Saphenofemoral Junction Research Articles

Comparing ultrasound guided foam sclerotherapy with surgical treatment in patients of varicose veins

Background: Venous disorders of lower limbs are frequently encountered problem. This study compares conventional surgery and (UGFS) ultrasound guided foam sclerotherapy for treatment of varicose vein. Methods: This study was conducted over a period of 18 months. Minimum of 50 patients with primary varicose vein due to SFJ (saphenofemoral junction) incompetence were selected and randomly assigned in each arm i.e. surgical and foam sclerotherapy. Results: Mean age of patients was 35.32 (p = 1) in both groups. Overall more than 90% of patients were male. Mean venous clinical severity score (VSCC) score dropped from7.84 to 1.72 (p <0.001) in surgery and 7.48 to 1.40 (p <0.001) in foam group at 3 month. Mean venous disability score (VDS) dropped from1.40 to 0.00 (p <0.001) in surgery and 1.36 to 0.20 (p <0.000) in foam group. Average procedure time was 103.2 min surgery and 29 min in foam group (p <0.001). Complications in both groups were comparable. Mean hospital stay was 31 hours in surgery and 2 hours (p <0.001) in foam group. Both groups shows 100% obliteration rate 0% pathological reflux at 1 month post treatment colour duplex. Mean time to return to normal activity was 9.88 days in surgery and 1 day (p <0.001) in foam group. Mean analgesic use was 4.46 days in surgery and 0.46 in foam group. Conclusions: Foam sclerotherapy come up as safe, promising and reliable method of treatment of varicose vein with ease of administration, no hospital stay, no risk of anesthesia, no interference to daily activity, immediate return to work and equally effective as surgery.

下肢静脈瘤に対する高位結紮術併用硬化療法の術式変遷と長期成績

下肢静脈瘤に対する高位結紮術併用硬化療法の術式変遷と長期成績

Patency and clinical success 22years after the Palma procedure.

Surgical reconstruction for chronic iliofemoral venous occlusive disease is rarely performed. These interventions are fraught with frequent early graft occlusions with the best results achieved with autologous venous conduits. Suprapubic great saphenous vein (GSV) transposition to bypass the occluded iliofemoral vein (IFV) with the contralateral GSV was described by Palma and Esperon with a reported patency of 70% to 85% at 3to 7-year follow-ups. Questions have been raised about longterm patency, and functional and clinical success that can be achieved with a relatively small conduit compared with the size of an iliac vein. We present a case of a patient who underwent a Palma procedure for chronic left IFV occlusion 22 years ago. The patient consented to publish this report. A 20-year-old woman presented in 1990 with symptoms of exertional pain and swelling consistent with chronic venous insufficiency without skin changes or ulcers. Two years previously she had postpartum deep venous thrombosis, treated with heparin and warfarin. A venogram showed left IFV occlusion with extensive collaterals. A Palma procedure, femorofemoral GSV transposition using the right GSV was performed (A). She was maintained with lifelong oral anticoagulation and advised to wear elastic stockings. At the 12-year follow-up, a mildly symptomatic 2.5-cm right saphenous vein aneurysm at the saphenofemoral junction was identified and a portion of the wall was excised (B). At the 22-year follow-up, the patient had minimal symptoms with no edema, skin changes, or varicosities. A computed tomography venogram showed a patent Palma graft with rapid flow, and diameter that was equal to that of the right common iliac vein, and no evidence of stenosis or aneurysm (C and D/Cover). This case shows an excellent result two decades after the Palma procedure and supports its use in select patients. Results tend to be the best in patients with good inflow, no significant infrainguinal obstruction or incompetence, and a saphenous vein size >5 mm. In our experience with 25 patients a 78% patency at 5 years was shown. Long-term dilation of the vein is possible and can provide good outflow. The Palma procedure continues to be our first treatment option for patients with symptomatic unilateral iliac vein occlusion, who are not candidates for, or in whom endovascular treatment has failed.

