Great Saphenous Vein Reflux Research Articles

The V-Block Occlusion Stent and Sclerotherapy Device for Varicose Vein Treatment: A Retrospective Analysis

The procedure aims to show our results with a novel nontumescent, nonthermal technique to treat varicose veins. The V-block occlusion stent is a minimally invasive device for treating reflux of the great saphenous vein (GSV). It is an office-based procedure that does not require tumescence anesthesia. The V-block stent is a self-expandable device that functions as a vein occluder and blood clot trap. Once the V-block is in place, further treatment of the saphenous vein such as ultrasound-guided sclerotherapy can be performed. The V-block device is intended to eliminate the possibility of forwarding passage of clot and sclerosant (embolization) to the deep and pulmonary circulations. Patients were treated in an outpatient setting with the V-block occluding device. Follow-up was performed using duplex ultrasound to assess occlusion of the saphenous vein as well as the Aberdeen Varicose Vein Questionnaire and Venous Severity Scoring to determine changes in quality of life after the procedure. Patients were followed up at 1week, 1month, and 3months after V-block placement. Duplex scanning was performed to confirm GSV occlusion at all follow-up visits. After deployment of the occlusion stent, a maximum of 2% polidocanol foam was injected with a double barrel syringe which simultaneously evacuated blood from the greater saphenous vein. Follow-up assessment for safety included evaluation of potential complications, device migration, and potential injury at the deployment site. Fifty-one symptomatic subjects with documented GSV reflux were enrolled in the study. Complete occlusion of the GSV was achieved in 98% of the patients during the 7-day postprocedural visit. There was no injury at the deployment site. No migration of the V-block device was observed. No deep vein thrombosis or any other complication was recorded. One patient of the 50 patients and 51 procedures experienced an adverse event, phlebitis that resolved under conservative therapy within 4days with no residual effect. There was a significant improvement in the Aberdeen Vein quality of life measurements and the pain scores. After 3years, 18 patients were willing to undergo a duplex follow-up examination. The occlusion rate after 3years was 77.8. There were no device-related complications after this period. The study demonstrated a good safety and performance profile without any major adverse events. The primary end point of vein occlusion and obliteration was met.

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).

Changes in trunk veins of the lower limbs in women with premenstrual leg heaviness and swelling.

The aim of this study was to investigate vein changes during the menstrual cycle in parous women with premenstrual leg heaviness. А total of 39 women with heavy legs before menstruation were examined. Great saphenous vein (GSV) in the groin, femoral vein (FV) and popliteal vein (PV) were examined with ultrasound scanning before 10 a.m. and after 6 p.m. on days 1 to 4 (menstrual phase) and 25 to 28 (secretory phase). To characterize biophysical features of veins we used: 1) interphase gradient of the diameter (IGd), i.e. the difference in vein diameters during the secretory and menstrual phases; 2) orthostatic gradient of the diameter (OGd), i.e. the difference in vein diameters measured in the evening and in the morning. Diameter changings for GSV, FV and PV were similar. GSV diameter increased from the morning during the menstrual phase to the evening during the secretory phase on average by 26.2%. OGd was 0.73 mm (95% CI: 0.59-0.87) during the menstrual phase and 0.62 mm (95% CI: 0.54-0.71) during the secretory phase. IGd was 0.73 mm (95% CI: 0.61-0.86) already in the morning. During the secretory phase 43.6% patients had the GSV reflux. During the whole menstrual cycle GSV diameter in the reflux zone increased on average by 40.6%. IGd of GSV in this zone reached 1.25 mm (95% CI: 1.02-1.48) in the morning and 1.30 mm (95% CI: 1.25-1.35) in the evening. Women with premenstrual leg heaviness have a minimal vein diameter in the morning during the secretory phase. The maximal diameter is revealed in the evening during the secretory phase. Clinically manifested expansion of veins, including GSV refluxes, is found during the secretory phase due to increased expansibility of veins. However, because of increased creeping ability one observes expansion of veins during the whole menstrual cycle in these women.

