Endovenous Techniques Research Articles

Stenting of calcified iliofemoral venous segment in post-thrombotic syndrome

Stenting of the iliac veins in patients with post-thrombotic syndrome is an intervention associated with a low risk of complications, high primary and secondary patency rates, low incidence of restenosis, leading to a significant decrease in the severity of symptoms of chronic venous disease and a high rate of trophic ulcer healing, as compared with conservative therapy. Unlike subcutaneous veins, the formation of calcinates in deep veins after endured thrombosis is of considerably less frequent occurrence. Described in the article is a clinical case report concerning successful stenting of the iliofemoral venous segment in a female patient presenting with post-thrombotic syndrome, a trophic ulcer of the crus, and the presence of linear calcinosis in the lumen of the iliac veins and common femoral vein. This case report demonstrates the possibilities of contemporary endovenous techniques in treatment of this cohort of patients. Despite calcified segments, stenting was performed without technical obstacles and with a favourable clinical outcome. Such interventions may be regarded as justified and safe provided the operating surgeon has appropriate skill and experience.

Long-term outcomes of endovenous laser ablation and conventional surgery for great saphenous varicose veins

The minimally invasive endovenous technique of laser ablation has sustained benefits at 5 years over traditional ligation and stripping for saphenous vein insufficiency.

Lessons Learned After 366 Thermoablated Veins

In the past few years, advances in surgical techniques have improved outcomes in varicose veins treatment. The aim of this retrospective study was to determine whether the use of laser and different parameters influenced morbidity rates and the learning curve for all technology improvements during the period. From 2009 to 2018 we performed 366 vein procedures using endovenous laser technique for varicose veins. During this period, negative outcomes diminished with adoption of new strategies and skills. Laser wavelength, radial fibre, ultrasound guidance, anaesthetic intumescence, laser power and energy, and hospital setting were changed during the evaluation period. Laser technology requires many parameter adjustments, there is an understandable steeper learning curve at first. The use of new strategies and improved procedure steps allowed us to achieve a significant improvement in morbidity rates in the group of patients operated on using the 1,470 nm laser and in later quintiles.

Endovenous Ablation in Patients with Venous Leg Ulcers

Varicose veins with superficial venous reflux can be treated with various endovenous techniques, including ultrasound-guided foam sclerotherapy and

Foam Sclerotherapy and Laser Ablation of Varicose Veins: Newer Option in Bangladesh Perspective

Background: Varicose vein is one of the most common vascular conditions in the adult population. These are conventionally treated with surgical high ligation of Sapheno-femoral junction and stripping of Great Saphenous Vein (GSV) with multiple phlebectomy. The aim of this study was to highlight the technical considerations in performing endovenous laser ablation of varicose vein, understanding the importance and role of Duplex Machine and Tumescent anesthesia with evaluation of outcome.Methods: In this retrospective study we examined the records of 297 limbs of 220 patients operated at Vascular Care Centre at Dhaka, Bangladesh between October 2013 and October 2015. Among them 1 year follow up was performed in 118 patients. Patients were contacted through telephone calls and mobile SMSs with requests for follow up.Results: Vast majority of the patients had a smooth recovery. Significant pain was present in only 10% of patients for 1week after laser therapy and 3% of patients noted bruising in thigh for 2 weeks. Among the 118 patients who reported for follow up at 12 months, 113 (96%) showed effective persistent occlusion of GSV.Conclusion: EVLA of varicose vein is gaining popularity day by day in Bangladesh. It has become established as a safe and effective treatment option for varicosities caused by GSV incompetence. Foam sclerotherapy with Sodium tetradecyl sulphate replacing the multiple phlebectomy may be a suitable adjunct. Quick return to normal activities, fewer wound infections, less leg pain and leg bruising are strongly associated with these endovenous techniques compared with Saphenous vein stripping.Cardiovasc. j. 2018; 10(2): 140-144

Comparison of Endovenous Ablation Techniques, Foam Sclerotherapy and Surgical Stripping for Great Saphenous Varicose Veins. Extended 5-year Follow-up of a RCT

Comparison of Endovenous Ablation Techniques, Foam Sclerotherapy and Surgical Stripping for Great Saphenous Varicose Veins. Extended 5-year Follow-up of a RCT

Обгрунтування показань і вибір способу хірургічного лікування хворих на рецидив варикозної хвороби нижніх кінцівок

