GSV Diameter Research Articles

Comparison of Radiofrequency Ablation and Cyanoacrylate Closure for Large-Diameter Great Saphenous Vein Insufficiency

ObjectiveTo compare radiofrequency ablation (RFA) and cyanoacrylate closure (CAC) for large-diameter great saphenous vein insufficiency (GSV) between diameters of 12 and 16 mm. Material-MethodsThis study is a single-centre retrospective study. Subjects who underwent endovenous treatment with RFA (Group A) or CAC (Group B) for GSV insufficiency between June 2015 and June 2021 who were followed up for at least 2 years were included in the study. Subjects who had a 12 to 16 mm target vessel diameter and subjects with grade 3 and grade 4 reflux were included. Subjects’ demographic data (age, sex), body mass indices (BMI), clinical, aetiological, anatomic, pathophysiologic (CEAP) classification, GSV diameter, reflux grade, target vessel length, preoperative venous clinical severity score (VCSS), procedural time, postoperative 1st-day pain scores, postoperative 14th-day patient satisfaction scale and postoperative complications were noted. In follow-up, subjects were evaluated with duplex ultrasonography and VCSS at 1, 6, 12 and 24 months. ResultsIn total, 142 subjects were included (n=71 for both groups). The mean GSV diameter was 13,21±1,00 for Group A and 13,51±0,97 for Group B. The groups did not differ in terms of age, sex, BMI, CEAP classification, GSV diameter, reflux grade, target GSV length, preoperative VCSS, complications, postoperative 24-hour pain status or postoperative 14-day patient satisfaction scale (p>0.05 for all comparisons). The procedure time was significantly shorter in Group B (34,68±4,22 min for Group A vs. 22,59±4,5 min for Group B, p=0,001). In the 1-month and 6-month Duplex ultrasonography of the subjects, partial closure and patency rates in Group B were significantly higher than those in Group A (p=0.003 and p=0.025, respectively). At the 12- and 24-month evaluation, closure rates did not show a statistically significant difference between the groups (p=0.056 and p=0.090, respectively). Preoperative and 1-month VCSS measurements did not show a statistically significant difference between groups (p>0.05 for all comparisons). The 6- and 12-month 24-month VCSS measurements of Group A were significantly higher than those in Group B. (p=0.043, p=0.009 and p=0.002, respectively). ConclusionBoth RFA and CAC were found to be effective in the treatment of large-diameter GSV incompetency. The complication rates were similar between the two techniques. CAC had a shorter procedure time. Although the closure rates in the early postoperative period were better in the RFA group, long-term follow-up demonstrated similar patency rates. The functional results in the long-term follow-up were better in the RFA group.

Modification of protocol with one extra drop of endovascular cyanoacrylate improved closure rates in incompetent great saphenous veins.

Great saphenous vein diameter (GSV) of >8mm was predictor of recanalization following Venaseal cyanoacrylate treatment. The aim of this study was to report our modified protocol with a single extra-drop for treatment for GSV>8mm, and comparative duplex results in closure rates. Patients in our single-centre registry treated with Venaseal were followed up by serial duplex examinations at week 1 and month(s)- 1, 6, 12, 18, 24, and then annually. The primary endpoint was successful obliteration of the GSV, secondary endpoints were closure distance from Saphenofemoral junction (SFJ), presence of endovenous glue-induced thrombosis (EGIT) or deep vein thrombosis. A total of 243 legs in 123 consecutive patients with duplex-proven SFJ/GSV incompetence were included in this study between September 2014 and October 2020. The median duplex follow-up period of this cohort of patients was 24 (range 0.2-58) months. Comparing closure rates in GSV diameter ≥8mm treated with normal protocol, the 'extra-drop protocol' significantly improved closure rates (p = .034). However, the closure rates of ≥8mm GSV treated with 'extra-drop protocol' was still not as good as GSV <8mm (p < .001). There were no statistically significant differences in the stump distance between the three groups and no difference in the occurrence of EGIT. There were no deep vein thrombosis. Our experience showed that VenaSeal cyanoacrylate worked best in GSV<8mm diameter. Even in GSV diameter of ≥8mm which has a higher recanalization rate on follow-up duplex, our modified extra-drop protocol significantly improved the closure rates, and did not predispose to development of EGIT.