Endovenous Laser Ablation with 1,470-nm Diode with Tumescence Anesthesia and Saphenofemoral Ligation: Propensity Score Match Comparison

The aim of this study is to compare 2 groups of patients treated for great saphenous vein (GSV) reflux with open surgical saphenofemoral ligation (SFL) and endovenous laser ablation (EVLA). Consecutive patients with primary unilateral GSV reflux undergoing EVLA treatment since 2014 were enrolled, and another series of patients treated with SFL was considered. The patients were stratified according to treatment and the results were compared using the propensity score (1:1). The covariables were age, gender, body mass index, CEAP (Clinical class, Etiology,Anatomy and Pathophysiology) staging, and GSV and saphenofemoral junction diameters. Primary outcomes were GSV occlusion or recurrent groin varicose veins at 1 year after treatment. Secondary outcomes included vein thrombosis, hyperpigmentation, paresthesia, postoperative pain, analgesic requirement, and ecchymosis assessed at discharge and CEAP stage and quality of life (QoL) assessment 1 month after surgery. A total of 123 patients were included in the study: 59 were treated with EVLA and 64 with SFL. At 12months, we observed 10 recurrent groin varicose veins after SFL (15.6%) and 6 GSV recanalization after EVLA (10.2%, P=0.369). Extra-saphenous recurrent varicose veins were observed in 36 patients (29.3%): 20 in the open group (31.2%) and 16 in EVLA group (27.1%, P=0.615). After matching procedure 74 patients were analyzed (37 patients by group), logistic regression model showed that the risk of outcome was not associated with the surgical treatment (odds ratio 1.76, 95% confidence interval 0.52-6.01). Both techniques to treat saphenous impairment have demonstrated to be safe, with good results in terms of efficacy and symptomatic improvement at follow-up. EVLA with 1,470nm seems to have lower rates of recurrence and good perceived QoL. Tumescent anesthesia is a good option with good results and may be extended to open surgical ligation.

Reference Data from the Vascular Laboratory and Application to Chronic Venous Disease Treatment

Several population studies have described the incidence and prevalence of chronic venous disease (CVD). This prospective study was designed to determine in detail the distribution of reflux and obstruction in all lower limb veins to provide reference data for the management of CVD patients. Consecutive patients presenting to a university vascular clinic and undergoing a duplex ultrasound examination were included in the study. Patients with C2 CVD class or higher regardless of symptoms or cosmetic concerns were evaluated. Every patient received a detailed history and physical examination by a vascular surgeon including all demographic information. All patients then had a bilateral lower extremity venous ultrasound examination for reflux and obstruction. The examination was performed in the standing position with the exception of iliac veins and inferior vena cava, which were assessed in the supine position. Location and extent of reflux, vein diameters, and presence of obstruction were recorded. Obstruction was characterized as partial or complete for each venous segment. History of objectively documented venous thrombosis and findings on ultrasound examination indicating previous thrombosis were noted. There were 491 patients who presented for evaluation. Excluded were 241 patients, of whom 49 had undergone previous treatment and 192 had only C0 or C1 disease bilaterally. The remaining 250 patients were 32.8% male and 67.2% female. The mean body mass index was 28.3 kg/m2 (range, 19.2-44 kg/m2); 55.2% identified as white, 11.2% as black/African American, 23.6% as Hispanic/Latino/Spanish origin, and 0.8% as American Indian/Alaska Native. Asymptomatic patients accounted for 17% of the cohort and symptomatic patients for 83%. Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) class was distributed as 43% C2, 28.8% C3, 15.2% C4, 7.6% C5, and 4.8% C6. In the superficial veins, 70.4% of patients had only unilateral disease; 29.6% had bilateral disease. Axial reflux was found in one vein 53.2% of the time; two veins, 27.6%; three veins, 4.8%; four veins, 4%; five veins, 0.8%; and six veins, 0.4%. Calculation of potential ablations was performed, excluding superficial reflux in 2.6% of limbs with small diameter, 5.6% with segmental reflux, 4.4% with tributary reflux, and 6.0% with nonsaphenous reflux that would receive adjunct procedures including microphlebectomy or ultrasound-guided foam sclerotherapy. These adjunct procedures would account for 18.6% of therapy, whereas 64.0% would be ablative therapy. Past deep venous thrombosis was found in 7.2%; 2.8% had concurrent superficial and deep venous thrombosis. From these data, we can assume that the average patient presenting with venous complaints would have symptomatic disease with great saphenous vein reflux and would require one or two ablations based on the prevalence of saphenous reflux in the population. Patients who had at least one saphenous vein with reflux would have an average of 1.6 ablations/patient.

