Saphenous Trunk Research Articles

Progression of superficial venous insufficiency: analysis and implications for therapy

Progression of superficial venous insufficiency: analysis and implications for therapy Vincenzo Puleo,1 Pier Luigi Castagno2 1Servizio di Angiologia e Diagnostica Vascolare, Torino, Italy; 2S.C. Chirurgia Vascolare 1, Azienda Ospedaliera Città della Salute e della Scienza di Torino, Torino, Italy Abstract: Challenges to the widely accepted concept of retrograde progression of superficial venous insufficiency (SVI) have come from studies showing that the conventional descending paradigm is unable to account for many clinical presentations that would be better explained by the ascending hypothesis for the condition. Evidence substantiating this hypothesis holds therapeutic importance because, if confirmed, it would further weaken the rationale for aggressive surgery, in keeping with the general trend for alternative procedures. To evaluate the progression of SVI we performed echo Doppler examinations twice yearly for 5 years (ten examinations per patient) in 100 patients with SVI in which superficial venous branches (suprafascial) or segments of saphenous vein were incontinent, while the saphenofemoral junction was continent. Ascending progression of SVI was found in about 76% of patients. In the remaining patients, stabilization of the condition was probably due to its slow natural history. Venous insufficiency initially affecting the superficial venous branches of the leg variously progressed upward to involve the saphenous trunk in most cases and different sites in the vein, sometimes involving the saphenous ostium as well. The ascending hypothesis provides a convincing explanation for the various clinical presentations of SVI and the recurrence of varicosities after saphenectomy. In addition to intrinsic weakening of the superficial venous wall, elevated pressure in the calf venous circulation pushing on the superficial compartments, devoid of protective mechanisms, could be an alternative/complementary pathogenetic mechanism leading to structural weakening of the perforating vein valves. From a therapeutic perspective, the hypothesis for ascending progression of SVI is consistent with the use of alternative methods that halt the progression of venous disease and preserve the saphenous axis. Anatomical and functional assessment of ostial incontinence is key to achieving good outcomes after treatment. Of equal importance are the diameter and length of the incontinent saphenous trunk and the length of the continent saphenous segment below the contiguous incontinent saphenous segment. In cases of crossectomy, meticulous short or ultrashort stripping can maintain saphenous drainage through the perforators into the deep circulation. Keywords: superficial venous insufficiency, hemodynamics, pathophysiology, surgery

Pattern and types of non-saphenous vein reflux

Venous reflux often originates from saphenous trunks and their tributaries. In about 10% of the patients reflux derived from non-saphenous veins (NSV) such as those located in the buttock, postero-lateral thigh, vulva, lower posterior thigh, popliteal fossa, knee or along the peripheral nerves such as the tibial and sciatic nerve. It is also important to note that patients who had saphenous vein stripping or ablation have higher odds of presenting with NSV reflux. The majority of patients with NSV reflux have varicose veins and lower extremity oedema; however, about 10% of those patients present with skin damage. This paper analyses the patterns and types of NSV reflux for diagnosis and treatment purposes.

大伏在静脈瘤に対する各種術式の治療成績

大伏在静脈瘤に対する各種術式の治療成績

Surgery for Recurrent Varicose Veins: Toward a Less-Invasive Approach?

Redo surgery for recurrent varicose veins, involving the saphenofemoral junction (SFJ) or saphenopopliteal junction has a bad reputation because it is a laborious, time-consuming intervention, characterized by a high incidence of postoperative complications. Moreover, outcome is worse than after primary surgery. This is illustrated by long-term (5 years) prospective follow-up of 235 reoperated limbs after redo procedure at the SFJ, all performed at the University Hospital of Antwerp between 1991 and 2009. Such invasive redo procedures will soon belong to the past because, nowadays, many less-invasive alternatives are available: phlebectomies without reopening the groin, focusing on the "varicose reservoir"; limited redo surgery with combined with foam sclerotherapy; endovenous ablation of a residual refluxing saphenous trunk; ultrasound-guided foam sclerotherapy; embolization treatment of pelvic vein incompetence; and treatment of an underlying deep-venous obstruction. All these interventions can be performed in an ambulatory setting, without need for general anesthesia.