Efficiency of the endovenous cyanoacrylate for the treatment of varicose veins using the VenablockTM system: a 24 months follow-up study of 116 patients

Objectives: Dilation of superficial veins and valvular insufficiency cause the common condition, varicose veins (VVs) on the lower extremities. The treatment modalities for VVS include endovascular thermal ablation techniques using laser, steam and radiofrequency, surgery, foam sclerotherapy, which has various adverse effects. N-butyl cyanoacrylate (NBCA) is a relatively novel polymerizating agent that is used for the treatment of VVs. The aim of this study is to evaluate and present the 24 months outcomes results of endovenous NBCA treatment in 116 patients with VV. Methods: This is a prospective study on 116 patients (71 females, 45 males), treated in a single-center between August 2017 and March 2019. NBCA administration (Venablock®, Invamed, Turkey) was carried out with local anesthesia under ultrasound guidance. All patients were scheduled for follow-up evaluation at 2 weeks, 3, 6, 9, 12, and 24 months. Clinical assessment, VCSS, and ultrasound were performed on patients in the follow-up visits.Results: The mean follow-up period was 16.27 ± 5.62 months. The preoperative and postoperative VCSS values were 6.93 ± 2.60 and 2.40 ± 1.12, respectively (p &amp;lt; 0.0001). The patients with a greater GSV diameter experienced an unfavorable outcome following the NBCA procedure (p &amp;lt; 0.001). The overall complication rate was 12.9%. The complete occlusion was achieved in 101 (87.0%) patients.Conclusions: The NBCA administration is a safe treatment method for the VVs, and provides a satisfactory occlusion ratio with improved outcomes.

Thrombus Extension after Great Saphenous Vein Mechanochemical Ablation

BackgroundThe objective of this study is to examine factors associated with thrombus extension after early experience with mechanochemical ablation, which combines mechanical damage to the venous endothelium with infusion of a sclerosant. MethodsA retrospective review was performed of patients who underwent mechanochemical ablation to treat saphenous vein insufficiency in the thigh including the saphenofemoral junction. Data abstracted included patient demographics, procedural details, and postprocedural outcomes. Thrombus extension was determined by postprocedural duplex ultrasound and classified as flush closure with the femoral vein and any extension of thrombus into the femoral vein. ResultsSeventy-three patients met inclusion criteria. The mean age of the population was 60, 17.8% were female, and the mean body mass index (BMI) was 30.7. Seven (9.6%) patients who underwent mechanochemical ablation experienced saphenous vein closure flush with the femoral vein. Eleven (15%) patients experience extension of thrombus to less than 50% of the diameter of the femoral vein and one patient experienced complete thrombosis of the femoral vein. There was no significant difference in age, sex, or comprehensive classification system for chronic venous disorders between the group with thrombus extension and the group without, with the exception of BMI. The mean BMI in the group with thrombus extension was 26.8 vs. 32 in the group without (P = 0.02). There was no significant difference between the 2 groups in sclerosant volume used, distance between catheter tip and SFJ, and mean diameter of GSV in the thigh. ConclusionsIn this cohort, the incidence of thrombus extension into the femoral vein with mechanochemical ablation was high relative to rates of thrombus extension associated with reported rates of thermal ablation. Further investigation with larger cohorts, and standardized reporting is required to characterize the true rate of thrombus extension after mechanochemical ablation and identify maneuvers which may prevent thrombus extension.

Pre-operative predictors of lower extremity swelling following total knee arthroplasty in patients with venous insufficiency and osteoarthritis.

