most interesting or unclear. The first issue concerns the role of vein size in the treatment protocol. According to the manufacturer's recommendations, in the majority of EVL devices the linear endovenous energy density (LEED) should be adjusted to the vein diameter.2Starodubtsev V. Lukyanenko M. Karpenko A. Ignatenko P. Endovenous laser ablation in patients with wide diameter of the proximal segment of the great saphenous vein: comparison of methods.Phlebology. 2015; 30: 700-705Crossref PubMed Scopus (10) Google Scholar Here, in the article, the authors did not mention that parameter at all. Do the authors think that with a 1,920 nm device the vein diameter does not have any importance for the final outcome? We agree with the authors' opinion from the Discussion that their ex vivo model, without tumescence, is a strong limitation of this study. It is noteworthy that proper tumescence is crucial for effective ablation, since it should result in symmetrical reduction of vein diameter (i.e., narrowing of the vein), associated with thickening of its wall. In such circumstances heat distribution across the vein wall is uniform and, therefore, even low energy may be sufficient for a homogeneous thermal injury, followed by vein fibrosis with complete occlusion. However, as shown in Fig. 1, there was only superficial damage of the tunica intima at 40 J/cm, whereas involvement of both intima and media required at least 60 J/cm. Moreover, the damage was rather local, and present only on one side of the flattened vein cross section. Hence, to support their conclusions, the authors should show data from both 1,470 and 1,920 nm devices in the same image. Otherwise, a generalised statement regarding the similar effectiveness of 1,920 and 1,470 nm EVL seems to be speculative. The next issue is the conclusion regarding the assessment of apoptosis in vein samples. Firstly, it is difficult to detect apoptosis within a few seconds of its induction, since it usually occurs within at least several minutes or even hours.3Galluzzi L. Vitale I. Aaronson S.A. Abrams J.M. Adam D. Agostinis P. et al.Molecular mechanisms of cell death: recommendations of the nomenclature Committee on cell death 2018.Cell Death Differ. 2018; 25: 486-541Crossref PubMed Scopus (2696) Google Scholar On the other hand, cells of the vein wall may display some baseline level of apoptosis.4Yongbo X. Wei H. Lei W. Jianhua Z. Tao W. Jinyuan T. et al.Changes in levels of apoptosis in the walls of different segments of great saphenous varicose veins.Phlebology. 2016; 31: 632-639Crossref PubMed Scopus (9) Google Scholar Most interestingly, as seen in Fig. 2, the most abundant Cy3 labelled red dots in the vein wall (which should correspond to phospho-p53 positive apoptotic cells) could be found in vein samples exposed to 20 and 40 J/cm of 1,920 nm EVL. It would be interesting to know the authors' explanation for this phenomenon. In the 60 J/cm sample (Fig. 2), we can observe evident signs of cell damage. However, it is heat induced coagulation and tissue necrosis rather than apoptosis. Finally, we would kindly ask the authors their opinion regarding the possible advantage of using a 1,920 nm device for endovenous ablation. What is the actual superiority of 1,920 nm over 1,470 nm in vein treatment? Would they recommend changing our 1,470 nm device to a new, 1,920 nm one? None. Histological and Immunofluorescent Analysis of a Large Tributary of the Great Saphenous Vein Treated with a 1920 nm Endovenous Laser: Preliminary FindingsEJVES Short Reports Vol. 39PreviewTo analyse the biological effects of a 1920 nm endovenous laser (EVL) on extra-fascial great saphenous vein (GSV) in vitro. Full-Text PDF Open AccessRe. “Comments to: Histological and Immunofluorescent Analysis of the Large Tributary of the Great Saphenous Vein Treated With a 1920 nm Endovenous Laser: Preliminary Findings”EJVES Short Reports Vol. 41PreviewI would like to thank Justyna Wilczko and her colleagues for their interest and comments on our work.1,2 Full-Text PDF Open Access

Histological and Immunofluorescent Analysis of a Large Tributary of the Great Saphenous Vein Treated with a 1920 nm Endovenous Laser: Preliminary Findings.