Neovascularization is not a major cause of varicose vein recurrence

Neovascularization is often seen as an important cause of varicose vein recurrence. Is this a convenient expression to explain some bad results in surgery? This clinical retrospective study (from 1/1/94 to 12/31/98) included 1880 patients (1348 females: 71.7%, 532 males: 28.3%, with the median age of 52) who received limb varicose vein operations. 2455 legs were operated on (575 bilateral). 1122 out of the 1880 patients (60.3%) were assessed by echotomography, 84% of them by the same investigator. All the recurrences were confirmed by echotomography. Surgical interventions consisted of long saphenous vein (LSV) stripping: 1822 (74.2%) and short saphenous vein (SSV) stripping: 304 (12.4%). Recurrence in LSV area was 258 (10.5%), in SSV area: 36 (1.5%), and miscellaneous perforators: 35 (1.4%). 91% of the patients showed good result. Bad results (9%) were documented by echotomography and were encountered in neglected lesions, multiple recurrences and obesity. Neovascularization was never observed, but in 14 cases (4.2%) was a primary cause of recurrence. In spite of the serpentine vessels at the saphenofemoral junction (SFJ), there was always a stump to function as a “feed faucet.” Thirty three recurrences (1.3%) localized at the groin area were due to perineal veins connected to the hypogastric system. Neovascularization, considered a normal process, is unable to remodel the anatomy of the SFJ. Prevention of neovascularization is incumbent upon accurate interpretation of duplex scanning, total resection of tributaries and a stripping of saphenous trunk.

Increased Vein Wall Apoptosis in Varicose Vein Disease is Related to Venous Hypertension

Objectives The study aimed to evaluate a wide range of apoptotic markers in the vein wall of patients with superficial chronic venous disease (SCVD) compared with normal veins. Design This was an observational study. Methods Vein specimens were obtained from 19 patients suffering from SCVD. From each patient, a specimen of the proximal part of the great saphenous vein (GSV), a specimen of the distal part of the vein and a specimen of a varicose tributary were obtained. Immunohistochemical analysis was used to localise the expression of BAX, p53, Caspase 3, BCL-2, BCL-6, BCL-xs, BCL-xl and Ki-67. Vein specimens from 10 healthy GSVs were used as controls. Results Saphenous vein specimens from patients with SCVD showed increased BAX, Caspase 3, BCL-xl and BCL-xs ( p < 0.01 for all) and Ki-67 ( p = 0.02) compared with healthy GSVs. In the venous disease group, GSV specimens from the distal ankle area showed increased BAX ( p < 0.01) and BCL-xs ( p = 0.031) compared with varicose tributaries specimens, which subsequently showed increased BAX ( p = 0.044), Caspase 3 ( p = 0.028) and BCL-xs ( p = 0.037) compared with specimens from the proximal GSV. In addition, in the venous disease group, specimens from distal GSV showed increased BAX ( p < 0.01), Caspase 3 ( p = 0.019) and BCL-xs ( p = 0.014) compared with the proximal GSV. Conclusion Varicose veins exhibit increased apoptotic activity, by means of increased BAX, Caspase 3, BCL-xl and BCL-xs, compared with normal veins. Patients with varicose vein disease show increased apoptosis in the distal saphenous trunk compared with the proximal saphenous trunk, suggesting an association between chronic venous hypertension and apoptosis.

Laser Saphenous Ablations in More Than 1,000 Limbs With Long-Term Duplex Examination Follow-Up

The goal of this study was to evaluate the duplex results of endovenous laser ablation in the treatment of incompetent great saphenous veins (GSV) and small saphenous veins (SSV) with at least 1-year follow-up. A retrospective registry was entered by 11 centers from Europe and America, organized by the International Endovenous Laser Working Group. Data concerning 1,020 limbs in patients with incompetence of the GSV and/or SSV, treated with the Endovenous Laser Ablation (EVLA) procedure, were collected. EVLA failures were defined on duplex imaging as reflux confined to the saphenofemoral or saphenopopliteal junction, reflux confined to the main saphenous trunk, or reflux of both junction and main trunk (totally patent saphenous vein) were analyzed at one or more years postoperatively. The mean age of patients was 54 ± 5 years (range: 18-91 years). The average body mass index was 25. There was a paucity of severe complications: One case of third-degree skin burn, six patients with postsurgical deep vein thrombosis (0.6%), and 27 cases of sensory nerve damage (2.7%). At 1-year, the rate of complete occlusion of the saphenous trunk was 93.1%. There were 79 cases of treatment failures as evidenced by duplex: 22 isolated junction failures (2.2%), 44 isolated trunk failures (4.4%), and 13 totally patent veins (1.3%). Two-year duplex results were reported for 329 limbs with the identification of 19 new cases of failure. No new cases of failure were reported at 3-year follow-up of 130 limbs. Cumulative failure rates estimated by Kaplan-Meier analysis were 7.7% at 1-year and 13.1% at 2- and 3-year follow-up. On the basis of a duplex scan performed at least 1-year post-treatment, this multicenter registry confirms the safety and efficacy of the EVLA procedure in the treatment of GSV and SSV reflux. Considering the continued failure rate documented in the present study, an annual follow-up by duplex is recommended to 2 years after EVLA.