Clinical Effectiveness of Mechanochemical Ablation Versus Radiofrequency Ablation for Symptomatic Great or Small Saphenous Vein Reflux

Mechanochemical ablation (MOCA) is a nonthermal technology approved by the Food and Drug Administration for the delivery of sclerosing agents to treat symptomatic saphenous vein reflux. Although the technology is considered durable, its effectiveness compared with radiofrequency ablation (RFA) in the great saphenous vein (GSV) and small saphenous vein (SSV) is ill defined. Data were prospectively collected in the Center for Vein Restoration’s electronic medical record system (NexGen Healthcare Information System, Irvine, Calif) and retrospectively analyzed. Patients were divided into the following treatment categories and stratified by Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) class: MOCA GSV, MOCA SSV, RFA GSV, and RFA SSV. The revised Venous Clinical Severity Score (rVCSS) was used to determine chronic venous disease treatment effectiveness in patients who underwent RFA and MOCA only in the GSV or SSV distributions. Patients with multiple treatment modalities were excluded from the analysis. In addition, the 20-item Chronic Venous Insufficiency Questionnaire (CIVIQ-20) was used to assess quality of life before and after intervention at 1 month. All statistical analyses were performed using GraphPad Prism 7 (GraphPad Software Inc, La Jolla, Calif). Treatment outcomes were assessed using unpaired t-tests and two-way analysis of variance. From January 2015 to December 2017, there were 21,383 patients (34,014 limbs) who underwent thermal or MOCA procedures for chronic venous disease. The average age of the cohort was 57.1 ± 14.04 years, and 73% were female. Patients/limbs were divided into the following groups: MOCA GSV (342/545), MOCA SSV (41/62), RFA GSV (15,069/25,153), and RFA SSV (1450/2087). Preintervention and postintervention rVCSS and CIVIQ-20 data were analyzed at 1 month. All postintervention rVCSS outcomes for RFA in the GSV or SSV demonstrated significant improvement compared with preintervention scores regardless of CEAP class (P ≤ .001). Patients treated with MOCA demonstrated improvement in all CEAP classes accept for C5 MOCA GSV patients and C6 MOCA SSV patients (P ≤ .001). CIVIQ-20 scores at 1 month were similar regardless of treatment modality or treatment outcome. CIVIQ-20 scores ranged from 50 before intervention to 35 after intervention at 1 month. MOCA appears to be as effective as RFA in the GSV across CEAP classes. By rVCSS, MOCA may not be as effective as RFA in patients with C5 and C6 disease in the GSV and SSV distribution, respectively. However, patient-reported outcomes between treatment modalities are similar. MOCA in the SSV appears safe. Further assessment and long-term data are required.

Two-year follow-up of a n-butyl-2-cyanoacrylate glue ablation for the treatment of saphenous vein insufficiency with a novel application catheter with guiding light.

Objectives This study aims to present the early results of a prospective study of the use of novel n-butyl-2 cyanoacrylate (VenaBlock)-based nontumescent endovenous ablation with a guiding light for the treatment of patients with varicose veins. Methods Five hundred and seventy-three patients with lower-limb venous insufficiency were treated within in the previous four years. The study enrolled adults aged 21–70 years with symptomatic moderate to severe varicosities (C2–C6 patients clinical, etiological, anatomical, and pathophysiological classification) and great saphenous vein reflux lasting longer than 0.5 s with great saphenous vein diameter ≥ 5.5 mm assessed in the standing position. Duplex ultrasound imaging and clinical follow-up were performed on the third day, first month, and sixth month. Clinical, etiological, anatomical, pathophysiological classification; venous clinical severity score; and completed Aberdeen varicose vein questionnaire were recorded. Results Five hundred and seventy-three patients aged 21–70 years with lower-extremity venous insufficiency treated with n-butyl-2. The mean treatment length was 30.6 ± 5.3 cm and the average n-butyl-2 delivered was 1.2 ± 0.3 ml. The mean procedure time was 10.8 ± 4.7 min. There was no deep venous thrombosis, pulmonary embolism, or paresthesia. We observed ecchymosis in eight patients (1.4%) at the entry site at the third day follow-up. Phlebitis was encountered with 10 (1.8%) patients. No skin pigmentation, hematoma, paresthesia, deep-vein thrombosis, or pulmonary embolism was observed. Procedural success was 100%, and complete occlusion was observed after treatment, at the third day follow-up and at first month. Kaplan–Meier analysis yielded with overall clinical recurrence-free rate after a mean follow-up of 23.96 months was 99.38%. All patients had significant improvement in venous clinical severity score and quality-of-life scores postoperatively ( p < 0.0001). Venous clinical severity score scores at preintervention and 24th month were 5.8 ± 1.0 (range 4–8) and 0.6 ± 0.6 (range 0–4), respectively ( p < 0.0001). Aberdeen varicose vein questionnaire scores at preintervention and 24th month were 19.7 ± 6.4 (range 9–30) and 4.4 ± 1.1 (range 1–9), respectively ( p < 0.0001). Conclusions The procedure appears to be feasible, safe, and efficient in treating the great majority of incompetent great saphenous veins with this technique.

