Recurrence Of Varices Research Articles

REVAT (Recurrent Varices After Treatment)

SummaryThe term “recurrent varicose veins” covers various entities. In the first instance, recurrent varicose veins may be the progression of the underlying disease, as there is a hereditary disposition to the condition, but we also find the phenomenon of neovascularisation, and lastly we repeatedly see recurrent varices as a result of technical or strategic surgical errors and the failure of endovenous procedures. No differentiation between these different types of recurrent varicose veins has previously been made in the literature, so that the numbers given vary between 6% and 60%. Up to the present time, few data on the progression of the underlying disease are to be found in the literature. Our own studies, on average 36 months postoperatively, demonstrated new varicose side branches that could be interpreted as progression of the underlying disease in 56.8% of the patients followed up.Several recent publications demonstrate neovascularisation as a cause of recurrence. While some authors give a figure of 24% for recurrence due to neovascularisation in patients who have had surgery, other publications regard neovascularisation as the main cause of postoperative recurrence.The data on technical or strategic surgical errors and recanalisation after endovenous procedures are also very varied. Numbers for technical errors as the cause of recurrent varicose veins following surgery range from 10.7% to more than 70%. Published recanalisation rates after endovenous laser therapy vary between 0% and 36%; the average recanalisation rate in the available prospective randomised studies on radiofrequency obliteration was 12.9%. Foam sclerotherapy has recanalisation rates between 69% and 86%, with a mean follow-up of 32.2 months.Given the different possible causes, it is extremely important, that recurrent varicose veins should be classified. The authors have developed a simple classification that can be used in routine daily practice. Recurrent varicose veins are given the acronym REVAT (recurrent varices after treatment). Generally speaking, on the one hand there is progression of the underlying disease (progression of disease = PD) and, on the other hand, varicosities after treatment as a result of technical error or failure of the method used (recurrence after treatment = RT). Progression of the underlying disease can be further subdivided into neovascularisation at the saphenofemoral or popliteal junction (progression of disease at the junction = PD-J) and new varices arising in the treated vascular territory (progression of disease at the limb = PD-L).In the case of recurrent varices after treatment we distinguish between a persisting or a new reflux at the saphenofemoral or the popliteal junction (recurrence after treatment at the junction = RT-J), untreated segments of the great or small saphenous veins or recanalisation of the trunk (recurrence after treatment at the trunk = RT-T) and untreated side branches or perforating veins (recurrence after treatment at side branches = RT-S). With the help of these abbreviations a simple formula can be generated to describe the recurrent varices, e.g. recanalisation of the left great saphenous vein (GSV) after endovenous treatment and a new varicosis in the vascular territory of the left great saphenous vein resulting from progression of the underlying disease: vascular territory left great saphenous vein = GSV-L, technical or tactical error due to recanalisation of the GSV = RT-T, progression of the underlying disease in the vascular territory of the GSV = PD-L. This generates the formula: GSV-L : RT-T, PD-L.Since there are no exact figures on the incidence of the individual causes of recurrent varicosis, a classification of recurrent varicosis is indispensable to ensure clarity in the future.

Portal hypertension secondary to myelofibrosis with myeloid metaplasia: A study of 13 cases

To describe the clinical presentation and complications of portal hypertension (PH) secondary to myelofibrosis with myeloid metaplasia (MMM). Medical records for 123 patients with MMM were reviewed. Thirteen patients with PH secondary to MMM were identified. Median ages at time of MMM and PH diagnosis were 61 and 66 years, respectively. The interval from MMM diagnosis to presentation with one of the PH features ranged from 1 to 11 years. Variceal bleeding and ascites were the most common presentations. Of the eight patients who presented with variceal bleeding, six patients underwent endoscopic variceal ligation (EVL) with no variceal recurrence or hematological worsening during a 12-mo follow up period. Patients with MMM might develop PH. Exact mechanisms leading to PH in MMM are still controversial. As in other etiologies, variceal bleeding and ascites are the most common presentations. Anemia may correlate with, and/or predict, the severity of the PH presentation in these patients. EVL can successfully control variceal bleeding in MMM. Further clinical studies are required.