What is the Current Role of Foam Sclerotherapy in Treating Reflux and Varicosities?

Foam sclerotherapy is not a defined procedure nor is the product uniform or licensed for use but it is now accepted practice in most territories worldwide. Foam sclerotherapy has been used to treat a wide range of venous conditions from the closure of incompetent great saphenous trunk veins to telangiectasia and from venous malformations to hemorrhoids with good outcomes being reported. There is a rapidly expanding body of literature supporting its safety and efficacy as well as a few case histories of serious complications. This article will focus on the current role of foam sclerotherapy in the treatment of varicose veins.

Incidence of Side Effects Using Carbon Dioxide–Oxygen Foam for Chemical Ablation of Superficial Veins of the Lower Extremity

Objectives To determine the incidence of side effects following treatment of varicose veins with carbon dioxide–oxygen (CO 2/O 2) foam sclerotherapy, and to compare results with historical controls using CO 2- or air-based foams. Design Cohort study with prospective data collection, private clinic setting. Patients The patient population consisted of one hundred patients, 95% women, age 52 SD 13 years-old, CEAP class C 2EpAsPr. Methods Patients underwent ultrasound-guided foam sclerotherapy following thermal ablation of saphenous trunks; 1–3% polidocanol and 70%CO 2–30%O 2 gas were mixed in a 1:4 proportion. Volume injected averaged 22 SD 11 (range: 2–46) mL. Vital signs were monitored for 1 h; side effects were recorded up to 24 h post treatment. Incidence of side effects was compared to CO 2- and air-based foam data. Results Heart rate decreased from 73 SD 11 at the start to 68 SD 9 bpm ( p < 0.001, paired t-test) following the procedure. Systolic and diastolic pressures, 127/75 SD 18/14 mmHg, respiratory rate, 15 SD 4 rpm and pO 2, 98 SD 2%, did not change significantly. Itching (7) or leg pain (24) reporting was similar to that for air-based foam ( p = NS). Lack of reported chest tightness and/or dry cough was superior to our previous data with CO 2 or air foam ( p < 0.05). Reporting of dizziness (1) was less than that for air-based foam ( p = 0.002). The incidence of visual disturbance (2%), was comparable with that for CO 2 (3%) or air (8%) foam, but too few cases were available for meaningful statistical analysis. Conclusions Foam sclerotherapy using CO 2/O 2 foam was well tolerated by patients and resulted in fewer side effects than similar treatment using air foams.

The distribution and significance of varicosities in the saphenous trunks

The purpose of this study was to determine the prevalence, distribution, and extent of varicosities and focal dilatations in the saphenous trunks, their association with the sites of reflux, and their correlation with CEAP classes. This prospective study included patients belonging to different CEAP classes (2-6) and a control group of age- and gender-matched healthy volunteers (group C). Color-flow duplex scan imaging was used to evaluate the entire venous system from groin to ankle for reflux and obstruction. Varicose segments and focal dilatations of the great and small saphenous veins (GSV and SSV) were recorded, and the diameters throughout the length of the saphenous trunks were measured. The presence of varicosities in the tributaries and accessory veins were documented. From the 739 consecutive patients, 239 were excluded due to superficial venous thrombosis (SVT), deep venous thrombosis (DVT), both SVT and DVT, previous interventions, or C3-C6 presentation with no chronic venous disease (CVD). The included 500 patients (681 limbs) were divided into two groups based on CEAP class: group A (C2 + C3) and group B (C4-6). Group A had significantly more women than group B and a younger mean age (48 vs 56 years). Overall, GSV reflux (86%) was more prevalent than SSV reflux (17%), P < .0001. Saphenous trunk diameters, saphenofemoral junction (SFJ) and saphenopopliteal junction (SPJ) involvement were greater in group B, (P < .01). Group C had smaller saphenous diameters compared to group A in all locations (P < .05) but the malleoli. The prevalence of the saphenous varicose segments in both groups was small with the GSV in group B being the highest (4.3%) and the SSV in group A being the smallest (1.2%). Focal dilatations were significantly more prevalent than varicosities in the saphenous trunks (P < .0001). Varicosities of tributaries and accessory veins were more prevalent than those of saphenous trunks (P < .0001). The mean length of varicose segments in the saphenous trunks was short (3.8 cm, range, 2.1-6.4 for group A vs 4.1 cm, range, 2.3-8.3 for group B, P = .09). A novel definition for varicosities in the saphenous trunks was established. Using this definition, it was determined that focal dilatations are far more common than varicosities. Because both of these entities are more prevalent in the accessory saphenous veins and tributaries, and CEAP class correlates positively with the extent of reflux and saphenous trunk diameter, studies on earlier interventions are warranted to prevent CVD progression.