Factors related to the size of venous leg ulcers

Venous leg ulcers (VLUs) are an important health problem, and the size of ulcers often affects patient care, healing time, and quality of life. However, the risk factors associated with ulcer size have been rarely reported. The aim of this study was to establish the risk factors for the size of venous ulceration by analyzing the patient demographics and the results of duplex ultrasonography.This study was an in-patient population-based cross-sectional study conducted at a single center during the period from 2013 to 2017. Men and women aged >18 years, who consecutively presented to our hospital with VLU, were included. According to the size of the ulcer, patients were divided into two groups, those with ulcers≤2 cm and those with ulcers >2 cm. Demographic, anthropometric, and clinical data were collected. For the analysis, univariate and multivariate logistic regressions were used.A total of 232 patients with VLUs were admitted to our hospital from 2013 to 2017, including 117 patients (50.4%) with ulcer diameters ≤2 cm and 115 patients (49.6%) with ulcer diameters >2 cm. According to the results of the multivariate analysis, the ulcer duration (P = .001), the diameter of perforating veins (PVs) around the ulcers (P = .025), the reflux time of common femoral veins (CFVs) (P = .013), the reflux time of great saphenous veins (GSVs) (P = .021), and the reflux time of PVs around the ulcers (P = .001) were independent risk factors for VLUs.These findings provide evidence that the size of VLU was significantly related to the ulcer duration, the diameter of PV around the ulcers, the CFV reflux time, the GSV reflux time, and the PV reflux time.

Chemokines and Growth Factors Produced by Lymphocytes in the Incompetent Great Saphenous Vein.

The role of cytokines in the pathogenesis of chronic venous disease (CVD) remains obscure. It has been postulated that oscillatory flow present in incompetent veins causes proinflammatory changes. Our earlier study confirmed this hypothesis. This study is aimed at assessing chemokines and growth factors (GFs) released by lymphocytes in patients with great saphenous vein (GSV) incompetence. In 34 patients exhibiting reflux in GSV, blood was derived from the cubital vein and from the incompetent saphenofemoral junction. In 12 healthy controls, blood was derived from the cubital vein. Lymphocyte culture with and without stimulation by phytohemagglutinin (PHA) was performed. Eotaxin, interleukin 8 (IL-8), macrophage inflammatory protein 1 A and 1B (MIP-1A and MIP-1B), interferon gamma-induced protein (IP-10), monocyte chemoattractant protein-1 (MCP-1), interleukin 5 (IL-5), fibroblast growth factor (FGF), granulocyte colony-stimulating factor (G-CSF), granulocyte-macrophage colony-stimulating factor (GM-CSF), platelet-derived growth factor-BB (PDGF-BB), and vascular endothelial growth factor (VEGF) were assessed in culture supernatants by a Bio-Plex assay. Higher concentrations of eotaxin and G-CSF were revealed in the incompetent GSV, compared with the concentrations in the patients' upper limbs. The concentrations of MIP-1A and MIP-1B were higher in the CVD group while the concentration of VEGF was lower. In the stimulated cultures, the concentration of G-CSF proved higher in the incompetent GSV, as compared with the patients' upper limbs. Between the groups, the concentration of eotaxin was higher in the CVD group, while the IL-5 and MCP-1 concentrations were lower. IL-8, IP-10, FGF, GM-CSF, and PDGF-BB did not reveal any significant differences in concentrations between the samples. These observations suggest that the concentrations of chemokines and GFs are different in the blood of CVD patients. The oscillatory flow present in incompetent veins may play a role in these changes. However, the role of cytokines in CVD requires further study.