Venøs insuffisiens i underekstremitetene

Venous insufficiency is a common condition that presents with various symptoms and is often treated inadequately. The purpose of the article is to provide an overview of the prevalence, recommended investigations and indications for treatment of venous insufficiency. The literature reviewed was identified through a non-systematic search in PubMed based on the authors' experience in research, investigations and treatment of this patient group. Venous insufficiency is a common condition with a prevalence of about 30 %. Some patients will develop distal dystrophic skin changes (prevalence <or= 3 %) and a few will experience venous leg ulcers (prevalence < 1 %). Dystrophic skin changes and venous leg ulcers can be caused by an isolated superficial venous insufficiency, accessible for varicose vein surgery. Further evaluations (e.g. colour duplex scanning and direct measurement of venous pressure or plethysmography) are recommended for all patients with skin changes, recurrent varices, previous deep venous thrombosis or other circumstances rendering it difficult to conclude from clinical investigations. Indications for superficial venous surgery are mainly based on symptoms. Prophylactic surgery on superficial veins is considered only in cases with dystrophic skin changes or ulcers. Compression therapy represents the best prophylactic measure to reduce varicose vein progression.

Natural History of Recurrent Varices Undergoing Reintervention

Natural History of Recurrent Varices Undergoing Reintervention

Blood vessels of the normal and pathologically changed wall of the human vena saphena magna

Abstract The vascular supply of the wall of human vena saphena magna was qualitatively studied by the use of several morphological methods on both normal and pathologically changed veins. The material was obtained from patients undergoing aortocoronary bypass or surgery of the varices, and material from cadavers. Under physiological conditions, the wall of vena saphena magna is supplied by delicate system of vasa vasorum, organized in a form of feeding vessels branched into an irregular loose adventitial mesh and continuing further as a microcirculatory network supplying the two outer thirds of the media. Small local dilatations and tortuosities of adventitial veins were found on heavy varicose veins. Slight increase of vasa vasorum growing into the innermost layer of media was detected, but the hyperplastic intima remained avascular. In patients with recurrent varices or with vein thrombophlebitis intimal hyperplasia, degradation of media and thrombosis, were found. Apparent massive increase of vasa vasorum growing into the whole media, hyperplastic intima and into the organizing thrombi, were regularly observed. The increase of vasa vasorum is a part of the complex of pathophysiological reactions of the vein wall on the hypoxia developing during the most serious pathological changes, and not as the primary varicogenic factor. The vascular supply of the wall of the human vena saphena magna was qualitatively studied by the use of several morphological methods on both normal and pathologically changed veins. The material was obtained from patients undergoing aortocoronary bypass grafting or surgery of varices, as well as materials from cadavers. Under physiological conditions the wall of vena saphena magna is supplied by a delicate system of vasa vasorum. It is organized in a form of feeding vessels branched into an irregular loose adventitial mesh, which continues further as a microcirculatory network supplying the outer two thirds of the media. Small local dilatations and tortuosities of adventitial veins were found on severe varicose veins. A slight increase of the vasa vasorum growing into the innermost layer of media was detected, but the hyperplastic intima remained avascular. In patients with recurrent varices or vein thrombophlebitis, intimal hyperplasia, degradation of media and thrombosis, were found. It was regularly observed that there was an apparent, massive increase of the vasa vasorum growing into the entire media, hyperplastic intima, and into the organizing thrombi. The increase of the vasa vasorum is due to the pathophysiological reaction of the vein wall as a result of hypoxia, which develops during the most serious pathological changes. The increase is not the primary varicogenic factor.

Natural History of Recurrent Varices Undergoing Reintervention: A Retrospective Study

Recurrent varices after surgery are a complex problem. Many studies regarding the causes of recurrence and the best procedures that can be used to study them have been conducted but few studies on the natural history of the operations performed for recurrence. To evaluate the efficiency of reintervention in controlling the varicose disease, its symptoms, and patient satisfaction. Of 71 patients operated on for surgical recurrence related to an inguinal cavernoma between 1996 and 2004, 51 were reassessed in May 2006 with a clinical and Duplex examination. Surgical and anesthesiological data were collected. The average follow-up after reintervention for the 51 of the 71 treated patients who came to the examination was 5.8 years; 38 (74.5%) of the patients were very satisfied, and one patient (2%) was dissatisfied. Thirty-five (68.6%) of the patients still had varices, but only 17 of these had real varices at the original site; 18 patients showed persistent or residual varices (3 patients, 5.8%) or a progression (15 patients, 29.9%) of the varicose disease. Surgical intervention on an outpatient basis may have a significant role in controlling the varicose disease with few complications.

