Small Saphenous Research Articles

Endovenous microfoam ablation of below knee superficial truncal veins is safe and effective in patients with prior saphenous treatment across a wide range of CEAP classes

ObjectivePatients requiring thermal or chemical ablation of below knee (BK) truncal veins often have their proximal saphenous veins treated initially and comprise a study population with multilevel, refractory chronic venous insufficiency. The study objective was to assess the outcomes after microfoam ablation of BK truncal and tributary veins in patients with a history of proximal great saphenous vein (GSV) ablation or stripping. MethodsA retrospective review of a prospectively maintained database was performed. All the patients who had undergone endovenous chemical ablation with commercially manufactured polidocanol microfoam for symptomatic BK truncal vein reflux after a previous saphenous ablation or stripping were identified. The patients had undergone duplex ultrasound scanning 48 to 72 hours after the procedure; those who had not adhered to the recommended follow-up protocol were excluded. The demographic data, CEAP (clinical, etiologic, anatomic, pathophysiologic) classification, venous clinical severity score (VCSS), procedure details, adverse thrombotic events, and follow-up data were abstracted. ResultsBetween April 2018 and April 2021, 201 limbs were treated for symptomatic superficial truncal vein reflux with microfoam ablation. Of the 201 limbs, 68 in 49 patients met the inclusion criteria for the present study. The veins treated included the BK GSV (n = 45) and small saphenous vein (n = 23). The median follow-up was 97 days (range, 33-457 days) for the entire cohort. Most patients (63%) had a preoperative CEAP classification of C4 to C6. The median preoperative VCSS was 12.5. All the limbs that had undergone microfoam ablation in this cohort had a previously treated proximal ipsilateral GSV, with either thermal ablation or stripping. The median postoperative VCSS after BK treatment decreased to 10 (P < .001). The closure rate at the last follow-up was 96%. The overall symptomatic relief was 78% at the last follow-up. The absolute ulcer healing rate during the study period was 64% (16 of 25 ulcers had healed). One patient had developed thrombus extension into the popliteal vein, which resolved with anticoagulation therapy. One asymptomatic patient had developed nonocclusive thrombus in a gastrocnemius vein after small saphenous vein ablation. Because she was asymptomatic, anticoagulation therapy was not prescribed. Postoperative pain, phlebitis, and swelling were reported in 12%, 12%, and 2% of patients, respectively, and all had resolved at the last follow-up visit. Three limbs treated with chronic oral anticoagulant agents had had recanalized truncal veins during the study period after initial closure. No pulmonary emboli or neurologic adverse events were reported. No symptoms of saphenous or sural nerve injury had occurred. ConclusionsEndovenous chemical ablation with commercially manufactured polidocanol microfoam of BK truncal veins is a safe and effective treatment for patients with severe, refractory chronic venous insufficiency and prior saphenous interventions. This technique results in excellent overall closure rates and symptomatic relief with low adverse venous thrombotic events, across a wide range of CEAP classes.

Cyanoacrylate Granuloma After Cyanoacrylate Closure of Incompetent Saphenous Veins.

BACKGROUNDCyanoacrylate closure (CAC) is a minimally invasive surgery to treat incompetent saphenous veins.OBJECTIVETo evaluate the incidence, the risk factors for, and the management of cyanoacrylate granuloma (CAG) after CAC of incompetent saphenous veins in patients with chronic venous disease.MATERIALS AND METHODSData specific to incompetent saphenous veins, including great saphenous veins, anterior accessory saphenous veins, and small saphenous veins, that were treated with CAC were retrospectively evaluated.RESULTSA total of 126 saphenous veins from 101 patients were included. Recapture of the delivery catheter before withdrawal was not performed in all patients. Cyanoacrylate granuloma occurred in 3 of 101 (2.9%) patients, and in 3 of 126 (2.3%) treated saphenous veins. All patients with CAG presented with granuloma and abscess at the puncture site 3 to 5 months after CAC. All patients were treated with incision, drainage, and removal of the glue foreign body. No recurrent granuloma was observed during the study period. No patient or procedural predictive factor for CAG was identified.CONCLUSIONCyanoacrylate granuloma is not a rare complication after CAC when recapture of the delivery catheter is not performed. Patients should be advised of the possibility of CAG after CAC.