Post-operative swelling and oedema following total knee arthroplasty (TKA) are one of the most important causes of dissatisfaction. We aimed to assess the clinical variables associated with post-operative swelling and edema after TKA and to compare their performance in respect of predicting them pre-operatively. The study cohort comprised 116 patients who underwent TKA between January 2018 and May 2019 in our centre. The diameters and the grade of venous insufficiency (VI) in the lower extremity veins were measured with duplex ultrasonography preoperatively and at one and three months post-operatively. The study cohort was divided into the patients with leg swelling positive with a difference in leg circumference of > 2cm (n = 56, 48.2%) and leg swelling negative with a difference of ≤ 2cm (n = 60, 51.7%) fromthe pre-operative leg diameter. Independent predictors for lower extremity swelling were pre-operative great saphenous diameter (GSV) diameter > 5.5mm [odds ratio (OR) 2.51, 95% CI 0.24-0.91; p = 0.0012], GSV reflux > 1s [OR 3.28, 95% CI 1.16-12.1; p = 0.003], deep only VI [OR 1.32, 95% CI 0.74-1.87; p = 0.021], CEAP C4-6 [OR 1.62, 95% CI 0.36-0.91; p = 0.018], and hypothyroidism [OR 1.55, 95% CI 1.31-11.2; p = 0.031]. GSV diameter of > 5.38mm and GSV reflux duration > 1.23s had the best predictive value for lower extremity oedema following TKA.

Great saphenous vein diameter at different regions and its relation to reflux

BackgroundGreat saphenous vein (GSV) incompetence is involved in most cases of varicose disease. Standard preinterventional assessment is required to decide the treatment modalities. GSV diameter was measured at saphenofemoral junction, proximal thigh, distal thigh, knee, proximal leg, and distal leg. Analysis was done to find at which diameter size the reflux is expected to occur.Patient and methodsThe study involved 100 limbs from outpatient vascular clinic. GSV diameter was measured at the saphenofemoral junction, the proximal thigh, the distal thigh, below the knee, and mid-leg and correlated with reflux.ResultsReflux in the sapheno-femoral junction (SFJ) (group I) occurred at 7.16±2.30 mm, proximal thigh (group II) at 6.60±1.89 mm, distal thigh (group III a) at 6.12±1.63 mm, knee (group III b) at 5.78±1.60 mm, proximal leg (group IV) at 4.61.24 mm, and mid leg (group V) at 3.59±1.16 mm.ConclusionMeasurement at six sites revealed higher sensitivity and specificity to predict reflux. GSV diameter correlates with reflux.

Can Great Saphenous Vein Diameter Be Correlated with Clinical Severity Scores and Quality of Life in Indian Population?

To study GSV diameter at proximal thigh and its correlation with CEAP, VCSS, and quality of life. Prospective observational study. All patients diagnosed as varicose veins in the department of general surgery at a tertiary care hospital between November 2017 and October 2018 were included in the study. Secondary varicose veins and other lymphovascular disorders were not included in the study. A total of 100 patients were included in the study after exclusion criteria. Eighty were males and 20 were females. There was non-significant positive statistical correlation between the GSV diameter at proximal thigh and C scoring of CEAP, VCSS, and quality of life (CIVIQ-14 questionnaire). GSV diameter cannot be made as a sole prediction criteria for clinical severity as other factors like early detection, compliance to treatment, presence of reflux, or not are a few of the many compounding factors.

DETERMINANTS OF RECURRENCE RATE DURING MIDTERM FOLLOW-UP OF PATIENTS AFTER ENDOVENOUS LASER ABLATION OF PRIMARY LOWER LIMB VARICOSE VEINS

Background: The goal of this prospective cohort study was to study the different determinants impacting primary varicose vein recurrence rates and patterns after endo venous laser ablation (EVLA) for primary lower limb varicose veins.Patients and Methods: 127 symptomatic patients (127 limbs) with great saphenous vein reflux (>0.5 seconds), GSV diameter> 3mm and pre-operative incompetent perforators were followed up within two years for recurrence after EVLA.Outcomes: Recurrence was defined clinically by venous clinical severity score (VCSS) and CEAP classification and radiologically by patterns of reflux on duplex ultrasound examination. Assessment was done at 1, 6, 12 and 24 months after the procedure. Results: Two-year life table analysis showed varicose vein recurrence in 9 (7.1%) of limbs. Varicose vein recurrence was mostly seen owed to due to BMI more than 30.5 kg/m2 in 77.8 % (p <0.001, 95% CI 1.105 to 1.590) of recurrence patients, refluxing anterior accessory saphenous vein in 77.8% of patients (p <0.001, 95% CI 3.2 to 1669.1) and postoperative incompetent perforators in 77.8% of patients (p <0.001, 95% CI 2.7 to 69.3). Age, gender and pre-operative GSV diameter ≥ 5.5 mm were statistically insignificant in determination of recurrence. Conclusion: BMI, refluxing anterior accessory saphenous vein and postoperative incompetent perforators are the most importantdeterminants of recurrence after EVLA with a statistically significant impact in comparison with age, gender and preoperative dilated GSV diameter ≥5.5 mm.