Stent-grafts in transjugular intrahepatic portosystemic shunts

Objective To retrospectively evaluate the efficacy of polytetrafluorothylene covered nitinol stent graft (Viatorr, Gore, Flagstaff Arizona, USA) in transjugular intrahepatic partosystemic shunt (TIPS). Methods Thirty-sevan consecutive patients underwent a TIPS procedure between May 2004 and June 2006 at the Dotter Interventionsl Institute in Portland, Oregon, USA. The average follow-up time was (15.2±9.3)months. Indications for the procedure included recurrent varieeal bleeding after attempted endoscopic management (n=17), refractory ascites or hydrothorax ( n = 18 ), and Budd-Chiari syndrome (n = 2). The t test was used for statistics. Results Forty-one stent-grafts were implanted in 37 patients, 3 of the devices were 8 mm in diameter and 38 were 10 mm. The covered stent length varied from 4 to 8 cm without complications. Portosystemic gradient (PSG) decresed significantly from (22.4±8.4) mm Hg (1 nun Hg=0.133 kPa) to(8.1±3.2)mm Hg, (t = 12.754,P <0.01). During the follow-up period, Variceal bleeding recurrence occurred in 1 of 17 patients and for ascites or hydrothorax, two of 14 patients. Shunt occlusion occurred in 2 of 37 (5.4%) patients (4 and 17 months post-shunt). The 1-year primary patency rate was 97.0%. Two patients died from multisystem organ failure (MSOF) with a patent stent-graft during the follow-up period. Five patients were excluded from the evaluation after liver transplantation. Conclusion TIPS created with a PTFE-covered stent (Viatorr) showed favorable patency rate and low complication rates. Key words: Hypertension,portal; Stents; Radiology,interventional

Meta-analysis: Combination Endoscopic and Drug Therapy to Prevent Variceal Rebleeding in Cirrhosis

Combining endoscopic therapy and beta-blockers may improve outcomes in patients with cirrhosis and bleeding esophageal varices. To assess whether a combination of endoscopic and drug therapy prevents overall and variceal rebleeding and improves survival better than either therapy alone. MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and conference proceedings through 30 December 2007. Randomized trials comparing endoscopic plus beta-blocker therapy with either therapy alone, without language restrictions. Two reviewers independently extracted data on interventions and the primary study outcomes of overall rebleeding and mortality. Metaregression and stratified analysis were used to explore heterogeneity. 23 trials (1860 patients) met inclusion criteria. Combination therapy reduced overall rebleeding more than endoscopic therapy alone (pooled relative risk, 0.68 [95% CI, 0.52 to 0.89]; I(2) = 61%) or beta-blocker therapy alone (pooled relative risk, 0.71 [CI, 0.59 to 0.86]; I(2) = 0%). Combination therapy also reduced variceal rebleeding and variceal recurrence. Reduction in mortality from combination therapy did not statistically significantly differ from that from endoscopic (Peto odds ratio, 0.78 [CI, 0.58 to 1.07) or drug therapy (Peto odds ratio, 0.70 [CI, 0.46 to 1.06]). Effects were independent of the endoscopic procedure (injection sclerotherapy or banding). No trial-level variable associated with the effect was identified through metaregression or stratified analysis. Statistically significant heterogeneity in trial quality and evidence for selective reporting and publication bias were found. A combination of endoscopic and drug therapy reduces overall and variceal rebleeding in cirrhosis more than either therapy alone.