Endovenous ablation and surgery in great saphenous vein reflux: a systematic review and network meta-analysis of randomised controlled trials protocol

IntroductionEndovenous ablations are the new standard procedures for treatment of great saphenous vein reflux including endovenous laser ablation (EVLA), radio frequency ablation (RFA), endovenous steam ablation (EVSA), mechanochemical ablation (MOCA),...

Great saphenous vein reflux treatment in patients with femoral valve incompetence, the Excluded Saphenous Vein Technique (ESVT): a pilot study.

To describe and evaluate feasibility and efficacy of a saphenous ablation technique performed in patients with varicose veins (VVs), great saphenous vein (GSV) incompetence, and proximal femoral valve incompetence: the Excluded Saphenous Vein Technique (ESVT). Patients with primary great saphenous and proximal femoral valve incompetence underwent ESVT. This technique is composed of selective crossectomy, GSV ligation next to the thigh incompetent tributary vein, and saphenous vein sclerosing performed from the proximal zone. Demographic, clinical and instrumental data were collected. CEAP classification was used to describe VVs severity. The primary outcome was perioperative complications. Secondary outcomes were 30-days, 6-months and 1-years GSV occlusion rate, and VVs recurrence rate. During a ten months period, 104 patients were analyzed. Among these, 82 patients underwent ESVT (59 female, age 50 ± 21 years), eighty C2 and two C5, according to CEAP classification. The average length of GSV treated was 23 ± 9 cm. No intraoperative complications occurred. A 1-year follow-up analysis revealed no partial or complete saphenous recanalization, deep venous thrombosis, pulmonary embolism. No VVs recurrence was detected during the follow-up period among the entire population. ESVT seems to be a safe and effective treatment for primary saphenous reflux and proximal femoral valve incompetence. Further studies are needed to assess long-term results.

LEV 2. Preliminary First in Human Ultrasound-Guided High-Intensity Focused Ultrasound Treatment in Superficial Lower Limb Veins

High-intensity focused ultrasound (HIFU) is an alternative to surgery or other thermal methods widely used in the treatment of thyroid, breast fibroadenoma, and uterine fibroma. HIFU generated by the Echopulse (Theraclion, Malakoff, France) device penetrates through tissues and causes localized hyperthermia responsible for irreversible protein denaturation and vein wall coagulation, whereas overlying and surrounding tissues are spared by focusing a beam into a given target. A focused transducer (3 MHz frequency) generates the ultrasound field. An imaging array of 7.5 MHz is centrally integrated to allow perfect alignment between the real-time imaging and the focal point. A first in human prospective study is ongoing, and patients were observed up to 3 months. We have several examples of positive results that are currently available. Most of the cases were performed without anesthesia and were well tolerated, and no severe adverse events were observed. A female patient presenting with recurrence after great saphenous vein (GSV) stripping received 12 pulses with a mean power of 45 W. No anesthesia was performed. The treated area was occluded acutely, and this result persisted at 3 months. A female patient presenting with a refluxing stump and neovascularization after GSV stripping as well as an active ulcer was treated at the groin level, over the stump and area of the neovessels. Ten pulses were delivered with a mean power of 42.9 W. No anesthesia was performed. The recurrent flow was abolished, and the ulcer was healed at 3 months. A male patient presenting with a refluxing calf perforator was treated after unsuccessful surgery and sclerotherapy. Nine pulses were delivered at a mean power of 45 W. No anesthesia was performed. The perforator was occluded acutely, and this result persisted at 3 months. A male patient presenting with a refluxing GSV and active ulcer was treated after surgery. Thirty-nine pulses were delivered with a mean power of 38 W. Tumescent anesthesia was performed. The vein was occluded acutely, and this result persisted at 3 months. The ulcer was healed at 3 months. In this first study using HIFU, the preliminary results are encouraging and show that HIFU could become a credible alternative method. In future studies, more cases and longer follow-up will be needed.