Great Saphenous Vein Diameter at Different Regions and its Relation to Reflux

Abstract Background: Great saphenous vein incompetence is in-volved in the majority of cases of varicose disease. Standard pre-interventional assessment is required to decide the treat-ment modalities. GSV diameter measured at sapheno-femoral junction, proximal thigh, distal thigh, knee, proximal leg, distal leg. Analysis done to find at which diameter size the reflux expected to occur. Aim of Study: To investigate a possible correlation of GSV diameters measured at sapheno-femoral junction, prox-imal thigh, distal thigh, below knee and at mid leg and there relation to the reflux. Patient and Methods: Study involved 100 limbs from outpatient vascular clinic, GSV diameter measurement at the sapheno-femoral junction, at the proximal thigh, at the distal thigh, below the knee, mid leg in correlation to reflux. Results: SFJ reflux (group I) at 7.16±2.30mm, proximal thigh (group II) at 6.60±1.89mm, distal thigh (group IIIa) at 6.12±1.63mm, knee (group IIIb) at 5.78±1.60mm, proximal leg (group IV) at 4.6±1.24mm, and mid leg (group V) at 3.59± 1.16mm. Conclusions: Measurement at six sites revealed higher sensitivity and specificity to predict reflux, GSV diameter correlates with reflux.

Effect of saphenous vein space packing in conventional varicose vein surgery

Background: Varicose veins are common. The prevalence has been variously reported from as little as 2% to over 20% in population studies. Management of varicose vein disease has changed drastically over the past decades. Since its introduction, 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. The objective was to study the effect on Saphenous vein space packing in conventional varicose vein surgery on intra-operative bleeding and post-operative patient recovery.Methods: A prospective comparative study was conducted in JSS Hospital, Mysuru from August 2016 to October 2018. A total of 60 patients were selected for the purpose of the study based on the inclusion and exclusion criteria. The patient was passed on post operative day 2, 4, 7 and 30. The study population was divided into 2 groups, Group 1: 30 patients undergoing varicose vein surgery with packing and Group 2: 30 patients undergoing traditional varicose vein surgery without packing.Results: On pre-operative evaluation of GSV diameter, the mean diameter was found to be 8.20±2.3 mm in the conventional group and 7.30±1.82 mm in vein packing technique. The pain was found to be more in conventional group than Saphenous vein packing technique and score was found to statistically significant between the two groups on day 2 and 4.Conclusions: Saphenous vein space packing is an easy, economical and effective way of reducing post-operative pain in conventional varicose vein surgery.

VSICON 2018 Prize Paper Abstracts

VSICON 2018 Prize Paper Abstracts

Minimization of skin incisions at stripping by Mayo of large-diameter veins.

The aim of the present study was to analyze the possibility to minimize of the skin incisions up to a puncture size at stripping by Mayo with the use of the stripper with an oval-ring head for large-diameter veins. The problem is solved due to the geometrical changing of the stripper head from a round to an oval one. The laboratory experiment showed that with a vein diameter of 10-20 mm the total cross-sectional area of its walls constituted 13.61 mm2, with a diameter of more than 20 mm it was 19.98 mm2. There were designed three types of the external dimensions for the stripper: 3.0×6.0 mm; 3.5×7.0 mm and 4.0×8.0 mm. From 1997 to 2017, the stripper with an oval-ring head was used in 1274 patients (421 males, 853 females) to treat 1832 lower limbs. Average age was 46.4±12.3 years (range, 29 to 73). GSV and SSV stripping was performed in 1165 and 137 cases, respectively, in patients with the trunk diameter of more than 10 mm, severe vein tortuosity, for a vein located immediately under the skin, as well as for patients with the history of thrombophlebitis. The pain level in the first evening after the operation was 1.59, on day 7, it decreased to 0.12 according to VAS-10. The motion activity level in the first evening after the operation was 7.24; on day 7, it decreased to 9.96 according to VAS-10. All patients had primary wound healing. Hematomas along the location of the eliminated veins were of a moderate nature and resolved, on average, within 17 days. With the GSV diameter of 10-20 mm the skin scars were of 2.93 mm (95% CI: 3.09-4.47 mm), with the GSV diameter of more than 20 mm the skin scars were of 4.10 mm (95% CI: 4.01-5.07 mm). After 3 months, 1102 patients (86.5%) were very satisfied and 172 (13.5%) were just satisfied with the performed operation. The use of the proposed stripper with an oval-ring head in patients with large-diameter subcutaneous trunks leads to the minimization of the skin incisions up to the punctures and, in general, makes the surgery significantly less traumatic, providing a quick recovery and minimization of the skin scars.