Sclerotherapy and foam sclerotherapy for varicose veins

To review published evidence concerning treatment of varicose veins using ultrasound-guided foam sclerotherapy (UGFS) to assess the safety and efficacy of this treatment. Medical literature databases including MedLine, Embase and DH-DATA were searched for recent literature concerning UGFS. Papers describing the early results and later outcome have been assessed and their main findings were included in this summary. Few randomized studies have been published in this field and much of the available data come from clinical series reported by individual clinicians. It is clear that foam sclerotherapy is far more effective than liquid sclerotherapy and that ultrasound imaging allows the treatment to be delivered accurately to affected veins. There is evidence that 3% polidocanol foam is no more effective than 1% polidocanol foam. The optimum ratio of gas to liquid is 4:1, although a range of ratios is reported in the published work. There is a wide variation in the volume used as well as the method by which it is injected. The use of carbon dioxide foam reduces the systemic complications, particularly visual disturbance, as compared with air foams. Very few serious adverse events have been reported in the literature despite the widespread use of this method. Rates of recanalization of saphenous trunks following UGFS are similar to those observed after endovenous laser and endovenous RF ablation of veins, as well as the residual incompetence after surgical treatment. UGFS is a safe and effective method of treating varicose veins. The relative advantages or disadvantages of this treatment in the longer term have yet to be published.

Side-effects and complications of foam sclerotherapy of the great and small saphenous veins: a controlled multicentre prospective study including 1025 patients

Increasing interest in foam sclerotherapy (FS) for saphenous insufficiency has highlighted the need to study the side-effects and complications of this treatment. The aim of this study is to better assess their nature and incidence. A multicentre, prospective and controlled study was carried out in which patients treated with FS for great (GSV) and small saphenous veins (SSV) trunk incompetence were included. Immediate untoward events were reported. Duplex ultrasound (DUS) examination was carried out to assess all patients between the eighth and 30th day. In addition, 20% of patients were called by an external auditor. In total, 818 GSV and 207 SSV were treated in 1025 patients in 20 phlebology clinics. Ninety-nine percent of patients were controlled with DUS and non-duplex-checked patients were all called. The saphenous trunk was occluded in 90.3% of patients. Twenty-seven (2.6%) side-effects were reported: migraine (n = 8, 4 with visual disturbance); visual disturbance alone (n = 7); chest pressure alone (n = 7); and chest pressure associated with visual disturbance (n = 5). Eleven thrombo-embolic events occurred: 10 deep vein thrombosis (DVT) but only five in symptomatic patients, and one pulmonary embolism that occurred 19 days following the FS without DVT identified by DUS. One transient ischaemic stroke, with complete clinical recovery in 30 minutes, and one septicaemia with satisfactory outcome were reported as well. This study demonstrates in a large sample of patients a low rate of adverse reactions after FS of great and small saphenous trunks. However, but the eventuality of exceptional but more serious complications has to be taken into account in the management of patients. A multicentre study like this one takes into account different practices and reports all possible complications, thus demonstrating the need for a common validated protocol.

Catheter-directed sclerotherapy

Catheter directed sclerotherapy (CDS) involves the use of a long catheter to deliver a sclerosing agent into a target vessel (saphenous trunks or venous malformations) under ultrasound guidance. Aims and Methods This article reviews the history, current techniques and devices and the evidence as it relates to these procedures. CDS was developed to increase the safety and efficacy of ultrasound-guided sclerotherapy (UGS). With the advent of foam sclerosants and tumescent anaesthesia, the procedure has enjoyed a higher primary success rate. CDS has a better safety profile when compared with UGS with virtually no risk of intra-arterial injection or sclerosant extravasation. Compared with endovenous laser (EVLA) and radiofrequency ablation (RFA), CDS is a quicker procedure with less associated pain. Some balloon catheters, however, have been found to force the sclerosant down the perforators causing femoral vein occlusion. Based on the current level of evidence, no firm conclusion regarding the efficacy of CDS techniques can be drawn in comparison with EVLA or RFA, but the primary success rate is probably higher than the standard UGS. CDS ensures a safe intraluminal delivery of the sclerosing agent into the trunk of the saphenous veins using a single access point. This procedure preceded EVLA and RFA, and remains a safe alternative for the treatment of saphenous incompetence and venous malformations.