LEV 3. Outcomes of Ultrasound-Guided Catheter-Directed Foam Sclerotherapy With or Without Perivenous Tumescent Enhancement in the Treatment of Great Saphenous Vein Reflux

LEV 3. Outcomes of Ultrasound-Guided Catheter-Directed Foam Sclerotherapy With or Without Perivenous Tumescent Enhancement in the Treatment of Great Saphenous Vein Reflux

Great Saphenous Vein Diameters in Phlebological Practice in France: A Report of the DIAGRAVES Study by the French Society of Phlebology

The aim was to evaluate the distribution of the diameter of the great saphenous vein (GSV) at mid-thigh level and to investigate its association with clinical class, symptoms, and proximal extent of reflux. Vascular physicians, members of the French Society of Phlebology, were invited to participate in a consecutive observational study in patients presenting with symptoms and/or signs of uni- or bilateral chronic venous disorders (CVDs) in previously untreated limbs (clinical class of the CEAP classification C0s - C6). Patients were included between January and March 2015. They completed a specially designed venous symptoms questionnaire. Duplex ultrasound of the included limbs was performed with the patient standing to detect reflux in the GSV and to measure the GSV inner diameter at mid-thigh. Between January and March 2015, 35 physicians examined 1245 patients (2450 limbs after excluding 40 limbs): 77% were female, mean age 52±14; 69% of the patients had venous symptoms in one or both legs. The most frequent symptoms were feeling of heaviness, feeling of swelling and aching. Predominant CEAP clinical classes were C2 (38% of limbs) and C1 (35%). In case of GSV reflux (40% of limbs), the average diameter was 5.6±2mm and the distribution was 62%<6mm, 30% between 6 and 8mm, and 8%>8mm. The study showed a clear association between clinical class and GSV diameter (the higher the clinical class, the larger the diameter; p<.0001), between venous symptoms and diameter (the larger the diameter, the higher the intensity of symptoms, p<.0001 for overall discomfort) and between proximal extent of reflux and diameter (the more proximal the extent of reflux, the larger the diameter, p<.0001). The DIAGRAVES study demonstrated that in France for patients consulting with CVDs, more than half of the incompetent GSVs had a diameter<6mm, while large diameters were relatively infrequent. This should be kept in mind when considering management strategies in patients with CVDs.

The Endovenous Laser Therapy for the Management of Varicose Veins

Introduction: Varicose veins of the lower limb are common condition affecting majority of people worldwide and has great effect on quality of life. The definitive therapy being surgery with stripping of the veins which is associated with surgical complications, prolong recovery time and significant recurrence. Endovenous laser therapy (EVLT) is a minimally invasive procedure which is widely used for the treatment of varicose veins with excellent results.Objective: To evaluate the safety and efficacy of EVLT for the management of varicose veins.Methodology: This was a prospective study of 40 patients who underwent endovenous laser therapy at the affiliated hospital of Inner Mongolia University for the Nationalities from October 2016 to September 2017. All patients with primary symptomatic varicose veins with sapheno-femoral incompetence or great saphenous vein (GSV) reflux were included in the study. The patient's information and data were recorded during the hospital stay in the proforma for EVLT with the informed consent. The variables used were mean operating time, intra-operative blood loss, duration of hospital stay, return to normal activity, complications and the recanalization. Following discharge, the patients were followed up to six months.Results: Forty patients with unilateral varicose veins were treated with EVLT. There were 24 female and 16 male with mean age of 52 yrs and the majority of patients having symptoms for more than five years. The mean operative time and intra-operative blood loss were 80 minutes and 52 ml respectively. The mean duration of hospital stay was 2.5 days with 90% patients returning to the normal activity in 10 days. Swelling and indurations were the most common complication in 10 patients followed by hypoesthesia in 8, ecchymosis in 7 and skin burn in 4 patients.Conclusion: EVLT seems to be safe and effective minimally invasive procedure with excellent clinical outcome in terms of lower postoperative pain, early return to normal activities and fewer complications. However large sample size with long follow up study should be conducted for evaluating long term benefits. BJHS 2018;3(2)6:437-442.

Experience of Using Shear Wave Elastography Imaging in Superficial Venous Insufficiency of the Lower Extremity.