Randomized trial of radiofrequency ablation versus conventional surgery for superficial venous insufficiency: if you don't tell, they won't know

OBJECTIVES:This study compared radiofrequency ablation versus conventional surgery in patients who had not undergone previous treatment for bilateral great saphenous vein insufficiency, with each patient serving as his own control.METHOD:This was a randomized controlled trial that included 18 patients and was carried out between November 2013 and May 2015. Each of the lower limbs of each patient was randomly assigned to undergo either radiofrequency ablation or conventional surgery. Clinical features (hyperpigmentation, hematoma, aesthetics, pain, skin burn, nerve injury, and thrombophlebitis) were evaluated at one week, one month, and six months postoperatively. Hemodynamic assessments (presence of resection or occlusion of the great saphenous vein and recurrent reflux in the sapheno-femoral junction and in the great saphenous vein) were performed at one month, six months, and 12 months postoperatively. The independent observer (a physician not involved in the original operation), patient, and duplex ultrasonographer were not made aware of the treatment done in each case. Clinicaltrials.gov: NCT02588911.RESULTS:Among the clinical variables analyzed, only the aesthetic evaluation by the physicians was significant, with radiofrequency ablation being considered better than conventional surgery (average, 0.91 points higher: standard deviation: 0.31; 95% confidence interval: -1.51, -0.30; p=0.003). However, in our study, we observed primary success rates of 80% for radiofrequency ablation and 100% for conventional surgery.CONCLUSIONS:If the physician is not required to inform the patient as to the technique being performed, the patient will not be able to identify the technique based on the signs and symptoms. Our study revealed that both techniques led to high levels of patient satisfaction, but our results favor the choice of conventional surgery over radiofrequency ablation, as patients who underwent conventional surgery had better hemodynamic assessments.

Padrões de refluxo nas veias safenas em homens com insuficiência venosa crônica

ResumoContextoA insuficiência venosa crônica (IVCr) é frequente e predomina nas mulheres, mas ainda há poucas informações sobre o refluxo nas veias safenas na população masculina.ObjetivosIdentificar os diferentes padrões de refluxo nas veias safenas magnas (VSMs) e parvas (VSPs) em homens, correlacionando esses dados com a apresentação clínica conforme a classificação Clínica, Etiológica, Anatômica e Fisiopatológica (CEAP).MétodosForam avaliados 369 membros inferiores de 207 homens pela ultrassonografia vascular (UV) com diagnóstico clínico de IVCr primária. As variáveis analisadas foram a classificação CEAP, o padrão de refluxo nas VSMs e VSPs e a correlação entre os dois.ResultadosNos 369 membros avaliados, 72,9% das VSMs apresentaram refluxo com predominância do padrão segmentar (33,8%). Nas VSPs, 16% dos membros inferiores analisados apresentaram refluxo, sendo o mais frequente o padrão distal (33,9%). Dos membros classificados como C4, C5 e C6, 100% apresentaram refluxo na VSM com predominância do refluxo proximal (25,64%), e 38,46% apresentaram refluxo na VSP com equivalência entre os padrões distal e proximal (33,3%). Refluxo na junção safeno-femoral (JSF) foi detectado em 7,1% dos membros nas classes C0 e C1, 35,6% nas classes C2 e C3, e 64,1% nas classes C4 a C6.ConclusõesO padrão de refluxo segmentar é predominante na VSM, e o padrão de refluxo distal é predominante na VSP. A ocorrência de refluxo na JSF é maior em pacientes com IVCr mais avançada.