Foam and liquid sclerotherapy for varicose veins

The objective of this study is to review the methods and outcome of ultrasound-guided foam sclerotherapy (UGFS) for the treatment of superficial venous incompetence. Medical literature databases including Medline were searched for recent literature concerning UGFS. Papers describing methods and outcome have been assessed and their main findings included in this summary. A detailed description of the methods used by the author has been included as an example of how successful the treatment may be achieved. A diverse range of practice is described in published literature in this field. Each group of authors used their own variation of the methods, described in the published literature, with good results. It is clear that foam sclerotherapy is far more effective than liquid sclerotherapy and that ultrasound imaging allows the treatment to be delivered accurately to affected veins. There is evidence that 3% policocanol foam is no more effective than 1% polidocanol foam. The optimum ratio of gas to liquid is 4:1, although a range of ratios is reported in published work. There is a wide variation in the volume used as well as the method by which it is injected. The use of carbon dioxide foam reduces the systemic complications, particularly visual disturbance, when compared with air foams. Very few serious adverse events have been reported in the literature despite the widespread use of this method. Rates of recanalization of saphenous trunks following UGFS are similar to those observed after endovenous laser and endovenous radiofrequency ablation of veins, as well as the residual incompetence after surgical treatment. UGFS is a safe and effective method of treating varicose veins. The relative advantages or disadvantages of this treatment in the longer term are yet to be published.

Leg ulcer treatment

Venous ulcers continue to cause problems for patients and health care systems. These are painful and unpleasant for the patient and expensive for health care providers to treat. This brief review highlights effective methods of management. There is level 1 evidence of the efficacy of compression (bandaging or stockings) in healing ulcers as well as maintaining healing. Patients with superficial saphenous reflux, with or without perforating and deep vein incompetence, benefit from superficial venous surgery. This does not speed ulcer healing but is effective at preventing recurrence after healing with compression. Minimally invasive methods of managing incompetence of superficial saphenous trunks, including endovenous laser ablation, radiofrequency ablation, and foam sclerotherapy are probably also effective in treating patients with venous leg ulcers. Perforating vein ligation is commonly combined with superficial venous surgery for leg ulcer patients, but no systematic data are available to define the role of this treatment. Some centers use deep vein reconstruction to restore competence to deep vein valves. Insufficient data have been published to allow any general recommendation to be made for this treatment. A limited number of drugs have efficacy in promoting leg ulcer healing. They may be used in combination with compression treatment in patients with ulcers refractory to other methods of management. No particular ulcer dressing has been shown to be effective in speeding ulcer healing.

Regional Femoral Nerve Block Combined with Local Anaesthesia in Day Surgery for Varicose Veins

Three anaesthetic techniques are commonly used in surgery of varicose veins: general anaesthesia, central nerve block and tumescent anaesthesia. In this report we evaluate the efficacy and safety of another method – regional femoral nerve block with additional local anaesthesia. We report the early postoperative outcome in a group of 56 patients managed using this type of anaesthesia. In all cases removal of all incompetent saphenous trunks and varices was accomplished without any operative complication. Two cases of wound infection occurred postoperatively and in three patients skin abrasions were caused by bandages. 62% of patients are asymptomatic 2 months after surgery. We have found this anaesthetic method to be safe, efficient, easy and quick to perform. It offers an alternative to tumescent or general anaesthesia for day surgery in patients with varicose veins.