Veno-accompanying artery fasciocutaneous flaps following wide excision of soft tissue tumors in the lower legs

BackgroundSoft tissue defects following wide excision of malignant soft tissue tumors (STTs) are sometimes too large for primary closure, especially in the lower legs where available soft tissue is limited. This study aimed to determine the clinical outcomes of reconstruction of a defect after wide excision of an STT with a veno-accompanying artery fasciocutaneous (VAF) flap in the lower leg. MethodsThis study comprised 9 patients with malignant STTs who had undergone reconstructive surgeries using VAF flaps after wide excisions, between October 2010 and September 2017. We retrospectively reviewed and collected data involving age, sex, follow-up period, histological diagnosis, surgical procedures, size and location of defects, size and location of the flaps, venous source of the flaps, direction of the pedicles, closing of donor sites, perioperative chemotherapies, postoperative complications, and the presence of postoperative local recurrence and metastasis. ResultsThe median follow-up period was 91.5 (range, 15.5–189.0) months. Four patients had defects located around the knee, 3 patients had defects located on the calf, and 2 patients had defects located around the ankle. The mean flap size was 95.6 × 119.4 (range, 50 × 100–130 × 140) mm. Six patients had venous sources from the small saphenous vein and 3 patients had venous sources from the great saphenous vein. The pedicles were proximally based in 4 patients and distally based in 5 patients. All flaps remained viable without any complications. ConclusionsOur findings showed that the VAF flap was easily elevated and reliable. Furthermore, it was effective in reconstructing soft tissue defects following wide excisions of STTs in the lower leg.

Correlation of body mass index with recanalization risk after endovenous thermal ablation

ObjectiveChronic venous insufficiency (CVI) has an increased prevalence among obese individuals with body mass indices (BMI) over 30. A safe, efficacious, and evidence-based recommended treatment for CVI due to superficial venous reflux (SVR) in great saphenous veins (GSVs), small saphenous veins (SSVs), accessory saphenous veins (ASVs), and reflux in the perforator veins (PVs) is endovenous thermal ablation (EVTA). We sought to identify if BMI is an independent risk factor for recanalization after EVTA. MethodsAll patients with CVI were initially managed conservatively, and those with pathologic SVR refractory to compression therapy were offered EVTAs depending on the site of reflux. Sonographic confirmation of SVR was defined as >500 milliseconds of reflux in the GSVs, SSVs, and ASVs and a diameter >4 mm. PV reflux was confirmed as >350 milliseconds of reflux and a diameter >2.5 mm. All patients received a follow-up duplex ultrasound 1 week after the procedure, every 3 months for the first year, and every 6 months thereafter. Multivariate analysis with logistic regression was performed regarding patients' age, ablation modality (laser vs radiofrequency ablation), vein location and laterality, BMI, and recanalization. ResultsFrom 2013 to 2018, 9739 endovenous ablations were performed on 3070 patients. Endovenous laser was used in 3862 procedures and radiofrequency ablation in 5831 procedures. Veins treated with EVTA were distributed as follows: 6182 GSVs, 2509 SSVs, 597 ASVs, and 451 PVs. The mean patient age was 61.1 years (15-99, standard deviation [SD] ±15.6) with a mean BMI of 31.2 kg/m2 (13.7-69.5, SD ±7.3). A total of 68.4% patients were women and 31.4% men. The mean follow-up was 25.8 months (0-65.9, SD ±12.9). Multivariate statistical analysis with logistic regression was used to determine potential statistical significance between BMI and vein recanalization after EVTA. Overall, obese patients experienced more recanalizations than nonobese patients (P = .032), with an average BMI of 33 kg/m2 for recanalizations. PVs were statistically more likely to recanalize than any other vein (P = .0001). A secondary analysis was performed with the exclusion of PVs, due to their five times increased risk of recanalization, and showed no significant difference of recanalization across all BMI subgroups (P = .127). ConclusionsBMI does not predict recanalization risk after EVTA, except for ablations performed on PVs.