Sclerotherapy: A Truly Minimally Invasive Technique

Foam sclerotherapy offers a treatment strategy with great potential. Recently, general and vascular surgery have become less invasive; so too, has the treatment of venous disorders. Sclerosants cause irreversible damage to the vascular endothelium by disrupting cell membranes resulting in sustained vasospasm and denudation of the venous monolayer. Prospective randomized outcome data support the hypothesis that foam sclerotherapy is superior to liquid sclerotherapy. All published reports of varicose vein treatment with foam describe efficacy in terms of immediate and primary venous occlusion of better than 80%. Severe complications of foam sclerotherapy are rare. Recurrent varices are in the 10% to 20% range. Use of foam sclerotherapy in our experience has proven to be effective, essentially pain-free, and durable in the short term. The treatment is quick, efficient, and cheap.

Management of recurrent varices at the popliteal fossa after surgical treatment

To analyze prevalence, incidence mechanisms, physiopathology, investigations, treatment techniques and results of recurrent varices at the popliteal fossa after surgery. Published literature was analyzed as personal experience. Recurrent varices after surgery at the popliteal fossa are much less frequent than at the sapheno-femoral junction because the short saphenous vein is less often the site of incompetence and treated by surgery. Precise prevalence and incidence is unknown. An analysis of recurrences at the popliteal fossa revealed three causes: (1) Incomplete division of the sapheno-popliteal junction (SPJ) at the terminal valve, which was incompetent at the initial surgery. The persisting reflux fills tributaries still connected to the saphenous stump; (2) Neovascularization reconnects the popliteal vein to the superficial network with new vessels, which are valveless; (3) Because the initial diagnoses is wrong and the incompetence involves the other veins of the popliteal fossa or arises from pelvic veins, which had not been recognized. Duplex scanning (DS) should identify the various sites of reflux and give precise anatomical and haemodynamic data. Treatment methods after recurrence at the popliteal fossa are repeat surgery, sclerotherapy or pelvic vein embolization when identified as the cause. Results provided by these different methods were analysed. At present, no randomized control has given grade 1A, 1B or 2A, 2B recommendations. We recommend that ultrasound-guided foam sclerotherapy should be the treatment of choice unless DS shows an incompetent stump at the SPJ with a gross reflux filling the venous network.

Usefulness of Transnasal Endoscopy with FICE for Diagnosis of Recurrent Esophageal Varices

Usefulness of Transnasal Endoscopy with FICE for Diagnosis of Recurrent Esophageal Varices

Should balloon-occluded retrograde transvenous obliteration be the first-line interventional radiologic treatment for bleeding duodenal varices? a case report and review of the literature

We report a 78-year-old woman who presented with repeated tarry stools, and having lower duodenal variceal bleeding caused by portal hypertension. Endoscopic therapy had been attempted, but was impossible because the endoscope could not be inserted into the lower duodenum. Thus, the lower duodenal variceal bleeding was treated with balloon-occluded retrograde transvenous obliteration in combination with embolization using microcoils. Complete hemostasis was achieved without complications, and neither the recurrence of varices nor rebleeding has occurred for the last 3 years. A review of the English-language literature reveals only 11 such cases. The world literature is reviewed.

Prognosis following endoscopic injection sclerotherapy for esophageal varices in adults: 20-year follow-up study

Objective. Endoscopic injection sclerotherapy (EIS) is beneficial in the management of active hemorrhaging and prevention of recurrent bleeding from esophageal varices. However, its long-term efficacy and safety are poorly defined. The aim of this study was to determine long-term cumulative survival and clarify negative predictive factors for survival following EIS in patients with esophageal varices. Material and methods. Between 1981 and 1987, 72 patients were prospectively enrolled in a post-EIS follow-up program. Variceal rebleeding, recurrence, and survival were recorded in follow-up examinations conducted for up to 20 years. Results. The mean follow-up period was 86.9 months. The cumulative survival rates were 65.2%, 53.6%, 26.1%, and 11.6% at 36, 60, 120, and 240 months, respectively, with liver failure the most common cause of death. Esophageal varices were eradicated in 93.1% of the patients following EIS and no recurrence of varices was seen beyond 7 years. Significant negative predictive factors for survival rate shown by Cox's proportional multivariate hazard model analysis were older age, advanced liver damage, presence of hepatocellular carcinoma, and occurrence of rebleeding. Conclusions. Long-term survival, rebleeding, and recurrence rates following EIS were clarified. Furthermore, our results clearly demonstrate negative predictive factors for survival after EIS.