Relationship between patient-reported symptoms, limitations in daily activities, and psychological impact in varicose veins.

The objective of this study was to evaluate the relationship between patient-reported symptoms, functional limitations, and psychological impact of varicose veins (VVs) vs pathophysiologic mechanism, incorporating demographic and behavioral factors. We conducted a pooled analysis from two clinical studies (Efficacy and Safety Study of Polidocanol Injectable Foam for the Treatment of Saphenofemoral Junction Incompetence [VANISH-1] and Polidocanol Endovenous Microfoam Versus Vehicle for the Treatment of Saphenofemoral Junction Incompetence [VANISH-2]) in patients with VVs (superficial venous reflux only). Health outcomes were classified on the basis of the Wilson-Cleary conceptual framework continuum linking clinical and anatomic factors (Clinical, Etiology, Anatomy, and Pathophysiology [CEAP] clinical class and great saphenous vein [GSV] diameter, respectively) to patient-reported outcomes: Varicose Vein Symptoms Questionnaire (VVSymQ) score; modified Venous Insufficiency Epidemiologic and Economic Study on Quality of Life/Symptoms (m-VEINES-QOL/Sym) limitations in daily activities (functional limitations hereafter) score; and m-VEINES-QOL/Sym psychological impact score. Association of clinical and anatomic categories with each of the patient-reported outcomes was assessed using analysis of variance for statistical significance and standardized mean differences for clinical meaningfulness. Hierarchical regression modeling was applied to evaluate the direct association of the VVSymQ symptom score with the m-VEINES-QOL/Sym functional limitations score and the indirect association with the m-VEINES-QOL/Sym psychological impact score, adjusting for clinical, behavioral, and demographic factors. Among 516 patients, approximately three-fourths were women (mean age, 49 years), approximately 70% were overweight or obese, 42% were C2 and 32% were C3, and 88% reported never or only intermittently wearing compression stockings. VVSymQ (symptom) scores did not vary by GSV diameter but were significantly worse for those with severe disease stage, especially C5 or C6. Among m-VEINES-QOL/Sym work-related function items, 47% of patients reported difficulty at work and 31% reported cutting down at work. On nonwork function items, standing for prolonged periods was most affected; 53% were limited a little and 22% were limited a lot. Concern about appearance and choice of clothing predominated among psychological impact items, with 74% and 65%, respectively, affected all or most of the time. The m-VEINES-QOL/Sym functional limitation and psychological impact scores varied by neither GSV diameter nor CEAP C class, but they varied directly with VVSymQ (symptom) score quartiles. Multivariable regression analysis revealed that VVSymQ symptom scores continued to be associated with m-VEINES-QOL/Sym psychological impact scores, even after adjustment for m-VEINES-QOL/Sym functional limitation scores. Substantial patient-reported functional limitation and psychological impact of VVs were observed. Limitations on work, standing for prolonged periods, concern about appearance, and clothing choice were most affected. Patient-reported VVSymQ (symptom) score, an objective patient-reported measure of symptom severity in VVs, was the key predictor of patient-reported m-VEINES-QOL/Sym functional limitations. Symptoms and functional limitations led to greater psychological impact. Physicians should routinely ascertain symptoms and functional limitations to enhance quality of care and to document medical necessity.