A randomized controlled trial to evaluate the safety and efficacy of transluminal injection of foam sclerotherapy compared with ultrasound-guided foam sclerotherapy during endovenous catheter ablation in patients with varicose veins

ObjectiveWe compared the safety, need for additional foam sclerotherapy, and 1-year venous clinical severity score (VCSS) improvement in the limbs of patients with chronic venous disease and great saphenous vein (GSV) reflux. These patients had undergone endovenous laser ablation (EVLA) using a 1470-nm diode laser and concurrent foam sclerotherapy (1% polidocanol) through the access sheath (transluminal injection of foam sclerotherapy [TLFS]) or EVLA and concurrent direct-puncture ultrasound-guided foam sclerotherapy (UGFS). MethodsIn the present study, we screened 467 patients (577 legs) with symptomatic primary GSV reflux for randomization to either TLFS with EVLA (n = 103 legs; TLFS group) or UGFS with EVLA (n = 94 legs; UGFS group). The exclusion criteria were (1) recurrent varicose veins after previous intervention; (2) hypersensitivity reaction to sclerotherapy; (3) acute deep vein thrombosis; (4) serious lower limb ischemic disease; (5) a coagulation disorder; and (6) simultaneous EVLA of both GSVs and small saphenous veins. The correlations of the VCSS changes with the clinical features, such as age, sex, CEAP (clinical, etiologic, anatomic, pathophysiologic) classification, total amount of sclerosant used at the original procedure, multiple punctures (more than two) for sclerotherapy at the original procedure, the use of TLFS, and linear endovenous energy density, were estimated using logistic regression. ResultsNo significant differences in the distribution of the CEAP classification were observed between the two groups. After 12 months of follow-up, all truncal veins were occluded. The VCSS had significantly improved in the TLFS group compared with the UGFS group (UGFS, −7.4 ± 1.8; TLFS, −8.7 ± 1.5; P < .0001). Multivariate analysis revealed that TLFS was the only significant factor for an improved VCSS (hazard ratio, 0.63; 95% confidence interval, 0.32-0.96; P < .0001). The need for additional second-stage sclerotherapy was significantly avoided in the TLFS group (n = 10; 10%) compared with the UGFS group (n = 51; 54%; P < .0001). ConclusionsTLFS combined with EVLA is a safe and feasible procedure that improves the VCSS and reduces the need for additional second-stage interventions compared with UGFS combined with EVLA.

The Success Rate and Complications of Post-radiofrequency Ablation in Patients With Small Saphenous Insufficiency

Aims: This study aimed to determine the success rate and complications occurring after Radiofrequency Ablation (RFA) in patients with small saphenous insufficiency who underwent RFA in Rasht. Methods &amp; Materials: Patients with small saphenous vein insufficiency who underwent RFA were explored respecting success rate and potential complications, such as pain, hematoma, neuropathy, Endothermal Heat-Induced Thrombosis (EHIT), and skin burns. The study subjects were assessed 2 weeks after the procedure. Reconanalysis was followed up in the study participants by ultrasound at 2 weeks, 3-6 months, and the first year after RFA. Findings: This study examined 62 patients. A 100% success rate was reported and no case of reflux was observed in the first control ultrasound 2 weeks after RFA. The mean pain score significantly decreased (P&lt;0.001). Besides, in one year, 3 cases of recanalization, 7 cases of EHIT, 9 cases of neuropathy, and 1 case of superficial thrombophlebitis were reported; no case of skin burn was observed. Conclusion: Considering the 100% success rate and slight adverse effects of this method, such as pain and recanalization, RFA is an acceptable approach. Furthermore, the incidence of EHIT should be considered.