Метою дослідження було визначення показань і вибір способу хірургічного лікування хворих з рецидивом варикозної хвороби (РВХ) нижніх кінцівок.Матеріали і методи. Обстежено 85 пацієнтів з рецидивом варикозної хвороби нижніх кінцівок після хірургічних втручань.Результати досліджень та їх обговорення. Показання до повторних хірургічних втручань при РВХ нижніх кінцівок умовно можна розділити на соціальні (відносні) і медичні (абсолютні). Відносні показання базувалися на бажанні хворого поліпшити естетичний ефект операції. Основною метою абсолютних показань було припинення прогресування порушень трофіки тканин. При ліквідації прямих співусть між підшкірною і глибокою венозними системами (сафенофеморальне, сафенопоплітеальне, перфорантні вени) перевагу віддавали лігуванню вен з мінідоступу. Протипоказаннями до виконання ендовенозної лазерної абляції (ЕВЛА) є поверхневе розташування, звивистість і великий діаметр (більше 1,0 см) варикозно змінених вен. Склеротерапія була способом вибору при усуненні рефлюксу по резидуальних звивистих рецидивних венах діаметром до 3 мм.

Radiofrequency ablation of varicose veins

SummaryBackground: In the search of alternative techniques to high ligation and stripping (HL/S) in the treatment of varicose veins, catheter-ablation methods have been implemented since 1998. Besides endovenous laser techniques (ELT) radiofrequency ablation (RFA) is a successful device in treating insufficiency of the Great (GSV) and Small saphenous vein (SSV). Methods: This review article sums up publications on Closure Plus™, ClosureFAST™, RFITT® (Celon Method), and EVRF®. It discusses the actually favorized treatment protocols and study results. Results of meta-analysis are presented, too.Results: The Closure Plus™ catheter was the first radiofrequency technique to be licensed in Europe in 1998. Trials and meta-analyzes show occlusion rates of 81–89 % after 5 years. The consecutive technique was the ClosureFAST™ (CLF) catheter that was introduced in 2007 and offered more standardization in treatment. Published data show occlusion rates of 98 % after 5 years and low profile on complications. Also in 2007 a bipolar radiofrequency technique called RFITT was presented. Due to lack of standards in treatment protocol it could not get accepted as well as CLF despite of good treatment results (92–98 % occlusion rates after 12 months) and low complications. A new RFA device called EVRF® shows weak evidence so far.Conclusion: Radiofrequency ablation of varicose veins has become a well-established treatment alternative to HL/S mostly represented by CLF.

Current clinical evidence on endovenous laser ablation (EVLA) from randomised trials

SummaryBackground Endovenous laser ablation (EVLA) is globally counted among the most frequently administered methods to treat saphenous vein incompetence. Technical development proceeded in three particular steps: EVLA #1 – Diode lasers linearly emitting wavelengths from 810 to 980 nm through optical bare fibres; EVLA #2 – Diode or Nd:YAG lasers emitting wavelengths from 1064 to 1500 nm; EVLA #3 – Modified optical fibres warranting an optimised emission geometry by centralisation of the fibre tip (Tulip-fibre, Jacket-tip) or radial emission of the laser beam. Due to the number of different EVLA techniques their value compared with standard surgery (high ligation and stripping, HLS) and other endovascular approaches has to be questioned.Methods Selective literature analysis based on a systematic PubMed search focussed on randomised controlled trials (RCT) comparing EVLA with HLS and other thermal or nonthermal ablation techniques – radiofrequency ablation (RFA), ultrasound guided foam sclerotherapy (UGFS), endothermal steam ablation (EStA).Results The search terms “endovenous”, “laser”, “varicose vein” resulted in 509 publications, hereof 57 RCTs, hereof 24 randomised studies comparing EVLA with other treatment approaches: 15 studies comprise comparisons with standard surgery and further 9 studies with other endovenous techniques. 6 RCTs contain long-term followup data on EVLA #1 vs. HLS suggesting superiority of HLS in terms of same site clinical and duplex detected recurrence from the groin. 15 RCTs are reporting short-term results clearly demonstrating inferiority of EVLA #1 against EVLA #2, EVLA #3, and RFA with respect to postoperative complaints and patients’ quality of life.Conclusions The first generation endovenous laser systems are disadvantageous or even harmful as compared with more advanced EVLA techniques and RFA in terms of patients’ complaints and side effects. Furthermore, evidence is rising that EVLA #1 is inferior to standard surgery regarding long-term treatment efficacy. Therefore, the application of EVLA #1 in the treatment of saphenous vein incompetence cannot be recommended any longer. In view of the more recently published RCTs reporting long-term superiority of standard surgery, HLS should still be implemented as control group in studies investigating endovenous treatment approaches.