Comparison of 1470 nm Radial Fiber Laser Ablation and Radiofrequency Ablation in Endovascular Treatment of Venous Insufficiency

Background: In this study, we aimed to compare the results of endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) in patients with lower extremity venous insufficiency due to great saphenous vein (GSV) reflux on efficiency, patient comfort and postoperative morbidity. Methods: Endovascular approach in treatment of GSV insufficiency was performed in 283 patients between 2011 and 2014 at our clinic. In group 1, EVLA was performed on 149 patients (42 male, 107 female; mean age 46.90 ± 11.43) and in group 2, RFA was performed on 134 patients (41 male, 93 female; mean age 47.02 ± 12.58). The results were compared in terms of local pain, ecchymosis, paresthesia, venous clinic severity score (VCSS), length of GSV that process performed, efficiency and Clinical Etiology Anatomy Pathophysiology (CEAP) classification data. Results: GSV diameter at saphenofemoral junction level was 10.65 ± 3.72 mm and 11.29 ± 3.78 mm in group 1 and 2, respectively. Length of GSV that process performed was 38.97 ± 6.88 cm in group 1 and 41.83 ± 4.82 cm in group 2. Postoperatively burn, pulmonary embolism (PE) and deep venous thrombosis (DVT) were not observed in both groups. Postoperative complications in group 1 were hematoma formation in 2 (1.3%) patients, ecchymosis in 13 (8.7%) patients, edema in 21 (14.1%) patients and paresthesia in 10 (6.7%) patients. Postoperative complications in group 2 were hematoma formation in 1 (0.7%) patient, ecchymosis in 8 (6%) patients, edema in 12 (9%) patients and paresthesia in 6 (4.5%) patients. The efficiency of the process was 96.6% in EVLA group and 98.5% in RFA group. Conclusion: We conclude that both RFA and 1470 nm radial fiber EVLA procedures are effective and reliable techniques in treatment of GSV insufficiency. No significant difference was found between two techniques in terms of efficiency and postoperative morbidity.

Effect of Diameter of Saphenous Vein on Stump Length after Radiofrequency Ablation for Varicose Vein.

Purpose:Radiofrequency ablation (RFA) has gained popularity for treatment of varicose veins. The diameter of the saphenous vein should be considered before RFA because occlusion of the vein may differ depending on its diameter. Until now, however, there have been few data about the correlation between the diameter of the saphenous vein and the stump length after RFA. The purpose of our study was to investigate its correlation.Materials and Methods:A retrospective review was performed from prospectively collected data of RFA patients between March 2009 and December 2011. Preoperatively, the saphenous vein diameter was measured. Ablation was initiated 2 cm distal from the junction. Postoperatively, stump length was measured at 1 week and 6 months. After 2 years, we measured the length from the saphenofemoral junction to the leading point of occlusion for great saphenous vein, and length from the saphenopopliteal junction to the leading point of occlusion for small saphenous vein. The paired t-test, independent t-test, and correlation analysis were used for statistical analysis. P-value <0.05 was considered statistically significant.Results:During the study period, RFA was performed in 201 patients. Endovenous heat-induced thrombosis developed in 3 patients (1.5%). After 2 years, the stump length was obtained in 74 limbs. The mean diameter and stump length of the saphenous vein were 6.7±1.8 mm and 12.5±8.5 mm, respectively. Correlation analysis showed that the Pearson correlation coefficient of these factors was −0.017.Conclusion:There was no correlation between the diameter of saphenous vein and stump length.

Prevalence of Non-thrombotic Iliac Vein Lesions in Patients with Unilateral Primary Varicose Veins