Clinical Features and Surgical Management of Varicose veins of Lower limbs

Introduction: Varicose veins are a common clinical condition affecting the lower limbs. Usually patient comes for a cosmetic problem, it can cause complications giving rise to significant morbidity if not treated in time. Different options are available for surgical management. The present study has been carried out to study demographic factors, evaluate clinical presentation and outcome of various modalities of management of varicose veins of lower limb. Material and Methods: This is a prospective, descriptive and observational study conducted at Department of General Surgery, Pt. Jawahar Lal Nehru Government Medical College and Hospital Chamba Himachal Pradesh. Seventy cases admitted and operated from all the surgical units during the period of 2018 April to September 2019 were studied. All the patients presenting with varicose veins of lower limb, which met the inclusion and exclusion criteria were selected for this study. Results: In our study, maximum number of patients were in 18-30 years and predominant were male. In this series, 37 patients had varicosity in the left lower limb and 29 had varicosity in the right lower limb and the remaining 4 had bilateral limb involvement. Among them prominent veins and pain were the main complain in 56 (80%) patients. Itching and pigmentation were present in 6 (8.5%) patients. Ankle edema was present in 5 (7.1%) patients. Pain and ulceration of lower leg were present in 3 (4.2%) patients. Out of 70 cases studied, 32 (45.7%) had only long saphenous vein, 10 (14.3%) had short saphenous vein and in 9 (12.8%) cases both short and long saphenous were involved. In addition to long saphenous vein, incompetent perforators were present in 19 (27.2%) cases. Conclusion: Varicose veins are commonly seen in males, maximum in the age group of 18-30 years. Most common presenting symptom is visible dilated veins over lower limb but more than half of the patients present with one or more complications. Most commonly venous system involved is great saphenous vein system and most commonly involved perforators are below knee perforators. If cases are selected properly with good operative technique the complications are negligible. This surgical procedure followed enable the patients to lead almost a normal life.

English

BACKGROUND Chronic venous disorders are an important cause of disease and disability worldwide. Varicose veins are dilated, tortuous elongated veins. Varicose veins are either primary or secondary. Most of the patients are asymptomatic. Indian populations present with complications like venous bleed, thrombophlebitis, chronic venous insufficiency leading to edema, eczema, lipodermatosclerosis, and venous ulcers. Varicose vein surgery is characterized by a high recurrence rate of 20 % to 60 % after 5 years and even higher after longer periods of observation. Recurrence may be due to several causes like inaccurate initial diagnosis, progression of disease, inadequate initial surgery, altered venous dynamics, and neovascularisation. METHODS In this cross sectional single center study, 100 patients above 18 years of of age of both genders presenting with complications of varicose veins and cases of postoperative recurrent varicose veins were included. This study was conducted in the Department of General Surgery, Sri Venkateswara Ramnarayan Ruia Government General Hospital (SVRRGGH), Tirupati, over a period of one year. RESULTS In the present study, the great saphenous vein (GSV) was involved in 85 % of cases, the short saphenous vein (SSV) in 2 %, and both long and short saphenous in 9 %. The commonest complication was edema in 88 % of the patients, followed by 43 % with eczema. Recurrent varicose veins were seen in 4 % of patients. CONCLUSIONS Complications were more common in our setting at the time of presentation. Variable anatomy of the venous system of the lower limb makes prior duplex scan assessment compulsory in the surgical management of cases. Surgical management is to be planned properly after complete evaluation and should be planned at the right time, as it is a progressing clinical entity. KEYWORDS Varicose Veins, Complications, Recurrence, Management

Arteriovenous supercharging: A novel approach to improve reliability of the distally based sural flap.

Complex soft-tissue defects of the distal third of the leg, foot and ankle with exposed bones/joints, tendons and implants need a flap for their closure. Distally based sural flap is commonly used, but it has a high partial necrosis rate due to venous insufficiency. We addressed this issue with AV supercharging by dorsalis pedis artery with short saphenous vein. Eight patients (seven males, mean age 34.12 years) with post traumatic lower limb defects over heel and foot were included. All flaps survived and healed although four flaps developed superficial partial epidermolysis. Average healing time was 20.12 days. Closure of the AV fistula was not required in any of the patients. At mean follow-up of two months, all patients were ambulatory with well settled flap. Arteriovenous supercharging of distally based sural flap through short saphenous vein improves the distal arterial perfusion in the flap and prevents distal flap necrosis.

Saphenous vein size as a surrogate marker for mortality of patients with chronic limb-threatening ischemia undergoing endovascular therapy

Background: The size of the autologous vein graft is an important determinant of prognosis in patients with chronic limb-threatening ischemia (CLTI) undergoing bypass surgery. However, it is unclear whether reconstruction using a small vein graft would directly affect prognosis, or a subgroup having small veins would be subject to a poor prognosis. If the latter is true, having small veins would work as a marker for a poor prognosis even in patients with CLTI undergoing endovascular therapy (EVT). Therefore, we investigated the association between the size of saphenous veins and prognosis in patients with CLTI undergoing EVT.Methods: This study included 209 consecutive patients with CLTI who primarily underwent EVT between January 2017 and December 2018. The diameter of the saphenous vein was measured at three locations (saphenous-femoral junction, knee, and ankle joint) per limb before EVT by ultrasonography. A small saphenous vein was defined as the mean diameter <3.0 mm.Results: All-cause mortality rate was significantly higher in patients with a small saphenous vein than in those with non-small one (46.3% versus 10.7% at 2 years, p<0.001). The multivariate Cox regression analysis revealed that a small saphenous vein was independently associated with an increased risk of all-cause mortality.Conclusions: Having a small saphenous vein was an independent marker for all-cause mortality in patients with CLTI undergoing EVT.