Varicose veins in very young

SummaryThe prevalence of varicose veins in very young patients is rather low. However, since this is not worked out in the literature, we considered on treatment strategies and techniques in this patients. Patients and methods: We included in our study 58 patients younger than 25 years, who presented to our clinic over a one year period. 42 patients revealed primary varicose veins with 68 legs affected. The average age was 21.5 years, 28 were female, 14 male. Due to CEAP 66 legs were classified as C2–C3, and two legs as C4. In 38 legs an incompetence of the saphenofemoral or saphenopopliteal junction (SFJ/ SPJ) was found. Generally, we recommended a conservative treatment approach and to play a waiting game. An active surgical treatment has been indicated in 21 legs based on increasing discomfort despite sufficient conservative therapy, reflux of the greater or lesser saphenous vein down to the ankle (Hach stage IV and III respectively), existence of a secondary deep vein incompetence or a strong patient’s demand. Finally, 15 patients have been treated surgically by flush ligation of the saphenofermoral/popliteal junction (SFJ/SPJ)), ligation of all side branches, oversewing the stump to protect from angiogenesis and complete removal of all superficial varicose veins in tumescent local anaesthesia. Results: After an average follow-up of five months 13 patients were reexamined. All junctional regions were without reflux and recurrent varices were not observed. One minor complication occurred (afferent nerve injury). Conclusion: Although all operations were performed without major complications our strategy is different now. After failure of conservative treatment we would advise at first to an endovenous obliteration. The aim is to gain time in young patients to avoid a first to third recurrence in the age of 40 to 50 years, because even after correctly performed ligation of the SFJ/SPJ recurrences may occur by neovascularization. We would perform an operation only if recurrences after endovenous therapy might develop or when a second endovenous procedure will not be favourable.

Percutaneous Transportal Sclerotherapy with N-Butyl-2-Cyanoacrylate for Gastric Varices: Technique and Clinical Efficacy

ObjectiveThis study was deigned to evaluate the technique and clinical efficacy of the use of percutaneous transportal sclerotherapy with N-butyl-2-cyanoacrylate (NBCA) for patients with gastric varices.Materials and MethodsSeven patients were treated by transportal sclerotherapy with the use of NBCA. For transportal sclerotherapy, portal vein catheterization was performed with a 6-Fr sheath by the transhepatic approach. A 5-Fr catheter was introduced into the afferent gastric vein and a microcatheter was advanced through the 5-Fr catheter into the varices. NBCA was injected through the microcatheter in the varices by use of the continuous single-column injection technique. After the procedure, postcontrast computed tomography (CT) was performed on the next day and then every six months. Gastroendoscopy was performed at one week, three months, and then every six months after the procedure.ResultsThe technical success rate of the procedure was 88%. In six patients, gastric varices were successfully obliterated with 1-8 mL (mean, 5.4 mL) of a NBCA-Lipiodol mixture injected via a microcatheter. No complications related to the procedure were encountered. As seen on the follow-up endoscopy and CT imaging performed after six months, the presence of gastric varcies was not seen in any of the patients after treatment with the NBCA-Lipiodol mixture and the use of microcoils. Recurrence of gastric varices was not observed during the follow-up period. Worsening of esophageal varices occurred in four patients after transportal sclerotherapy. The serum albumin level increased, the ammonia level decreased and the prothrombin time increased at six months after the procedure (p < 0.05).ConclusionPercutaneous transportal sclerotherapy with NBCA is useful to obliterate gastric varices if it is not possible to perform balloon-occluded retrograde transvenous obliteration.