A role of non-thrombotic iliac vein lesions (NIVLs) in the development of primary varicose veins (PVVs) has not been studied. It seems that intravascular ultrasound (IVUS) is the most accurate method to diagnose these lesions. The aim of the study was to investigate the association between the presence of NIVLs and PVVs and the frequency of NIVLs in asymptomatic and PVV limbs. This was an observational study. Thirty-three patients with unilateral PVV and great saphenous vein incompetence who were qualified for surgical treatment were analyzed. Nineteen patients (57%) presented with varicose veins on the right side. During varicose vein surgery, IVUS of the iliac veins and the inferior vena cava was performed. In all patients the iliocaval outflow was interrogated by IVUS in both the limb with and without PVVs. The PVV side was accessed through the surgically exposed sapheno-femoral junction and the non-PVV side was accessed by an ultrasound guided percutaneous puncture of the common femoral vein. In both the common iliac (CIVs) and the external iliac veins (EIVs) the minimal and reference lumen area were measured and the percentage stenosis calculated. There were no intra- or post-procedural complications. The minimal lumen area (MLA) was smaller and the stenosis of the CIV was greater on the left side than the right: median 57 and 108 mm(2) (p = 0.001) and 69 and 34% (p < 0.001), respectively. However when the PVV and non-PVV sides were compared, no statistically significant differences of MLA or stenosis of the CIV were found: 88 and 67 mm(2) (p = 0.38) and 44% and 51% (p = 0.40), respectively. With regard to EIVs, no statistically significant differences in either MLA or stenosis between the left and right and PVV and non-PVV sides were found. The frequency of ≥50% stenosis of CIV and EIV in the PVV limbs and the non-PVV limbs was 42% and 48% and 51% and 39%, respectively. NIVLs are common in patients with PVV but do not seem to be associated with the presence of ipsilateral PVV.

Anatomical Predictors of Venous Thromboembolism Recurrence after Isolated Superficial Vein Thrombosis

Background: Isolated superficial vein thrombosis (iSVT) (i.e. without concurrent deep-vein thrombosis or pulmonary embolism) is a frequent event. Its clinical significance and management are controversial. Data on long-term follow-up are scarce and the impact of anatomical characteristics of iSVT on the risk of venous thromboembolism (VTE) (DVT and/or PE) recurrence has not been assessed.Objective: To determine the impact of anatomical characteristics of iSVT on the long-term risk of VTE recurrence.Methods: Using data from the The OPTIMEV (OPTimisation de l'Interrogatoire dans l'_evaluation du risque throMbo-Embolique Veineux) study, a prospective, observational, multicenter study, we assessed at 3 years in patients recruited for an objectively confirmed iSVT i) cumulative rates of DVT, PE and SVT recurrences using the Kaplan-Meier method; and ii) anatomical predictors of VTE recurrence (SVT involving the sapheno-femoral junction (i.e. ≤3 cm), SVT of the trunk of the great saphenous vein, bilateral SVT, SVT occurring in a varicose vein (i.e. C≥2 according to CEAP classification) using a Cox multivariable model adjusted for age, sex, cancer and personal history of VTE. At baseline, all patients with SVT underwent a complete bilateral swhole leg ultrasound to exclude concurrent DVT and during follow-up, all suspected VTE recurrences were confirmed/ruled out with objective tests. All recurrences were centrally adjudicated by the study's expert committee.Results: Among the 479 recruited patients with iSVT, 12.5% (n=60) had a thrombotic recurrence during the 3 years of follow-up. Cumulative rates of recurrence as a PE, DVT and iSVT were 1.9%, 4.8% and 5.8%, respectively. In multivariate analysis, a thrombus involving the sapheno-femoral junction at baseline independently increased the risk of VTE recurrence (HR=3.34 [1.5-7.2]). Presence of varicose veins also increased the risk but this result did not reach statistical significance (HR=1.8 [0.9 - 3.9], p=0.11).Conclusion: In an unselected population of patients with iSVT, long-term risk of VTE recurrence is substantial. Involvement of the sapheno-femoral junction is a strong independent predictor of VTE during the subsequent 3 years. Our results suggest the need for more aggressive management and follow-up of patients with iSVT exhibiting this anatomical characteristic. DisclosuresGalanaud:Daichi: Membership on an entity's Board of Directors or advisory committees, Research Funding; bayer: Membership on an entity's Board of Directors or advisory committees, Research Funding. Sevestre:bayer: Membership on an entity's Board of Directors or advisory committees, Research Funding; Daichi: Membership on an entity's Board of Directors or advisory committees, Research Funding. Pernod:pfizer: Consultancy; leo: Consultancy; bristol meyers: Consultancy; Daichi: Consultancy; bayer: Consultancy. Brisot:bayer: Membership on an entity's Board of Directors or advisory committees; daichi: Membership on an entity's Board of Directors or advisory committees. Quéré:3-M: Research Funding; thuasne: Research Funding; aspen: Research Funding; daichi: Membership on an entity's Board of Directors or advisory committees; bayer: Membership on an entity's Board of Directors or advisory committees; leo: Membership on an entity's Board of Directors or advisory committees.