Rivaroxaban for the prevention of venous thromboembolism after radiofrequency ablation of saphenous veins concomitant with miniphlebectomy, sclerotherapy, or no treatment of varicose tributaries.

To assess the efficacy and safety of once-daily 10 mg rivaroxaban for venous thromboembolism prophylaxis after ClosureFast radiofrequency ablation (RFA) of saphenous veins. The medical records of patients, who had a Caprini score of ≥3, underwent RFA, received prophylactic rivaroxaban for five days, and completed follow up at one month were reviewed for efficacy (a combination of endovenous heat-induced thrombosis [EHIT] grade of 2-4, any symptomatic or asymptomatic deep vein thrombosis [DVT], and symptomatic pulmonary embolism [PE]) and safety (a combination of major and clinically relevant non-major [CRNM] bleeding) outcomes. The results of RFA for 248 great saphenous and 24 small saphenous veins with the concomitant miniphlebectomy (63.8%) and sclerotherapy (16.5%) were analyzed. The primary efficacy outcome occurred in 5 of 218 (2.3%; 95%CI, 1.0-5.3%) patients: three EHITs and two symptomatic DVTs. The CRNM bleeding was reported in two patients (0.9%; 95% CI, 0.2-3.3%). No difference was observed in comparison with 79 similar patients who received 40 mg of subcutaneous enoxaparin during the same time period. Once-daily 10 mg rivaroxaban is suitable for VTE prophylaxis after RFA of saphenous veins.

Risk factors for saphenous vein recanalization after endovenous radiofrequency ablation.

Target vein recanalization is defined as the postoperative detection of blood flow in a venous segment previously ablated. It can be occurred after thermal-tumescent procedures, as radiofrequency (RFA) and endovenous laser (EVLA) ablation techniques. Despite several papers described and analyzed incidence and consequences of recanalization, limited data are published on risk factors for this condition. The aim of this general review is to investigate clinical and instrumental risk factors for great and small saphenous veins recanalization after RFA, indicating their impact in the follow-up period. Articles were obtained through a detailed search of the scientific journal databases (PubMed, Scopus, Web of Science) for those published between January 1, 2011 to December 31, 2020. The term "radiofrequency venous ablation" was combined with "risk factors", "recanalization" and "recurrence", to obtain the first article cluster. Risk factors analysis for saphenous vein recanalization after ablation is not a well-studied problem. Although several studies have analyzed recanalization patterns and anatomical causes of ablation failure, few and disaggregate data are available regarding clinical preoperative risk factors. BMI and saphenous trunk diameter seem to be the only two recognized characteristics that may affect short and long-term recanalization rate, though CVI status, sex, target vein treatment length and others factors may be taken into account. Physicians should consider risk factors for recanalization in patient selection and treatment recommendations, but also recognize that not all "ablation failures" are of clinical relevance.

Acute effects of graduated and progressive compression stockings on leg vein cross-sectional area and viscoelasticity in patients with chronic venous disease