Radiofrequency ablation of varicose veins improves venous clinical severity score despite failure of complete closure of the saphenous vein after 1 year

Endovenous treatment is increasingly supplanting open surgery for the treatment of varicose veins. Among emerging endovenous techniques, radiofrequency ablation (RFA) with a ClosureFast catheter is popular in Korea. The objective of this study was to evaluate and compare the efficacy and patient-reported outcomes of RFA of varicose veins. This is a retrospective study of a prospectively registered database of patients who underwent RFA for varicose veins from 2012 to 2013 in St. Mary's Hospital in Seoul. Korea. Efficient ClosureFast RFA catheters (Medtronic, San Jose, CA, USA) were used. The techniques used for RFA of varicose veins were performed according to the manufacturer's recommendations. Duplex scans and venous clinical severity scores (VCSSs) were used to document treatment outcome and patient symptoms before and after the procedures. Treatment outcomes were estimated before the procedure and 3months, 6months, and 12months after the procedure. Outcomes were analyzed by paired t test, chi-square test, or Fisher's exact test as well as by logistical regression. A total of 117 patients were evaluated for 183 consecutive RFA procedures (183 limbs). The initial technical success was 97.3% (178/183). The estimated mean VCSS changed over time from 4.0±1.67 at preprocedure to 0.6±1.05, 0.5±1.02, and 0.6±1.14 at 3months, 6months, and 12months after the procedure, respectively. The improved VCSS was maintained 1year after the procedure (p<0.001). Recanalization of the saphenous vein was detected in 20 limbs at the 1-year follow up. The treatment failure group also exhibited a significant decline in the VCSS between preprocedure and 12months (4.8±1.76 vs. 1.8±2.04, p<0.001). Specifically, in the treatment failure group, 65% of limbs with episodic recanalization (13/20) were reoccluded or recanalized without venous reflux at the 1-year follow up. In this study, RFA of varicose veins had an initial success rate of 97.7% and a significantly improved patient VCSS at 1year. Patients with episodic recanalization of the saphenous vein also exhibited an improved VCSS with favorable duplex findings at 1year.

Varicosis: Crossectomy and stripping versus endovenous techniques

Varicosis: Crossectomy and stripping versus endovenous techniques - When to use which method and why – A categorisation attempt

Long-term follow-up for different varicose vein therapies: is surgery still the best?

Management of varicose vein disease has changed drastically over the past decades. Since its introduction in vein practice, surgery has gone through several stages of evolution until the method of ligation with stripping eventually became and remained the standard for a long time. It was found to be effective at treating the condition and, indications of its beneficial impact on patients' quality of life soon also became evident. However, being associated with significant morbidity, surgery gradually fell out of favour, especially, once the newer endovenous techniques were launched around the turn of the century. These endothermal methods allowed procedures to be carried out under local anaesthetic as day case interventions, often with a similar or even better effect on occlusion rates and quality of life. In addition, there is mounting evidence that these newer techniques might be more cost-effective. This review evaluates surgical treatment of varicose veins compared to endovenous methods and also assesses its place in current phlebological practice.

Vena Safena Magna Yetmezliğinde İki Farklı Endovenöz Ablasyon Tekniğinin Karşılaştırılması: Prospektif Randomize Klinik Çalışma

Vena Safena Magna Yetmezliğinde İki Farklı Endovenöz Ablasyon Tekniğinin Karşılaştırılması: Prospektif Randomize Klinik Çalışma

Injection Sclerotherapy and Ablation

Closure of incompetent superficial veins via endovenous techniques has become the standard of care for treatment of patients with chronic venous insufficiency and symptomatic varicose veins. The safety and efficacy of these procedures have been supported by the peer-reviewed literature, and these procedures have largely replaced the surgical treatments of high ligation and stripping. Three major developments have led to the current endovenous techniques: laser and radiofrequency catheters that deliver thermal energy, tumescent anesthesia, and duplex ultrasonography. This review covers relevant anatomy, pathophysiology, clinical signs and symptoms, diagnostics, treatment, tumescentless therapy, ClariVein (mechanochemical ablation), and the VenaSeal Closure System. Figures show telangiectasias, reticular veins, varicose veins, edema/swelling, hyperpigmentation, venous stasis ulcers, the ClosureFast Catheter, access using the great saphenous vein proximal to the popliteal region, application of tumescent anesthesia, segmental ablation using the ClosureFAST system, the NeverTouch Direct Procedure Kit by AngioDynamics, Varithena foam sclerosant, the ClariVein Occlusion Catheter, and the VenaSeal Sapheon Closure System. Tables list perforating veins of the lower extremity, Clinical, Anatomic, Etiologic, Pathophysiologic classification, and the Venous Clinical Severity Score. This review contains 12 figures, 3 tables, and 103 references

Glue, steam and Clarivein--Best practice techniques and evidence.