Endovascular Recanalization of Chronic Non-malignant Obstruction of the Inferior Vena Cava

70 J/cm) for SSV. The complete occlusion of the treated saphenous vein was defined as absence of flow on color Doppler imaging and was achieved in 174/177 (98.3%) subjects at 4 weeks and 132/135 (97.7) patients at 12 months. Partial occlusion was observed in three patients and was defined as reflux >3 cm distal to the junction. The mean length of non-occluded stump at the junction between saphenous vein and deep vein was 0.5 cm (range 3.6 to 5.0 cm) 4 weeks postoperative. Mean postoperative reduction of the diameter of GSV and SSV at 1 year was 40% and 56% respectively (p< 0.05%). In the early postoperative phase paraesthesia was observed in 15/177 (8.5%), ecchymosis in 4/177 (2.3%), lymphocoele in 1/ 177 (0.6%), hyperpigmentation in 1/177 (0.6%). Endovenous heat induced thrombus (EHIT) propagation was observed in 4/177 (2.3%) subjects. There were no skin burns or phlebitis. No patient reported severe pain. The mean postoperative pain intensity (Visual Analog Scale) was 1.3. The mean convalescence period was 2 days (1e30 d). No long-term complications and recurrent reflux was observed at 1 year follow-up. Conclusion: ELT using Thulium laser (1940 nm) with radial fiber efficiently eliminates the reflux in the saphenous veins by occlusion and significant diameter reduction with no reflux recurrence at 1 year follow up. The complication rates are less or comparable to the other endothermal and surgical procedures. These benefits are offered with low postoperative pain, analgesia requirement and rapid convalescence.

The Case of GSV Transient (Evening, Orthodependent) Reflux in a Hip Going into the Tributary in Woman with Reticular Varicose Veins (C1s)

A 41-year-old woman presents with complaints of aesthetic defect of legs. She works as a shop assistant in a store. Her working day in a standing position lasts up to 10 hours. She has been pregnant twice and now has two children. She notes the family history of varicose veins from mother’s side. While evening examination at 6 p.m. (after her working day) the skin is of normal colour and there is an artery pulsation in all pulse points. Both hip superficies contain spider veins and single reticular varicose. She states leg heaviness and tiredness, aching in the internal hip surface of the right leg in its lower part at the end of the working day, night cramps. The results of DS after «a day orthostatic loading test» (shortly DOL-test) showed that the diameter of GSV in the right area of saphenofemoral junction is 6.5 mm which is the same for the area between the middle and the lower third of the hip. There is a 12 cm reflux in the middle third of the hip going into the extended hypodermic tributary with commissural GSV valve insufficiency in the area between the middle and the lower third (Figure 1).

Endovenous Laser for the Treatment of Saphenous Reflux and Varicose Veins

Background: In this presentation, we aim to report our experience about endovenous laser treatment (EVLT) for lower extremity varices during six months follow-up period. Patients and Methods: Forty-six patients with lower extremities varices who underwent EVLT treatment with the 940-nm diode laser were enrolled into the study. The diagnosis of GSV incompetence with reflux was made by clinical evaluation and duplex Doppler examinations. Clinical outcomes, complications, and duplex ultrasound of the GSV were assessed after 1 week, 1 month, 3 months, and 6 months, after the endovascular laser treatment. Results: The mean age of our patients was 44 + 11 years (2470) and 23 (50%) were female. Improvement in visible varicosity was seen in 39 (84.8%) patients after six months. (P = 0.011) The baseline mean diameter of GSV was 4.9 + 1.6 mm which dropped to 3.5 + 1.3 after six months. (P < 0.0001). After Six months, 95.7% of our patients were satisfied and mentioned that recommend this procedure to others. Conclusions: Endovascular laser ablation is a safe and effective method for the treatment of lower limb varices.