Comparison of 1% and 3% Polidocanol Foam in Ultrasound Guided Sclerotherapy of the Great Saphenous Vein: A Randomised, Double-Blind Trial with 2 Year-Follow-up. “The 3/1 Study”

Objectives: To compare 1% and 3% POL foam in treating the great saphenous vein (GSV) by ultrasound guided sclerotherapy. Design: Multicentre, prospective, randomised, double-blind trial with 2 year-follow-up. Patients and methods: 148 patients with GSV reflux (saphenous trunk diameter 4–8 mm) were randomised to undergo ultrasound guided foam sclerotherapy using either 1% or 3% POL foam in a single session. Foam production was standardised using a sterile disposable syringe kit including sterile air and the Turbofoam® machine. Duplex ultrasonography was used to assess the outcome at 3 weeks, 6 months, 1 year, 18 months and 2 years. The main criterion of success was the disappearance of the venous reflux. The length of occlusion of the vein (only measured at 3 week-echography assessment) was a secondary criterion. Side effects were assessed. Results: 74 patients were included in each group. The mean volume of foam injected was 4.4 ml for the 3% group and 4.6 ml for the 1% group. After 3 weeks, reflux was abolished in 96% (71 patients) of the 3% group and 88% (68 patients) of the 1% group (NS). The mean occlusion length of the vein was 38 cm for the 3% group and 34 for the 1% group (NS). After 2-years, reflux was absent in 69% of the 3% group and 68% of the 1% group (NS). 14 patients were lost to follow-up at 2 years. Conclusion: This study demonstrates equivalent efficacy for 1% POL and 3% POL foam in sclerotherapy of the GSV where the trunk is less than 8 mm in diameter. These data obtained two years of follow-up confirm our previously reported 6 month-follow-up data published in 2005.

Primary chronic venous disorders

Primary chronic venous disorders, which according to the CEAP classification are those not associated with an identifiable mechanism of venous dysfunction, are among the most common in Western populations. Varicose veins without skin changes are present in about 20% of the population while active ulcers may be present in as many as 0.5%. Primary venous disorders are thought to arise from intrinsic structural and biochemical abnormalities of the vein wall. Advanced cases may be associated with skin changes and ulceration arising from extravasation of macromolecules and red blood cells leading to endothelial cell activation, leukocyte diapedesis, and altered tissue remodeling with intense collagen deposition. Laboratory evaluation of patients with primary venous disorders includes venous duplex ultrasonography performed in the upright position, occasionally supplemented with plethysmography and, when deep venous reconstruction is contemplated, ascending and descending venography. Primary venous disease is most often associated with truncal saphenous insufficiency. Although historically treated with stripping of the saphenous vein and interruption and removal of major tributary and perforating veins, a variety of endovenous techniques are now available to ablate the saphenous veins and have generally been demonstrated to be safe and less morbid than traditional procedures. Sclerotherapy also has an important role in the management of telangiectasias; primary, residual, or recurrent varicosities without connection to incompetent venous trunks; and congenital venous malformations. The introduction of ultrasound guided foam sclerotherapy has broadened potential indications to include treatment of the main saphenous trunks, varicose tributaries, and perforating veins. Surgical repair of incompetent deep venous valves has been reported to be an effective procedure in nonrandomized series, but appropriate case selection is critical to successful outcomes.

Efficacy and Safety of Great Saphenous Vein Sclerotherapy Using Standardised Polidocanol Foam (ESAF): A Randomised Controlled Multicentre Clinical Trial

To assess the safety and efficacy of sclerotherapy of the great saphenous vein (GSV) comparing standardised polidocanol foam to liquid polidocanol in a randomised controlled trial (RCT). A multicentre randomised controlled clinical trial was carried out in which saphenous trunks were treated by sclerotherapy. 106 patients with primary varicose veins due to an incompetent GSV were treated with either standardised 3% polidocanol foam or 3% liquid polidocanol. The primary efficacy criterion was elimination of reflux (<0.5 sec) measured 3 cm below the sapheno-femoral junction (SFJ) by duplex ultrasonography 3 months after the last injection. A significantly greater number of patients were successfully treated by foam sclerotherapy resulting in 69% elimination of reflux compared to 27% patients treated with liquid sclerosant. The secondary endpoints of vein occlusion, reflux time, refilling time and patient satisfaction also improved significantly more in the foam group. The mean number of treatment sessions was 1.3 in the foam group compared to 1.6 in the liquid group. Differences between study centres occurred with a mean of 96% reflux elimination in 6 centres versus 39% in 4 other centres. Centres with a high response rate injected a higher mean volume (4.3 vs. 3.6 ml) in the first session in a vein with a smaller diameter (7.5 mm vs. 8.4 mm). No difference in adverse drug reactions was observed between treatment groups. Standardised 3% polidocanol foam is more efficient and equally safe compared to 3% liquid polidocanol for treatment of GSV. In comparison to other studies a relatively small volume was injected into relatively large 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.