Percutaneous transhepatic varices embolization with cyanoacrylate in the treatment of varices

To test the safety and validity of percutaneous transhepatic variceal embolization (PTVE) with tissue adhesive cyanoacrylate. PTVE with cyanoacrylate was performed on 92 patients with gastroesophageal varices, 53 males and 39 females, aged 62.5 (7-84): cyanoacrylate was injected into the varices and the afferent veins. Endoscopy and CT were performed to evaluate the embolization. PTVE was successfully completed in 89 of the 92 patients with a technical success rate of 96.7%, and 3 patients died within 1 month. Among the other 86 patients 3 types of cyanoacrylate embolization were achieved: embolization of coronary vein, vessels around gastric fundus, and variceal lower esophagus veins in 40 patients, embolization of coronary vein, gastric fundus and pericardial varices in 33 patients, and embolization of sole gastric coronary vein stem in 13 patients. Acute variceal bleeding in 18 patients was immediately arrested after the procedure, with an acute bleeding control rate of 100%. Eighty-six patients were followed up for 31.5 (6-52) months. The general variceal recurrence rate was 14.1% (10/71), and the variceal recurrence rate of the coronary vein embolization group was 100% (2/2), significantly higher than those of the groups of esophagus and fundus embolization and gastric fundus and cardia varices embolization [7.5% (3/40) and 17.2% (5/29) respectively, P = 0.006]. The general rebleeding rate was 16.3% (14/86), and the rebleeding rates of the group of coronary vein embolization was 69.2% (9/13), significantly higher than those of the groups of esophagus and fundus embolization and gastric fundus and cardia varices embolization [7.5% (3/40) and 15. 2% (5/33) respectively, P = 0.0092]. No obvious ectopic embolization was found. The mortality was 24.7% (22/89). The cause of rebleeding in coronary vein embolization was mainly recurrent variceal bleeding, whereas that in the group of fundus and esophagus variceal embolization was mainly hypertensive gastropathy. PTVE with cyanoacrylate is safe and effective for the obliteration of gastroesophageal varices in cirrhotic patients.

Balloon-Occluded Retrograde Transvenous Obliteration of Gastric Varices: Outcomes and Complications in 49 Patients

Our aim was to evaluate the clinical outcomes, techniques, and complications of balloon-occluded retrograde transvenous obliteration for treating gastric varices with spontaneous gastrosystemic shunts. From November 2002 through October 2005, 49 consecutive patients with gastric varices were treated by balloon-occluded retrograde transvenous obliteration. The sclerosant was injected through the outflow veins during balloon occlusion. Immediate postprocedural CT scans were obtained to evaluate the procedural details. Recurrence and rebleeding of gastric varices and worsening of esophageal varices were evaluated by endoscopic examination and CT. The survival rates and prognostic factors after the procedure were also assessed. There were six procedural failures and two procedure-related deaths. Disappearance or marked shrinkage of the treated gastric varices with no recurrent gastric variceal bleeding was noted in 39 patients (79.6% clinical success rate). Approximately two thirds of our patients experienced worsening of esophageal varices during the median follow-up period of 457 days. The cumulative survival rates at 1 year and 3 years after balloon-occluded retrograde transvenous obliteration were 83.1% and 65.7%, respectively. The prognostic factors associated with survival were the preprocedural Child-Pugh classification and the total bilirubin level. The survival rates and procedural outcomes for the patients with severely compromised liver function were poor. Balloon-occluded retrograde transvenous obliteration is an effective treatment for the obliteration of gastric varices. However, application of this procedure to severely compromised patients should be considered carefully.

A Modified Percutaneous Transhepatic Variceal Embolization with 2-Octyl Cyanoacrylate Versus Endoscopic Ligation in Esophageal Variceal Bleeding Management: Randomized Controlled Trial