Endovenous Laser Therapy of Great Saphenous Veın: Six Months Follow-Up

Objectives: The aim of this study is to analyze the outcome results and short term follow-up of our Endo Venous Laser Therapy (EVLT) cases operated in a hospital setting. Patients and Methods: This is a retrospective study. Two hundred patients were enrolled. Of these 200 patients, 124 (62%) were female and the average age of the patients was 37.7 ± 10.8 (ranged, 19 to 64). Reflux duration >0.5 s in ultrasound was considered as significant. The preoperative GSV diameter was measured in the standing position with USG was 12.3 ± 3.9 mm in average (ranged, 4.1 to 27.7 mm). Operations were performed with a 980 nm diode laser system (Gigaa SVLase 30w Surgical Diode Laser System, Wuhan, PRC). Laser energy applied GSV length was 31.1 ± 3.3 cm in average (ranged, 26-39 cm). Total delivered laser energy was 2783.3 ± 426.1 J (ranged, 1992-3464 joules). Follow up controls were performed at 1st week, 1st, 3rd and 6th months after the operation. Results: Forty-four left, 64 right and 92 bilateral legs were treated. Phlebectomy was performed in 98 (49.0%) cases. The median follow up period for all of the patients was 11 months (range, 6-14 months). Most common complication during follow-up was paresthesia, especially on the first week control (n=8, 4.0%). The rate of symptomatic complications like paresthesia, phlebitis and hematoma gradually disappeared during follow-up as expected. The recanalization rates of ablated GSV were 1.0% in the 1st week and 3.5% recanalization rate was present by 6th month. Conclusion: EVLT is a comfortable and safe method for treatment of venous insufficiency. It is important not to forget that EVLT is not free of complications and reducing these complications may help to improve the outcome results.

Comment to: Great saphenous vein diameter at the saphenofemoral junction and proximal thigh as parameters of venous disease class, by Mendoza E, Blättler W, Amsler F. Eur J Vasc Endovasc Surg 2013;45:76-83.

The aim of this study was to investigate a possible correlation of GSV diameters measured at the SFJ and the proximal thigh (PT) with the importance of the venous disorder. Between October and December 2009. 844 legs were screened and 182 legs included in the survey (CEAP C1-C5). The criterion for patient inclusion was the presence of a GSV reflux beginning at the terminal or the preterminal valve and escaping through a mid-thigh branch vein (above knee reflux, -51 legs- group II) or escaping through a lower leg branch vein (above and below knee reflux-71 legs-, group III). Legs with varices but no GSV were recruited as controls (-60 legs- group I). Vein diameters were measured holding the probe transversely with no pressure at the SFJ distal to the terminal valve and 15 cm below the junction. Measurement of GSV vein diameter at the SFJ is challenging for the curvature of the inguinal GSV, the presence of epigastric, pudendal and accessory veins and eventual aneurysmatic dilatations. The PT site 15 cm below the SFJ, chosen by CHIVA Group members, is located in the truncal portion of GSV where the vein is cylindrical and largely devoid of joining branches, so well accessible, and diameter measurements can be taken reliably. GSV diameters in all groups, measured at both sites, were not related with patients&rsquo; age and sex or calf muscle-pump function. Modest correlations were found with body weight and BMI but not with height. GSV diameters in controls (group I) measured 7.5 mm (&plusmn;1.8) at the SFJ and 3.7 mm (&plusmn;0.9) at the PT. In patients with GSV reflux (groups II and III), they measured 10.9 mm (&plusmn;3.9) at the SFJ and 6.3 mm (&plusmn;1.9) at the PT, respectively. Vein diameters were larger in the presence of reflux, compared with its absence, by an average of 3.4 mm at the SFJ and 2.6 mm at the PT. No difference in diameters was found between group II and group III. Thus, the degree of vein dilatation was independent of the length of reflux above knee only versus above and below knee. A GSV diameter above the 2 SD margin of group I legs was found in 2% in group I at either point of measurement. In groups II and III, a significantly different prevalence was observed when measurements made at the SFJ and PT, respectively. The 2 SD margin was exceeded by 43% of patients when measured at the SFJ and by 62% when measured at the PT. A mathematical formula was developed to mutually convert measurements taken at the SFJ and the PT, used to revise published data. Conversion PT to SFJ (95% CI 1.698&ndash;1.836): diameter SFJ (mm) = 1.767 &times; diameter PT (mm) Conversion SFJ to PT (95% CI 0.544&ndash;0.548): diameter PT (mm) = 0.566 &times; diameter SFJ (mm) Measurement at the PT as compared to measurement at the SFJ demonstrated higher accuracy and both higher sensitivity and specificity for venous disease class as well as for prediction of reflux. GSV diameter, venous hemodynamic (PPG refilling times) and clinical disease class did not differ whether reflux was above knee only or above and below knee. Diameter assessment at the PT seems suitable for stratification of patients allocated to future interventional trials as well as for outcome evaluation.