ObjectiveTo determine the effects of graduated and progressive elastic compression stockings (ECS) on postural diameter changes and viscoelasticity of leg veins in healthy controls and in limbs with chronic venous disease (CVD). MethodsIn 57 patients whose legs presented with C1s, C3, or C5 CEAP classes of chronic venous disease and were treated primarily with compression, and 54 healthy controls matched for age and body mass index, we recorded interface pressures (IFP) at 9 reference leg levels. Cross-sectional areas of the small saphenous vein (SSV) and a deep calf vein (DCV) were measured with B-mode ultrasound with patients supine and standing, recording the force (PF) applied on the ultrasound probe to collapse each vein with progressive ECS, and with and without graduated 15 to 20 mm Hg and 20 to 36 mm Hg elastic stockings. We chose these veins because they were free of detectable lesion and could be investigated at the same level (mid-height of the calf), and their compression by the ultrasound probe was not hampered by bone structures. ResultsIFP decreased from ankle to knee with graduated 15 to 20 and 20 to 36 mm Hg, but increased with progressive ECS, and were 8.4 to 13.8 mm Hg lower for C1s than for control or C3 and C5 limbs. Without ECS, the SSV median [lower-upper quartile] cross-sectional area was 4.9 mm2 [3.6-7.1 mm2] and 7.1 mm2 [3.0-9.9 mm2] in C3 and C5 limbs versus 2.9 mm2 [1.8-5.2 mm2] and 3.8 mm2 [2.1-5.4 mm2] in controls (P < .01), respectively, while supine and standing. It remained greater in C3 and C5 than in C1s and control limbs wearing any ESC. Wearing compression, especially with progressive ECS, decreased the SSV and DCV cross-sectional area only with patients supine, thus decreasing postural changes, which remained highly diverse between individuals. The SSV cross-sectional area versus PF function traced a hysteresis loop of which the area, related to viscosity, was greater in C3 and C5 limbs than controls, even with graduated 15 to 20 or 20 to 36 mm Hg ECS. Progressive ECS decreased vein viscosity in the supine position, whereas 20 to 36 mm Hg and progressive ECS increased distensibility in the standing position. ConclusionsECS decrease the cross-sectional area of SSV and DCV with patients supine, but not upright. C1s limbs show distinctive features, especially regarding IFP. Graduated 20 to 36 mm Hg and progressive stockings lower viscosity and increase distensibility of the SSV.

Sonographic Clues in Suspicion of Compartment Syndrome in a Lower Extremities Venous Study: A Case Study

Compartment syndrome occurs when excessive pressure builds up inside an enclosed muscle space in the body. The dangerously high pressure in compartment syndrome impedes the flow of blood to and from the affected tissues. It can be an emergency, requiring surgery to prevent a permanent injury. In this case study, a lower extremities venous examination was performed on a male patient suspected of having compartment syndrome, as an incidental finding. Sonographic evaluation of the right leg revealed the absence of popliteal and small saphenous veins, and acute thrombus in the posterior tibial veins. The evaluation further revealed an incidental finding of double pseudo-aneurysm in the popliteal fossa, which was suspected for increasing the excessive compartmental pressure. This unique case study presents sonographical evaluation strategies when compartment syndrome is suspected.

Efficiency of Prophylactic Ablation of the Tributary Venous Pathways Draining Around the Saphenofemoral Junction to Decrease the Rate of Future Varicose Vein and Symptoms Occurence

There are various other collaterals draining into the venous system around the saphenofemoral junction in addition to the great saphenous vein. We aimed to determine the efficiency of prophylactic ablation of tributary veins in long term varicose vein and symptom recurrence. Two hundred and sixty-three consecutive patients whom underwent radiofrequency ablation therapy for the treatment of superficial venous reflux disease were investigated. There were 129 patients who received isolated great saphenous vein ablation (Group A) where as 134 patients underwent ablation of the other tributary veins in addition to the great saphenous vein (Group B) between June 2015 and January 2017. The tributary superficial veins; refluxing and/or not refluxing, draining into the saphenofemoral junction were selectively catheterized and ablated in Group B. Patients are followed at least 1 year after the procedures regulary and researched for recurrence of varciose veins and symptoms. Gender, mean age, body mass index, diameter of the great saphenous veins, small saphenous vein disease, and grade of deep venous insufficiency did not differ significantly between the two groups. The mean number of tributary veins were similar in both groups (n: 1.9 ± 0.4 in Group A vs. n: 1.8 ± 0.7 in Group B) which were detected preoperatively as well as during the procedure. The mean number of ablated tributary venous pathways could be 1.4 ± 0.6 in Group B. During the follow up period symptoms related with varicose veins recurred in 19 patients in Group A where as in 7 patients in Group B (P < 0.05). Three of these symptomatic patients in Group B were the ones in whom the tributary pathways could not be catheterized ablated where as 14 patients in Group A were diagnosed with newly refluxing tributary pathways. All the symptomatic patients in both groups were managed medically and/or with additional interventions. The absence of any fascial unsheathing and the parietal weakness are suggestive of a lower resistance of the tributary veins wall, so collapse and size of veins make it more complex to catheterization regarding to great saphenous vein. Ablation of the tributary superficial venous pathways during the treatment of great saphenous vein reflux disease decreased the rate of recurrence of superficial venous reflux disease and patients symtoms in our modest cohort.