In July 2013, the National Institute of Health and Clinical Excellence (NICE) recommended "endothermal" ablation (meaning endovenous thermal ablation) is the first line treatment for truncal venous reflux in varicose veins. The initial endovenous thermoablation devices were radiofrequency ablation and endovenous laser ablation. More recently, Glue (cyanoacrylate), endovenous steam and Clarivein (mechanochemical ablation or MOCA) have entered the market as new endovenous techniques for the treatment of varicose veins. Glue and Clarivein do not require tumescent anaesthesia and do not use heat and therefore termed non-tumescent non-thermal (NTNT). Steam both requires tumescence and is also a thermal technique (TT). This article reviews the current position of these 3 new technologies in the treatment of varicose veins.

Clarivein® mechano-chemical ablation an interim analysis of a randomized controlled trial dose-finding study.

The ClariVein® system is an endovenous technique that uses mechano-chemical ablation to treat incompetent truncal veins. This study was conducted to identify the ideal Polidocanol dosage and form for mechano-chemical ablation in order to occlude the great saphenous vein. When adhering to safe dosage levels, sclerosants with higher concentrations potentially limit the extent of treatment. It has been demonstrated that this problem may be overcome by using Polidocanol as a microfoam. This paper was established on findings of a preliminary analysis. The initial study was a single-blinded multicenter randomized controlled trial where patients are allocated to three treatment arms. Group 1 consisted of mechano-chemical ablation +2% Polidocanol liquid, group 2: mechano-chemical ablation +3% Polidocanol liquid and group 3: mechano-chemical ablation +1% Polidocanol foam Eighty-seven, 34 males and 53 females (60.9%), mean age 55 years s.d. 16.0 (range 24-84), were enrolled in the study. Treatment length was 30 cm (range 10-30) for 95.2% of the patients. Mean operating time was 16 minutes (range 5-70). The mean saphenofemoral junction diameter (7.7 mm) was similar in all three groups. At 6 weeks post-treatment duplex ultrasound showed that 25 out of 25 = 100%, 27 out of 28 = 96.4% and 13 out of 23 = 56.5% were occluded in the mechano-chemical ablation + 2% Polidocanol liquid, mechano-chemical ablation + 3% Polidocanol liquid and mechano-chemical ablation + 1% Polidocanol microfoam respectively (p < 0.001). However, stricter scrutiny showed that the anatomical success rate defined as occlusion of at least 85% of the treated length to be 88.0%, 85.7% and 30.4% respectively (p < 0.001). Mechano-chemical ablation using ClariVein® combined with 1% Polidocanol microfoam is significantly less effective and should not be considered as a treatment option of incompetent truncal veins. Further investigation to determine the ideal Polidocanol liquid dosage with mechano-chemical ablation is advocated and is being conducted accordingly.

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.

Clinical effectiveness and cost-effectiveness of foam sclerotherapy, endovenous laser ablation and surgery for varicose veins: results from the Comparison of LAser, Surgery and foam Sclerotherapy (CLASS) randomised controlled trial