Comment to: Catheter-directed foam sclerotherapy for insufficiency of the great saphenous vein: occlusion rates and patient satisfaction after one year, by Williamsson C, Danielsson P, Smith L. Phlebology 2012:1-6.

Between November 2007 and October 2008, 100 consecutive symptomatic patients with verified axial reflux in the GSV were treated with a catheter-directed foam sclerosation technique (CDS). CDS delivers the foam during a short period of time directly to the intended site, along the length of the GSV, with less impact from surrounding factors. The catheter induces a vasospasm which might further enhance drug interaction with the vein wall. Median age was 52.5 years (range 18&ndash;92), 28 men and 72 women. All patients had visible varicose veins. Twenty-three had recurrent varicose veins. The treatment was performed in the outpatient clinic by a team consisting of two vascular surgeons and two nurses. Exclusion criteria were allergy to polidocanol, a very tortuous vein (which could make the catheters impossible to advance) or a GSV diameter exceeding 10 mm at the terminal valve. The skin was infiltrated with local anesthesia. The vein was accessed by a micro-puncture introducer set and a 0.35 Fr guide wire was advanced proximally under US surveillance and positioned at the SFJ. A catheter was introduced over the guide wire and positioned approximately 2 cm distal to the SFJ and the guide wire was removed. The table was slightly tilted to elevate the leg to empty the GSV. Ten mL sclerosing foam (SF) was made by mixing 2 mL chilled 3% polidocanol and 8 mL air. The SFJ and site of puncture was compressed for five minutes and the thigh massaged to fill superficial varicosites with foam. No additional local injection of foam was given. All patients wore two-layer short stretch compression bandages for one to five days after treatment. Evaluation with US was performed at two weeks and at one year after treatment. Foam delivery along the GSV was technically successful in 94 of the 100 patients. The median time for the procedure was 22 (8&ndash;90) min. The complete treatment exceeded 30 min in 20 patients, but only in two patients following the 50th patient. At the US control two weeks after treatment, the GSV was completely occluded in 92 of the 94 successfully treated patients. At the one-year follow-up, 84% (79/94) were satisfied with the result. The one-year US showed that 70% (64/91) of the GSVs were completely occluded, 15% (14/91) of the GSVs were recanalized and 14% (13/91) were partly occluded. No major complications occurred such as visual disturbance, pulmonary embolism, DVT or infection. Two patients had superficial thrombophlebitis; at the one-year follow-up 26 patients had pigmentations to some extent. The cost for the drugs and the single-use medical material was calculated to be 106 EUR.

Great Saphenous Vein Diameter at the Saphenofemoral Junction and Proximal Thigh as Parameters of Venous Disease Class

BackgroundGreat saphenous vein (GSV) incompetence is involved in the majority of cases of varicose disease. Standardised pre-interventional assessment is required to analyse the relative merit of treatment modalities. We weighed GSV diameter measurement at the sapheno-femoral junction (SFJ) against measurement at the proximal thigh 15 cm distal to the groin (PT), established a conversion factor and applied it to selected literature data. MethodsLegs with untreated isolated GSV reflux and varices limited to its territory and control legs were studied clinically, with duplex ultrasound and photoplethysmography. GSV diameters were measured at both the SFJ and the PT. A conversion factor was calculated and used to compare published data. ResultsOf 182 legs, 60 had no GSV reflux (controls; group I), 51 had above-knee GSV reflux only (group II) and 71 had GSV reflux above and below knee (group III). GSV diameters in group I measured 7.5 mm (±1.8) at the SFJ and 3.7 mm (±0.9) at the PT. In groups II and III, they measured 10.9 mm (±3.9) at the SFJ and 6.3 mm (±1.9) at the PT (p < 0.001 each). Measurement at the PT revealed higher sensitivity and specificity to predict reflux and clinical class. Good correlation between sites of measurement (r = 0.77) allowed a conversion factor (SFJ = 1.767 * PT, PT = 0.566*SFJ) to be applied to pre-interventional data of published studies. ConclusionsGSV diameter correlates with clinical class, measurement at the PT being more sensitive and more specific than measurement at the SFJ. Applying the conversion factor to published data suggests that some studies included patients with minor disease.