Real time echo-guided endolaser for thermal ablation without perivenous tumescence

Abstract Background There is no consensus in the medical literature on the ideal procedure for endovenous laser application. Objective To assess the safety and efficacy of real time echo-guided endovenous laser for thermal ablation of great saphenous vein (GSV) incompetence, without perivenous tumescence. Methods Thirty-four limbs of patients with CEAP clinical scores of 2 to 6 and bilateral incompetence of the saphenofemoral junction (SFJ) and GSV, confirmed by Echo-Doppler, underwent endovenous laser therapy and were followed for 1 year. Laser ablation was performed using a 600 µ bare optical fiber introduced endovenously close to the malleolus along the full extent of the GSV in an anterograde direction, using a standardized echo-Doppler-guided AND? 15 watt continuous mode 980 nm diode laser with real-time monitoring of thermal ablation of the whole target vein. Adverse effects and complications were recorded. Results Hyperesthesia, cellulitis, and fibrous cord, all transitory, developed in 2.9% of the 34 limbs treated; 8.8% developed hypoesthesia in the perimalleolar region, which was transitory and had no clinical consequences; there were no cases of deep venous thrombosis. Immediate occlusion was achieved in 100% of the 34 saphenous veins that underwent photocoagulation, although one exhibited recanalization without reflux at 1-month follow-up. After 6 months and 1 year, occlusion was 100% according to echo-Doppler findings. Conclusions Real-time echo-guided 980 nm endovenous laser ablation without perivenous tumescence provided controlled thermal ablation with safe, effective, immediate and medium-term GSV occlusion and can therefore be recommended as a method for the treatment of chronic venous disease.

Quantifying saphenous recirculation in patients with primary lower extremity venous reflux.

The great saphenous vein (GSV) in patients with superficial venous insufficiency might act as a beneficial conduit for antegrade venous drainage and also as a harmful conduit for promotion of reflux and/or recirculation and subsequent skin changes. The aim of this study was to measure the antegrade and retrograde GSV volume displacements during calf compression and release maneuvers. This was used to quantify harm over benefit with a recirculation index (RCI). Sixteen legs (nine right) from 16 patients (nine male) with primary superficial venous insufficiency were scanned standing with duplex ultrasound, at the upper thigh GSV, 10 cm below the sapheno-femoral junction. The clinical, etiological, anatomical, pathophysiological class was C2 = 3, C3 = 2, C4a = 6, C4b = 4, C5 = 1. The median age (range), venous clinical severity score, and refluxing GSV diameter were 63 (21-79) years, 8 (4-16), and 7 (5-10) mm, respectively. A manual calf compression and release (MCCR) maneuver was performed once, and a cyclical calf compression and release (CCCR) three times for repeatability. With the CCCR maneuver, the calf-cuff and inflation-deflation pump provided a cyclical compression pressure of 120 mm Hg (3 seconds) with a release time of 16.4 seconds to standardize venous refilling time. The results are expressed as median [interquartile range]. The CCCR compared with the MCCR resulted in longer reflux duration (16.4 [8.2-16.4] seconds vs 5.7 [3.7-6.8] seconds; P < .0005), higher time-averaged mean velocities in reflux (23.5 [14.9-27.9] cm/s vs 14.1 [9-17.6] cm/s; P < .0005) and greater reflux volume displacements (81.7 [38.8-152.8] mL vs 27.3 [16.4-53.4] mL; P < .0005). There were significant correlations between increasing antegrade volume measurements and increasing reflux volume measurements irrespective of whether CCCR, (r = 0.841; P < .0005) or MCCR (r = 0.762; P = .001) was used. This implies that the displaced antegrade volume might have a causal effect on the resulting reflux volume. The ratio of reflux volume/antegrade volume (RCI) was 2.14 [1.58-2.74] with the CCCR. This supports the recirculation phenomenon. Adjusted to a standard median for each leg, the repeatability limits (three times) of the RCI was excellent at 2.14 (95% confidence interval, 2.09-2.21). In this study we measured the behavior of the GSV in terms of harmful reflux over beneficial drainage using the RCI. We recognize that reflux values depend on the type of provocation test and the amount of displaced antegrade volume. This limitation might be overcome by factoring reflux as an expression of antegrade flow using the RCI. When standardized, a test for quantifying saphenous recirculation might have many clinical applications. The next step should be a prospective study to validate the RCI with clinical and quality of life parameters.