We investigated the effectiveness of shear wave elastography (SWE) in patients with lower extremity superficial venous insufficiency (VI). A total of 138 symptomatic patients, 51 asymptomatic volunteers, and a total of 359 lower extremities (257 symptomatic, 102 asymptomatic) were examined. All participants underwent Doppler ultrasound (US) evaluation to determine VI and SWE measurements performed by manually drawing vein wall and perivenous tissue with free region of interest at the great saphenous vein (GSV) and small saphenous vein (SSV). The GSV, SSV diameter, VI, and volume flow of reflux were compared with the SWE values. The SWE values of the symptomatic group for GSV and SSV were significantly higher than those of the asymptomatic control group regardless of whether VI was detected by Doppler US (P < 0.001). There was a statistically significant increase in SWE values for the symptomatic group who were diagnosed as having reflux in GSV and SSV (P < 0.001). A significant positive correlation between increased GSV, SSV diameter, and SWE values was seen (P < 0.001). Venous insufficiency can be diagnosed with a 84.7% sensitivity and 84.2% specificity when 2655 m/s was designated as cutoff value, and with a 85.4% sensitivity and 84.2% specificity when 22,350 kPa was designated as the cutoff value in GSV. Venous insufficiency can be diagnosed with a 84.3% sensitivity and 82.4% specificity when 2845 m/s was designated as cutoff value, and with a 85.7% sensitivity and 84.4% specificity when 27,100 kPa was designated as the cutoff value in SSV. Shear wave elastography may be used effectively in addition to conventional Doppler US examination in diagnosing and following VI.

Cytokines Produced by Lymphocytes in the Incompetent Great Saphenous Vein.

The pathogenesis of chronic venous disease (CVD) remains unclear, but lately inflammation is suggested to have an important role in its development. This study is aimed at assessing cytokines released by lymphocytes in patients with great saphenous vein (GSV) incompetence. In 34 patients exhibiting oscillatory flow (reflux) in GSV, blood was derived from the cubital vein and from the incompetent sapheno-femoral junction. In 12 healthy controls, blood was derived from the cubital vein. Lymphocyte culture with and without stimulation by phytohemagglutinin (PHA) was performed. Interleukins (IL) 1β, 2, 4, 10, 12 (p70), and 17A; interleukin 1 receptor α (IL-1ra); tumor necrosis factor-α (TNF-α); interferon-gamma (IFN-γ); and RANTES were assessed in culture supernatants by the Bio-Plex assay. In both stimulated and unstimulated samples, in the examined group, IL-1β and IFN-γ had higher concentrations and RANTES had lower concentrations when compared to those in the control group. In the examined group, IL-4 and IL-17A had higher concentrations without stimulation and TNF-α had higher concentrations with stimulation. The GSV samples had higher IL-2, IL-4, IL-12 (p70), and IFN-γ concentrations without stimulation and lower IL-2 and TNF-α concentrations with stimulation when compared to those of the upper limb in the examined group. These observations indicate that the oscillatory flow present in incompetent veins causes changes in the cytokine production by lymphocytes, promoting a proinflammatory profile. However, the relations between immunological cells, cytokines, and the endothelium require more insight.

Five-year follow-up of a randomized clinical trial comparing open surgery, foam sclerotherapy and endovenous laser ablation for great saphenous varicose veins

New treatment methods have challenged open surgery as a treatment for great saphenous vein (GSV) insufficiency, the most common being ultrasound-guided foam sclerotherapy (UGFS) and endovenous laser ablation (EVLA). This study evaluated the long-term results of surgery, EVLA and UGFS in the treatment of GSV reflux. Patients with symptomatic GSV reflux were randomized to undergo either open surgery, EVLA or UGFS. The main outcome measure was the occlusion rate of the GSV at 5 years after operation. The study included 196 patients treated during 2008-2010; of these, 166 (84·7 per cent) participated in the 5-year follow-up. At 5 years, the GSV occlusion rate was 96 (95 per cent c.i. 91 to 100) per cent in the open surgery group, 89 (82 to 98) per cent after EVLA and 51 (38 to 64) per cent after UGFS (P < 0·001). For patients who had received no additional treatment during follow-up, the occlusion rates were 96 per cent (46 of 48), 89 per cent (51 of 57) and 41 per cent (16 of 39) respectively. UGFS without further GSV treatment was successful in only 16 of 59 patients (27 per cent) at 5 years. UGFS has significantly inferior occlusion rates compared with open surgery or EVLA, and results in additional treatments.