Foam sclerotherapy (foam) and endovenous laser ablation (EVLA) have emerged as alternative treatments to surgery for patients with varicose veins, but uncertainty exists regarding their effectiveness in the medium to longer term. To assess the clinical effectiveness and cost-effectiveness of foam, EVLA and surgery for the treatment of varicose veins. A parallel-group randomised controlled trial (RCT) without blinding, and economic modelling evaluation. Eleven UK specialist vascular centres. Seven hundred and ninety-eight patients with primary varicose veins (foam, n = 292; surgery, n = 294; EVLA, n = 212). Patients were randomised between all three treatment options (eight centres) or between foam and surgery (three centres). Disease-specific [Aberdeen Varicose Vein Questionnaire (AVVQ)] and generic [European Quality of Life-5 Dimensions (EQ-5D), Short Form questionnaire-36 items (SF-36) physical and mental component scores] quality of life (QoL) at 6 months. Cost-effectiveness as cost per quality-adjusted life-year (QALY) gained. Quality of life at 6 weeks; residual varicose veins; Venous Clinical Severity Score (VCSS); complication rates; return to normal activity; truncal vein ablation rates; and costs. The results appear generalisable in that participants' baseline characteristics (apart from a lower-than-expected proportion of females) and post-treatment improvement in outcomes were comparable with those in other RCTs. The health gain achieved in the AVVQ with foam was significantly lower than with surgery at 6 months [effect size -1.74, 95% confidence interval (CI) -2.97 to -0.50; p = 0.006], but was similar to that achieved with EVLA. The health gain in SF-36 mental component score for foam was worse than that for EVLA (effect size 1.54, 95% CI 0.01 to 3.06; p = 0.048) but similar to that for surgery. There were no differences in EQ-5D or SF-36 component scores in the surgery versus foam or surgery versus EVLA comparisons at 6 months. The trial-based cost-effectiveness analysis showed that, at 6 months, foam had the highest probability of being considered cost-effective at a ceiling willingness-to-pay ratio of £20,000 per QALY. EVLA was found to cost £26,107 per QALY gained versus foam, and was less costly and generated slightly more QALYs than surgery. Markov modelling using trial costs and the limited recurrence data available suggested that, at 5 years, EVLA had the highest probability (≈ 79%) of being cost-effective at conventional thresholds, followed by foam (≈ 17%) and surgery (≈ 5%). With regard to secondary outcomes, health gains at 6 weeks (p < 0.005) were greater for EVLA than for foam (EQ-5D, p = 0.004). There were fewer procedural complications in the EVLA group (1%) than after foam (7%) and surgery (8%) (p < 0.001). Participants returned to a wide range of behaviours more quickly following foam or EVLA than following surgery (p < 0.05). There were no differences in VCSS between the three treatments. Truncal ablation rates were higher for surgery (p < 0.001) and EVLA (p < 0.001) than for foam, and were similar for surgery and EVLA. Considerations of both the 6-month clinical outcomes and the estimated 5-year cost-effectiveness suggest that EVLA should be considered as the treatment of choice for suitable patients. Five-year trial results are currently being evaluated to compare the cost-effectiveness of foam, surgery and EVLA, and to determine the recurrence rates following each treatment. This trial has highlighted the need for long-term outcome data from RCTs on QoL, recurrence rates and costs for foam sclerotherapy and other endovenous techniques compared against each other and against surgery. Current Controlled Trials ISRCTN51995477. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 27. See the NIHR Journals Library website for further project information.

Debate: should persistent incompetent truncal veins be treated immediately? The case in support of the statement.

Debate continues as to the best method of treating patients with varicose veins and which will lead to durable clinical outcomes. Many modern techniques of treating varicose veins rely on ablation of the saphenous vein alone or in combination with phlebectomy or sclerotherapy of varices. However, it has been suggested that methods which leave the saphenous trunk untreated may result in similar outcomes. A search of medical databases was made for literature which compared the outcomes of saphenous vein stripping, sclerotherapy and modern methods of vein ablation. Surgical methods which have been used range from simple phlebectomy, ligation of the saphenous trunk to stripping of the saphenous vein. Systematic comparison of striping of the saphenous vein in addition to ligation of the sapheno-femoral junction appears to improve the outcome of varicose veins surgery compared to saphenous ligation alone. The 21st century endovenous treatments for varicose veins all rely on ablating the saphenous trunk. Duplex ultrasound studies show some variation in the efficacy of saphenous ablation with these methods. However, a randomised clinical trial shows similar patient reported outcomes with all endovenous techniques and surgical stripping of the saphenous vein. A clinical series shows that after endovenous thermal ablation recurrent varices arise in residual sections of saphenous trunk, accessory veins and residual tributaries. Studies based on clinical criteria require follow-up of about six years to yield reliable data. Before this time varices may be forming but cannot be detected clinically and over-optimistic results of treatment are reported. Data from surgical and endovenous treatment studies suggest that the more extensive and effective the ablation of saphenous trunks, accessory veins and tributaries, the better the long-term outcome that is achieved.

Muller’s phlebectomy

SummaryMore than 50 years ago, the Swiss dermatologist Dr Robert Muller developed ambulatory phlebectomy, a brilliant demonstration of the major role of dermatologists in the field of phlebology. The technique is safe, reliable and cost-effective, while at the same time producing aesthetically pleasing results. Patients can usually resume normal daily activities immediately after the procedure or are off work for a few days at most. Indications for ambulatory phlebectomy include incompetent saphenous veins (except the junctions) and their tributaries, perforators, reticular veins and reticular feeder veins, large spider veins and dilated veins in other areas such as around the eyes, on the arms or on the back of the hands.The tiny skin incisions do not usually leave any scars or give rise to complications. Phlebectomy can be used alone or in combination with other procedures such as sclerotherapy, endovenous techniques and surgery.