Saphenous sparing laser modern options (comment to Gianesini et al., Veins and Lymphatics 2013;2:e21 and Veins and Lymphatics 2015;4:5246)

Not required

Endovenous laser ablation of varicose veins

PurposeTo assess the value of endovenous laser ablation as a treatment of varicose veins. Materials and methodsStudy included 30 patients (22 females, 8 males) with a mean age of 38.4years (age range from 25 to 55years) presented with varicose vein caused by saphenofemoral junction (SFJ) incompetence with Great Saphenous Vein (GSV) reflux. Patients underwent Endovenous Laser Therapy (EVLT) with 980-nm diode laser as an outpatient procedure. Patients were re-examined one week, 1, 2 and 3months postprocedure. ResultsImmediate postoperative successful occlusion that is defined as absence of flow by duplex ultrasound, was achieved in 29 GSVs (97%). Failure occurred in one case with large vein (GSV diameter>0.8cm). The procedure was well tolerated by all patients. The mean GSV diameter measured in upright position, was 6.5mm (range from 4 to 9mm). The mean length of treated GSV was 44.2cm (range from 38 to 50cm). Ecchymosis was seen in 18 patients (72%). Indurations were observed in 2 patients (6%) and resolved within two weeks. No paresthesia, superficial burns or DVT was detected. ConclusionEndovenous laser ablation for GSV reflux is a safe, feasible and efficient outpatient technique.

Five-year follow-up of a randomized, controlled trial comparing saphenofemoral ligation and stripping of the great saphenous vein with endovenous laser ablation (980 nm) using local tumescent anesthesia

The objective of this study was to compare the long-term results (groin-related recurrence, great saphenous vein [GSV] occlusion rate, Clinical class, Etiology, Anatomy, and Pathophysiology [CEAP] staging, and quality of life [QoL]) after the treatment of a GSV incompetence by saphenofemoral ligation and stripping (SFL/S) with endovenous laser ablation bare fiber, 980 nm (EVLA). Patients with GSV insufficiency and varicose veins were randomized to either undergo SFL/S or EVLA, both of which were performed under tumescent anesthesia. The long-term results, which included the anatomic occlusion rate, varicose vein recurrence at the saphenofemoral junction (SFJ), relief of venous symptoms and QoL, were compared up to 5 years after treatment. A total of 130 legs of 121 patients were treated with either SFL/S (n = 68) or EVLA (n = 62). In the first 12 months, three recanalizations of the GSV were observed after EVLA. Up to 5 years later, more recurrent varicose veins caused by neoreflux in incompetent tributaries of the SFJ were observed in after EVLA (31%; 19/61) compared with SFL/S (7%; 4/60; P < .01). Neovascularization in the groin with clinically visible recurrence identified at 3 and 5 years post-treatment follow-up was only observed in the SFL/S group (n = 6). After 5 years, clinically visible recurrences originating from the SFJ region after EVLA were observed 33% (20/61) compared with 17% of patients (10/60) after SFL/S (P < .04). In both treatment groups, venous symptoms improved significantly. Patients in both groups reported a continuing significant cosmetic improvement measured on a visual analog scale of 1 to 10 (mean, 7.49; P < .01). There was no difference in the CEAP staging and a standardized, non-disease-specific instrument for describing and valuing health states (EuroQol-5D), between the groups up to 5 years after follow-up. At the 5-year follow-up, a significantly higher varicose vein recurrence rate originated at the SFJ region after EVLA compared with SFL/S. There were no differences in the relief of venous symptoms, CEAP staging, or general QoL between the groups.