A retrospective study of a new n-butyl-2-cyanoacrylate glue ablation catheter incorporated with application guiding light for the treatment of venous insufficiency: Twelve-month results.

Objective This study aims to present the early results of a retrospective study of the use of novel n-butyl-2-cyanoacrylate (VenaBlock)-based nontumescent endovenous ablation with a guiding light for the treatment of patients with varicose veins. Methods Patients with lower limb venous insufficiency were treated with n-butyl-2-cyanoacrylate (VenaBlock Venous Closure System) between April 2016 and July 2016. The study enrolled adults aged 21-70 years with symptomatic moderate to severe varicosities (C2-C4b) and great saphenous vein reflux lasting longer than 0.5s with great saphenous vein diameter between 5.5 and 15 mm assessed in the standing position. No compression stockings were used after the procedure. Duplex ultrasound imaging and clinical follow-up were performed on the third day, first month, sixth month, and 12th month. Clinical, etiological, anatomical, pathophysiological classification; venous clinical severity score; and completed Aberdeen varicose vein questionnaire were recorded. Results Five hundred thirty-eight patients with great saphenous vein incompetency underwent n-butyl-2-cyanoacrylate ablation. The mean ablation length was 25.69 ± 4.8cm, and the average amount of n-butyl-2-cyanoacrylate delivered was 0.87 ± 0.15ml. The mean procedure time was 11.7 ± 4.9min. Procedural success was 100%, and complete occlusion was observed after treatment and at the third-day follow-up. We observed ecchymosis in five patients (1.00%) at the entry site at the third-day follow-up. Phlebitis was encountered with six (1.20%) patients. No skin pigmentation, hematoma, paresthesia, deep vein thrombosis, or pulmonary embolism was observed. Kaplan-Meier analysis yielded an occlusion rate of 99.4% at the 12-month follow-up. All patients had significant improvement in venous clinical severity score and Aberdeen varicose vein questionnaire scores postoperatively ( p <0.0001). Venous clinical severity score scores decreased from 5.43 ± 0.87 to 0.6 ± 0.75. Aberdeen varicose vein questionnaire scores decreased from 18.32 ± 5.24 to 4.61 ± 1.42. Conclusions The procedure appears to be feasible, safe, and efficient in treating the great majority of incompetent great saphenous veins with this technique.

Venous ultrasonography findings and clinical correlations in 104 Thai patients with chronic venous insufficiency of the legs

The pattern of venous reflux in Thai patients with chronic venous insufficiency (CVI) was studied in correlation with clinical manifestations. Ultrasonography findings and clinical data were prospectively collected and retrospectively reviewed. CVI was found in 104 legs of 79 patients (mean age 59.8 ± 12.5 years; C4: 24.1%, C5: 8.9%, C6: 67.1%). 6.7% of the legs had a history of deep vein thrombosis (DVT). The prevalence of superficial vein reflux (SVR), deep vein reflux (DVR), and combined SVR and DVR in 90 legs without previous venous surgery was 82.2%, 63.3% and 57.8%, respectively. In legs with SVR, the prevalence of great saphenous vein reflux (GSVR), small saphenous vein reflux (SSVR), and combined GSVR and SSVR was 91.9%, 33.8% and 25.7%, respectively. 77.0% of SVR involved the calf segment. For medial ulceration, 79.6% had GSVR and 35.2% had SSVR. For lateral ulceration, 46.7% had SSVR and 33.3% had isolated GSVR. Pulsatile venous signal was found in 3.3% of legs. In 17 legs with ulceration after previous surgical treatment, calf vein reflux (residual calf great saphenous vein or small saphenous vein) was found in 13 (76.5%) legs. Calf vein reflux plays an important role in CVI and in patients with recurrent ulceration after previous superficial venous surgery. Although GSVR was present in most patients with CVI in the legs, SSVR may present in one-third of patients, especially those with lateral ulceration. The high prevalence of DVR in the absence of DVT and the presence of a pulsatile venous signal in some patients highlight the incomplete understanding of CVI aetiology.