Conventional percutaneous transhepatic varices embolization (PTVE) has rarely been used in recent years due to high rates of variceal recurrence and rebleeding. Herein we report a modified PTVE with 2-octyl cyanoacrylate (2-OCA) in which the whole lower esophageal and peri or para-esophageal varices, the submucosal varices, and the advertitial plexus of the cardia and fundus were sufficiently obliterated. We compared this PTVE with endoscopic band ligation (EVL) in the treatment of esophageal variceal bleeding. In this prospective randomized controlled trial, cirrhotic patients with acute or recent esophageal variceal bleeding were assigned randomly to PTVE (52 patients) or EVL (50 patients) groups. Upper gastrointestinal (UGI) rebleeding, esophageal variceal rebleeding, and survival were followed-up. Computerized tomography (CT) scanning and portal venography were used to observe 2-OCA distribution. During the follow-up period (median 24 and 25 months in the PTVE and EVL groups, respectively) UGI rebleeding developed in eight patients in the PTVE group and 21 patients in EVL group (P = 0.004). Recurrent bleeding from esophageal varices occurred in three patients in the PTVE group and twelve in the EVL group (P = 0.012, relative risk 0.24, 95% confidence interval 0.05-0.74). Multivariate Cox analysis indicated that the treatment was the only factor predictive of rebleeding. A Kaplan-Meier curve showed there was no significant difference between survival in the two groups (P = 0.054). With the whole lower esophageal and peri or para-esophageal varices, the submucosal varices, and the adventitial plexus of the cardia and fundus sufficiently obliterated by 2-OCA, this modified PTVE was more effective than EVL in the management of esophageal varices recurrence and rebleeding. Survival in these two groups was not significantly different, however.

Recurrence Rates Following External Valvular Stenting of the Saphenofemoral Junction: A Comparison with Simultaneous Contralateral Stripping of the Great Saphenous Vein

Objectives: The incidence of recurrent varicose veins remains high despite the development of new ablative treatments for varicose veins associated with incompetence of the saphenofemoral junction. External valvular stenting (EVS) of the terminal and/or subterminal valves of the great saphenous vein (GSV) provides a reparative, physiological approach that requires long-term evaluation. The aim of this study was to compare recurrences following EVS with perforate invaginate (PIN) stripping of the GSV. Methods: Included in the study were 193 patients (386 limbs) all of whom underwent simultaneous PIN-stripping of the GSV in one limb and EVS in the contralateral limb. Duplex scanning of the GSV and venous valves established suitability for each procedure. Only valves with visible, mobile cusps on ultrasound imaging are suitable for EVS. Stents were specifically designed Dacron reinforced silicone for left and right saphenofemoral junctions and for the subterminal valve. In a separate group of patients identified from a database where unilateral and bilateral stents had been implanted, 39 limbs with recurrent varices were examined clinically and ultrasonically to determine the aetiology of recurrences. Results: Follow up was available to a maximum of 147 months. The total recurrence rate was 12.4%; stripping (22.2%) and EVS (4.6%) (P<0.01). The residual reflux as measured by postoperative Valsalva on duplex was 9% but rarely was associated with recurrences. The most common cause of recurrence was incompetent perforators and ovarian vein incompetence filling varices of the pudendal veins. Conclusion: This non-randomised study included more severely affected limbs in the PIN stripping limbs, favouring a better outcome in the EVS group. In those patients at an early stage of the disease process where venous valve structure is essentially intact, EVS is a physiological alternative to PIN stripping in the treatment of varicose veins.

Varicose Vein Stripping vs Haemodynamic Correction (CHIVA): a Long Term Randomised Trial

To compare the long-term results of stripping vs. haemodynamic correction (Ambulatory Conservative Haemodynamic Management of Varicose Veins, CHIVA) in the treatment of superficial venous incompetence resulting in chronic venous disease (CVD). Randomised comparative trial. 150 patients affected by CVD, CEAP clinical class 2-6, were randomised to saphenous stripping or to CHIVA. The clinical outcome was assessed by an independent observer who recorded the Hobbs clinical score for treated limbs. A subjective report of the outcome was provided by the patients. Recurrence of varices was assessed by both clinical examination and duplex ultrasonography. The mean follow-up was 10 years, 26 patients were lost to follow-up. The Hobbs score similar in the stripping and CHIVA groups. However recurrence of varicose veins was significantly higher in the stripping group (CHIVA 18%; stripping 35%, P<0.04 Fisher's exact test), without significant differences in the rate of recurrences from the sapheno-femoral junction. The associated risk of recurrence at ten years was doubled in the stripping group (OR 2.2, 95% CI 1-5, P=0.04). Recurrent varices occurred more frequently following saphenous stripping than after CHIVA treatment. The deliberate preservation of the saphenous trunk as a route of venous drainage in the CHIVA group may have been a factor reducing the recurrence rate.