Comparative study between great saphenous vein endovenous laser ablation and modified hemodynamic correction (conservative hemodynamic correction of venous insufficiency) as a treatment for varicose veins

Background Varicose veins could be a complicated condition, which may lead to limb swelling, pain, and venous ulcer. Conservative hemodynamic correction of venous insufficiency (CHIVA) has been developed through the past two decades and is currently the second most common surgical procedure for the operative treatment of varicose veins. Endovenous laser treatment of great saphenous vein was approved by FDA in 2002 and short saphenous vein (SSV) was approved in 2003. Endovenous laser ablation (EVLA) is a clinically safe, feasible, and well-tolerated technique without scar and allows people to return to their normal daily activities rapidly. Patients and methods In a prospective comparative study between January 2018 and January 2020, 40 patients complaining of varicose veins were assessed according to the Clinical-Etiological-Anatomical-Pathophysiological (CEAP) classification and ultrasonic duplex and arranged into group I (CHIVA) and group II (EVLA). Both CHIVA operation and EVLA were performed under local anesthesia. Follow-up for 6 months was done. Results Recurrence occurred in 2/20 and 0/20 patients in CHIVA and EVLA groups, respectively. Regarding the aesthetic satisfaction of the patient, EVLA was better, with two unsatisfied patients in EVLA in contrast to five unsatisfied patients in CHIVA. The wound infection rate was 1/20 and 0/20 in CHIVA and EVLA, respectively. CHIVA is favored over EVLA considering the rest of the complications. Bruises, thrombosis, and nerve damage are found to be 5/20, 0/20, and 0/20, respectively, in CHIVA group when compared with the results of EVLA group, which were 9/20, 1/20, and 2/20, respectively. Conclusion CHIVA is safe, effective, and less invasive. EVLA is now considered as one of the top technologies to be used in the management of varicose veins with good functional outcome. EVLA can be done as an outpatient procedure. Each type of these interventions should be tailored according to each patient’s variables such as degree of reflux in great saphenous vein, presence of incompetent perforators, and aesthetic requirements of the patient.

Defining the popliteal fossa by bony landmarks and mapping of the courses of the neurovascular structures for application in popliteal fossa surgery.

Surgical access to the posterior knee poses a high-risk for neurovascular damage. The study aimed to define the popliteal fossa by reliable bony landmarks and comprehensively mapping the neurovascular structures for application in posterior knee surgery. Forty-five (20 male, 25 female) embalmed adult cadaveric knees were included. The position of the small saphenous vein (SSV), medial cutaneous sural nerve (MCSN) and lateral cutaneous sural nerv (LCSN), tibial nerve (TN) and common fibular nerve (CFN) nerves, and popliteal vein (PV) and popliteal artery (PA) were determined in relation to either medial (MFE) or lateral (LFE) femoral epicondyles, medial (MTC) and lateral (LTC) tibial condyles and the midpoint between the MFE and MTC and LFEF and LTC. The distance between the MFE and the PA, PV, TN, MCSN, and SSV was 38.4±12.1 mm, 38.4±12.9 mm, 39.4±10.2 mm, 39.2±14.0 mm and 37.6±12.5 mm respectively for males and 34.6±4.9 mm, 32.8±5.6 mm and 38.0±8.1 mm 38.8±10.1 mm and 37.9±8.2 mm respectively for females. The distance between LFE and the CFN and LCSN was 13.4±8.2 mm and 24.9±7.3 mm respectively for males and 8.4±9.1 mm and 18.4±10.4 mm respectively in females. This study defined the popliteal fossa by reliable bony landmarks and provided a comprehensive map of the neurovascular structures and will help to avoid injuries to the important neurovascular structures.

Stump Length Changes after Endovenous Cyanoacrylate Closure or Radiofrequency Ablation for Saphenous Vein Incompetence.