Analysis of consecutive open surgeries for varicose vein at Dhulikhel hospital.

Varicose veins are prominent dilated veins in the lower limb primarily due to disease in the junction between superficial and deep venous system. Operative treatment of such condition significantly improves quality of life and also demonstrably decreases the potential complications. We present with analysis of fifty one consecutive open surgeries for varicose vein at Dhulikhel Hospital. To analyze consecutive open surgeries for varicose vein in terms of gender, age, presenting complaints, findings and post operative outcomes. All the cases posted for open surgeries for varicose vein at Dhulikhel Hospital during September 2012 - July 2013 were included. If great saphenous vein in thigh was more than 3 mm, segmental stripping was done. The collected data was analyzed using SPSS version 13.0. There were 51 cases with 47% male and 53% female. Mean age was 48.9 years. Prominent dilated vein was the most common presenting complaints. Incompetent saphenofemoral junction was present in 68.6% cases. Segmental stripping was done in 51% cases. Mean days of admission was 2.6 days. Mean pain free day was on 3.2 days. In an average, patient were able to walk normally in 4.1 days. Analysis of hospital admission days, ability to walk normally and pain free day attained in between stripping required and stripping not required group showed significant difference with higher values in stripping required group. Although conventional stripping surgery has long been performed for varicose vein, this is associated with prolonged hospital admission, prolonged time required for ability to walk normally, and prolonged time taken for pain free status. Hence newer modalities of treatment like radiofrequency ablation is warranted in our setup too.

Commentary on ‘Same Site Recurrence is More Frequent After Endovenous Laser Ablation Compared with High Ligation and Stripping of the Great Saphenous Vein: 5 Year Results of a Randomized Clinical Trial (RELACS Study)’

Recurrence after “curative” procedures for varicose veins due to great saphenous vein (GSV) incompetence is widely considered the Achilles heel of all types of intervention, including the “radical” gold standard of high ligation and stripping of the GSV accompanied by phlebectomies. Although the introduction of minimally invasive endovenous thermal methods has challenged this traditional gold standard, further information on the long-term recurrence rates of the two methods is required to adequately inform decision making. In this issue, the RELACS (Randomized Study Comparing Endovenous Laser Ablation With Crossectomy and Stripping of the Great Saphenous Vein) investigators report on the 5 year results of a randomized controlled trial (RCT) comparing endovenous laser ablation (EVLA) with saphenofemoral junction (SFJ) flush ligation (with a non-absorbable 0-0 suture and stump oversewing with a 40 polypropylene suture to reduce groin neovascularization) and invaginated stripping of the GSV to just below the knee. Three similar RCTs on 542 patients have already reported 5 year results. These trials compared EVLA, performed with bare tip 810 nm or 980 nm diode laser, with stripping. Of note, the surgical technique was different in all four RCTs. SFJ flush ligation and GSV cryostripping to 5 cm below the knee was performed in the first trial; SFJ flush ligation and GSV PIN (perforateeinvaginate) stripping to just below the knee, in the second one; and SFJ flush ligation (with a non-absorbable 0-0 suture and stump intimal destruction with bipolar cautery to reduce groin neovascularization) and invaginated stripping of the GSV to the distal point of reflux in the third. Unlike these RCTs, RELACS included mainly patients with chronic venous insufficiency [clinical, etiologic, anatomic, and pathological (CEAP) clinical class C3eC6]. Consistent with other RCTs, venous severity scores and quality of life measures were equally improved with EVLA and stripping in RELACS. Also, in agreement with the other RCTs, recurrent varicose veins were reported to be equally frequent 5 years after EVLA and stripping (45% vs. 54%; p 1⁄4 .15) in RELACS; however, clinical recurrence in the operated region was more frequent after EVLA (18% vs. 5% for stripping; p < .001), and different site recurrence was more frequent after stripping (50% vs. 31% for EVLA; p 1⁄4 .002). Neovascularization and recurrence unrelated to

Clarivein mechanochemical ablation of the great and small saphenous vein: Early treatment outcomes of two hospitals.