ObjectivesTo analyse the biological effects of a 1920 nm endovenous laser (EVL) on extra-fascial great saphenous vein (GSV) in vitro.MethodsA 10 cm length of a large tributary bypassing a hypoplastic segment of the GSV (sometimes called an “extra-fascial GSV”) was obtained during routine varicose vein surgery. The length was treated in five sections with different LEEDs (0 (control), 20, 40, 60, and 80 J/cm) with a 1920 nm EVL at 4W power, in a novel in vitro treatment model. The biological effects were assessed by histological staining of the samples for haematoxylin and eosin (HE) and Martius Scarlet Blue (MSB), and by immunofluorescent detection of p-p53 and VCAM-1.ResultsHistological analysis showed significant structural damage at LEEDs above 60 J/cm, especially in the intima and media, with the treatment at 80 J/cm causing perforation of the vein wall. In addition, there was a significant increase in p-p53 expression in treated tissue at 60 and 80 J/cm.ConclusionsUsing this ex vivo model, the results indicate that in vitro treatment with a 1920 nm EVL, at or above an LEED of 60 J/cm and 4 W power, causes significant vein wall cell death reaching deep into the media by a combination of direct thermal damage and apoptosis. A wavelength of 1920 nm appears to be effective for the endovenous ablation of truncal veins.

Re. "Comments to: Histological and Immunofluorescent Analysis of the Large Tributary of the Great Saphenous Vein Treated With a 1920 nm Endovenous Laser: Preliminary Findings".

Re. "Comments to: Histological and Immunofluorescent Analysis of the Large Tributary of the Great Saphenous Vein Treated With a 1920 nm Endovenous Laser: Preliminary Findings".

Novel Biomatrix Sclerofoam: Equal to or Better Than Thermo-Occlusion?

Common sclerofoams (Cabrera type, including Varithena [BTG International, West Conshohocken, Pa) are inferior to thermo-occlusion in regard to primary and long-term results. Such foams are of low viscosity and stability; they will collapse within 60 to 240 seconds and rapidly loose effect. With increasing vein diameters, common foams will displace blood less but float on it with zones of uncertain effects. A novel viscous microfoam using a biomatrix based on denatured autologous blood proteins with an in vitro half-life of >60 minutes and fast disintegration within flowing blood was evaluated in the great saphenous vein (GSV) using a safety setting to prevent foam migration through the junction. There were 120 patients (78 women, 42 men; 32-81 years) with GSV insufficiency (diameter, 6-24 mm; mean, 10.3 mm) who were randomized to two modalities of treatment: A, junction closure by endovenous laser (EVL) in coaxial perivenous anesthesia (EVL 810 nm, ball tip, or 1470 nm, slim/radial; segment length, 3-20 cm), combined with catheter sclerofoam (biomatrix sclerofoam [BSF], 1% Aethoxysklerol; segment length, 28-35 cm; n = 60), for the segment below; and B, EVL alone for comparison (treated segment length, 38-55 cm; n = 60). Both modalities used the same polytetrafluoroethylene vein catheter (PhleboCath 2.3 mm, over the wire). BSF was deployed during catheter withdrawal. Postinterventional examinations with ultrasound were performed after 2 weeks and at 2, 6, and 12 months by independent investigators. Initial vein occlusion was obtained in all cases (120/120). There were no adverse events, in particular no thoracic or cerebral symptoms in the group receiving BSF. The patterns of echogenicity were similar in both groups at all presentations. Vein diameter regression and mild postinterventional symptoms were similar for EVL and BSF. Concerning group A, the investigators were not able to discriminate any borderline of the methods (Fig). During 1-year follow-up, junction segments showed reperfusion in 2 of 60 cases (A, 3.33%) and 1 of 60 cases (B, 1.6%). The thigh-to-knee segments, representing the closure quality of each method, showed reperfusion in 5 of 60 cases (8.33%) after BSF and in 6 of 60 cases (10%) after EVL alone. BSF seems to provide a quality of vein occlusion similar to that of EVL, apart from the GSV junction segment. BSF is more convenient for patient and physician as no tumescence is required. Studies using BSF also in the junction with temporary or permanent blocking devices (eg, V-block) or hyaluronan vein compression (IntraShape project) will follow.