PurposeThe aim of this study was to analyze changes in stump length over time in patients with saphenous vein incompetence treated with cyanoacrylate closure (CAC) or radiofrequency ablation (RFA).MethodsMaterials and We retrospectively analyzed data collected from patients with saphenous vein incompetence who underwent either CAC or RFA at Seoul National University Hospital between November 2015 and December 2018. The stump lengths were measured using duplex ultrasonography (DUS) within 1 month and 6 months after treatment. The Venous Clinical Severity Score (VCSS) and Aberdeen Varicose Vein Questionnaire (AVVQ) score were used to assess clinical outcomes.ResultsA total of 97 veins (64 great saphenous veins and 33 small saphenous veins) were analyzed. The stump length was not significantly different between the two groups at <1 month (P=0.311). However, the stump length in the CAC group was significantly longer than that in the RFA group at 6 months (P=0.004). At 6 months, the mean change in stump length was 1.41±2.28 cm in the CAC group and 0.51±0.54 cm in the RFA group (P=0.006). The VCSSs and AVVQ scores significantly improved after both procedures but were not significantly different between the two groups.ConclusionDUS at 6 months after treatment showed that the stump length in the CAC group increased more than that in the RFA group. No other factors affected the changes in stump length.

КЛИНИЧЕСКАЯ АНАТОМИЯ ПЕРФОРАНТНЫХ ВЕН ПРОКСИМАЛЬНЫХ ОТДЕЛОВ НИЖНИХ КОНЕЧНОСТЕЙ

Objective. To clarify the topographic and anatomical feature of the perforating veins (PVs) in the proximal part of the lower extremity. Methods. 70 amputated lower extremities from the patients with severe ischemia were subjected to sectional anatomical study; 2800 patients with varicose disease underwent lower extremity sonography. Results. PVs were primarily located on the medial surface of the thigh. In the upper third of the thigh PVs drain into superficial femoral vein. It was detected that one or two PVs occur sin the lower third of the hip draining into superficial femoral vein and originating from the great saphenous vein in 73.6% cases. All PVs were accompanied by an arterial branch from the superficial femoral artery. Anatomical sectional study revealed that a nervous branch accompanied PVs in the lower third of the thigh. Two or four PVs were detected on the lateral surface of the thigh. PVs in the popliteal fossa could be referred to as “atypical” due to their rare occurence (0.4% of cases at sonography) in combination with absent typical sapheno-popliteal junction. PVs in this area were not supported by the intermuscular septa. PVs drained laterally into popliteal vein of the lower limb in 100% cases, while small saphenous vein drained into great saphenous vein in the upper third of the leg or into the intersaphenous vein. Conclusion. Perforating veins constitute perforating bundles (PV, arterial branch, nervous branch), which are predominantly located along the intermuscular septa, which create a constant and strong orientation along the direction of the great vessels. This ensures stable hemodynamics of great vessels and perforating complexes and does not allow squeezed tham togeter during physical exertion. What this paper adds For the first time it has been proved that the perforating veins of the gluteal region pass through the fascia and the thickness of the gluteus maximus muscle and enter the superior and inferior gluteal veins, being transmuscular perforating veins. For the first time it has been established that the location of the femoral perforating veins along the intermuscular septa allows preserving the hemodynamics of the perforating complexes without any squeezed in physical exertion.

Cyanoacrylate Closure of Small Saphenous Vein Insufficiency.

As minimally invasive techniques were issued, endovenous thermal ablations have emerged. However, the thermal-associated complication has been reported in the treatment of small saphenous vein (SSV) insufficiency, such as sural nerve injury. Recently introduced cyanoacrylate closure (CAC) is a nonthermal modality, so this thermal-associated complication can be avoided. This retrospective study analyzed the feasibility, safety, and 2-year results of CAC for treating SSV insufficiency, particularly the incidence of sural nerve injury. One hundred sixty-three SSV insufficiencies in 128 patients were treated with CAC were reviewed. Pain, venous severity, and quality of life (QoL) scores were evaluated. Postoperative duplex scanning also evaluated anatomical and clinical success rates. The mean patient age was 56.8 years. The initial technical success rate was 100%. The occlusion rate after 2 years was 96.3%. Pain, venous severity, and QoL scores were improved significantly from 2.4 to 0.0, 4.39 to 0.47, and 11.95 to 2.69, respectively, before and 2 years after CAC. No major complications were observed, such as sural nerve injury. Cyanoacrylate closure for the ablation of SSV insufficiency could be a great alternative to endothermal ablation with an excellent success rate and shorter procedure time.