Mechanochemical endovenous ablation is a novel technique for the treatment of great saphenous vein and small saphenous vein incompetence which combines mechanical injury of the endothelium with simultaneous infusion of liquid sclerosant. The main objective of this study was to evaluate early occlusion. All consecutive patients who were eligible for the treatment with mechanochemical endovenous ablation were included. Inclusion period was from the introduction of the device in the hospitals (September 2011 and December 2011) until December 2012. A total of 449 patients were included representing 570 incompetent veins. In 506 treated veins, duplex ultrasonography was performed at follow-up: 457 veins (90%) were occluded at a follow-up of 6 to 12 weeks. In univariate and multivariate analysis, failure of treated great saphenous vein was associated with saphenofemoral junction incompetence (OR 4; 95% CI 1.0-17.1, P = 0.049). The Clarivein device proves to be safe and had a high short-term technical effectiveness.

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

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

The use of SPECT/CT for anatomical mapping of lymphatic drainage in vulvar cancer: possible implications for the extent of inguinal lymph node dissection.

To determine the lymphatic drainage pattern using SPECT/CT in clinically node-negative (cN0) patients with vulvar cancer, and to evaluate the possible implications for the extent of inguinal lymph node dissection. A total of 83 patients with vulvar cancer scheduled for sentinel node (SN) biopsy were injected peritumorally with radioactive nanocolloid particles followed by lymphoscintigraphy and SPECT/CT for anatomical localization. The SN and higher-echelon nodes on SPECT/CT were located in different zones in the groin and pelvic region. The groin was divided into five zones according to Daseler et al.: four zones obtained by drawing two perpendicular lines over the saphenofemoral junction and one zone directly overlying this junction. The nodes in the pelvic region were classified into three zones: external iliac/obturator, the common iliac and the paraaortic zones. A total of 217 SNs and 202 higher-echelon nodes were localized on SPECT/CT. All SNs were located in the five zones according to Daseler et al.: 149 (69%) in the medial superior region, 31 (14%) in the medial inferior region, 22 (10%) in the central region, 14 (6.5%) in the lateral superior region and only 1 (0.5%) in the lateral inferior region. The higher-echelon nodes were located both in the groin (15%) and in the pelvic region (85%). In patients with cN0 vulvar cancer, lymphatic drainage occurs predominantly to the medial regions of the groin. Drainage to the lateral inferior region of the groin is only incidental and in SN-positive patients this zone might be spared in subsequent extended lymph node dissection. This may lead to a decrease in the morbidity associated with this procedure. SPECT/CT is able to personalize lymphatic mapping, providing detailed information about the number and anatomical location of SNs for adequate surgical planning in the groin.

Study on the Long-Term Results of Endovenous Laser Ablation for Treating Varicose Veins.

Background Endovenous laser ablation (EVLA) is widely performed since the early 2000s, but there are few long-term results. Objectives The aim of this study was to evaluate the long-term results of EVLA employed for treating varicose veins of the lower limbs by duplex ultrasonographic study. Methods A total of 24 limbs of 17 patients who underwent EVLA between 2004 and 2007 were examined with duplex ultrasonographic scans. The mean follow-up period was 66.1 months. Results There were five recurrences of saphenofemoral junction reflux. The occlusion rate was 79.2% at a mean follow-up of 66.1 months. There were 14 recanalizations and 5 recurrences of the great saphenous vein. Five partial and nine total recanalizations were observed. Conclusions EVLA is an effective and minimally invasive treatment for varicose veins. Our long-term result was acceptable, but the result was not outstanding.