Black veins: a case of minocycline‐induced pigmentation post‐sclerotherapy and a review of literature

Minocycline-induced pigmentation (MIP) is an uncommon but well-described adverse effect of oral minocycline treatment. MIP is clinically and histopathologically distinct from post-sclerotherapy pigmentation. We report a case of a patient presenting with blackened skin overlying veins recently treated with endovenous laser and foam sclerotherapy. The patient was a 44-year-old male with systemic sclerosis who commenced minocycline for the treatment of rosacea 5 months prior. Histological examination of the discolored tissue and underlying vein revealed hemosiderin deposition in the dermis and pigmented macrophages within the sub-endothelial layer of the vein wall with a staining pattern consistent with MIP. Venous tissue has not previously been reported in the literature as a target of minocycline pigmentation. Our patient preferred to control his rosacea by continuing to take minocycline. Follow-up ultrasound examinations revealed the treated vessels to be fully occluded with no evidence of recanalization, residual flow or ongoing thrombophlebitis. Despite a good sclerotherapy outcome, the pigmentation did not subside over 2 years. This case demonstrates that oral minocycline may induce significant and potentially long-term pigmentation in predisposed patients undergoing sclerotherapy.

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.

Laser-assisted strategy for reflux abolition in a modified CHIVA approach

The aim of this study was to assess feasibility and efficacy of an endovenous laser (EL) assisted saphenous-sparing strategy in chronic venous disease (CVD). Fourteen CVD patients (C2,3,4s Ep As Pr1,2,3) underwent a saphenofemoral junction (SFJ) treatment by EL just from below the superficial epigastric vein downward for a limited tract, together with a flush ligation of the incompetent tributaries of the great saphenous vein (GSV) along the leg. The following GSV parameters were assessed 15 cm below the SFJ: reflux time, caliber, peak systolic velocity (PSV), end diastolic velocity (EDV), resistance index (RI). Venous clinical severity score and the Clinical, Etiological, Anatomical, and Pathophysio logical (CEAP) classification clinical classes were assessed. At 1 year follow up 3 cases were considered failures because of a GSV thrombosis, even if they presented a GSV recanalization with a laminar flow within at the 2 years follow-up. Eleven procedures succeeded because neither minor nor major peri-procedural complications were reported, apart 2 cases of self-healing bruising. In these last 11 cases the procedure led to a GSV reflux suppression (from 3.1±0.4 s to a retrograde laminar draining flow), to a GSV caliber reduction (from 9.4±0.5 to 3.1±0.2 cm, P&amp;lt;0.001), to a PSV reduction (from 50.2±4.6 to 18.4±3.5 cm/s, P&amp;lt;0.001), to a RI reduction (from 0.9±0.2 to 0.51±0.2, P&amp;lt;0.005) and to an oscillatory flow suppression (EDV from -8.9±1.6 to 6.2±2.3 cm/s, P&amp;lt;0.001). Both CEAP and venous clinical severity score improved from 3 to 1 (P&amp;lt;0.001) and from 7±2 to 2±1 (P&amp;lt;0.05), respectively. The GSV flow reappeared below the shrunk tract draining into the re-entry perforator. Sapheno-femoral reflux suppression can be obtained by just a GSV segmental closure. An almost 80% of success rate of the present investigation paves the way for an even wider diffusion of endovenous techniques, moreover erasing the surgical requirements for those who would like to perform a saphenoussparing strategy. In this way new devices could be used inside equally innovative strategies.