Symptomatic Venous Disease Research Articles

Thrombotic complications after radiofrequency and cyanoacrylate endovenous ablation: Outcomes of a multicenter real-world experience: Presented at the Thirty-fourth Annual Meeting of the American Venous Forum, Orlando, FL, February 23-26, 2022.

Objective: Chronic venous insufficiency (CVI) affects >40% of the U.S. population; thus, intervention for symptomatic venous disease comprises a large portion of many vascular practices. The treatment of superficial CVI has evolved from open surgical treatment to minimally invasive endovenous closure, including both thermal and nonthermal techniques. Thrombotic complications of thermal ablation have been well reported, with an overall complication rate of <2%. However, a paucity of high-powered, real-world data is available on the thrombotic outcomes of nonthermal techniques.

Thrombotic complications after radiofrequency and cyanoacrylate endovenous ablation: Outcomes of a multicenter real-world experience

ObjectiveChronic venous insufficiency (CVI) affects >40% of the U.S. population; thus, intervention for symptomatic venous disease comprises a large portion of many vascular practices. The treatment of superficial CVI has evolved from open surgical treatment to minimally invasive endovenous closure, including both thermal and nonthermal techniques. Thrombotic complications of thermal ablation have been well reported, with an overall complication rate of <2%. However, a paucity of high-powered, real-world data is available on the thrombotic outcomes of nonthermal techniques. In the present study, we compared the incidence of endovenous heat-induced thrombosis (EHIT) and endovenous glue-induced thrombosis (EGIT) in a large cohort of patients with CVI. MethodsA retrospective review was conducted at two tertiary-level institutions of patients who had undergone superficial endovenous ablation from 2018 to 2021. The patient demographics, comorbidities, and periprocedural outcomes were collected through medical record review. A Caprini risk assessment model score was assigned using the information available from the electronic medical records. The patients were categorized by procedure type (ClosureFast [Medtronic Inc, Minneapolis, MN] radiofrequency ablation [RFA] vs VenaSeal [Medtronic Inc] cyanoacrylate glue closure [CAG]). The primary end point was the incidence of EHIT or EGIT. The secondary end point was the incidence of deep vein thrombosis and/or pulmonary embolism. ResultsA total of 803 patients had undergone 1096 procedures during the study period. Their mean age was 62 ± 15 years, and 67% were women. Of the 1096 procedures, 700 were RFA and 396 were CAG procedures, with a combined closure rate of 98% by postprocedure duplex ultrasound at 7 days. The average Caprini score was 5.2 ± 1.8 (RFA, 5.0; vs CAG, 5.4; P < .001). The incidence of EHIT and EGIT was 1.9% and 1.3%, respectively (P = .57). The deep vein thrombosis rate was 0.1% in the RFA cohort and 0.3% in the CAG cohort (P = .81). A comparative analysis of thermal vs nonthermal techniques was performed. A univariate analysis of the risk factors for EHIT and EGIT revealed no significant factors predisposing to thrombotic events. ConclusionsThe results from the present study have demonstrated the safety of RFA and CAG closure techniques for CVI, with lower thrombotic rates than previously reported. Further work might help to identify how these results can be achieved across all venous ablative techniques for CVI, even for patient populations with advanced venous disease and possibly a greater than average risk of thrombotic events.

Phlebectomy Techniques for Varicose Veins.

Ambulatory phlebectomy is a well-known and widely used procedure for residual symptomatic venous disease. Tumescent anesthesia complements the procedure, providing the ability to perform this intervention in a wide range of practice settings. The procedures are well tolerated by most patients, and complications are rare. They include venous thromboembolism, infection, and hematoma and are generally simple to manage. Alternative and emerging techniques of powered phlebectomy and cyanoacrylate glue are providing alternative forms for treatment and will advance the practice further.

Contemporary outcomes after venography-guided treatment of patients with May-Thurner syndrome.

Patients with May-Thurner syndrome (MTS) present with a spectrum of findings ranging from mild left leg edema to extensive iliofemoral deep venous thrombosis (DVT). Whereas asymptomatic left common iliac vein (LCIV) compression can be seen in a high proportion of normal individuals on axial imaging, the percentage of these persons with symptomatic compression is small, and debate exists about the optimal clinical and diagnostic criteria to treat these lesions in patients with symptomatic venous disease. We evaluated our approach to venography-guided therapy for individuals with symptomatic LCIV compression and report the outcomes. All patients with suspected May-Thurner compression of the LCIV between 2008 and 2015 were analyzed retrospectively. Patients with chronic iliocaval lesions not associated with compression of the LCIV were excluded from analysis. Criteria for intervention included LCIV compression in the setting of (1) leg edema/venous claudication with associated venographic findings (collateralization, iliac contrast stagnation, and contralateral cross cross-filling), or (2) left leg deep venous thrombosis. Outcome measures included presenting Clinical, Etiology, Anatomy, Pathophysiology (CEAP) score, postintervention CEAP score, primary patency, and secondary patency. Technical success was defined as successful stent implantation without intraoperative device complications, establishment of in-line central venous flow, and less than 30% residual LCIV stenosis. Of the 63 patients evaluated, 32 (51%) had nonthrombotic MTS and presented with leg edema (100%) or venous claudication (47%). Thirty-one patients (49%) had thrombotic MTS and presented with acute (26%) or chronic (71%) DVT, leg edema (100%), or venous claudication (74%). The mean presenting CEAP score was 3.06 and 3.23 for nonthrombotic and thrombotic MTS, respectively. Forty-four patients (70%) underwent successful intervention with primary stenting (70%) or thrombolysis and stenting (30%); 14 nonthrombotic MTS patients were treated conservatively with compression therapy alone, and 5 thrombotic MTS patients were treated with lysis or angioplasty alone. Clinical improvement and decrease in CEAP score occurred in 95% and 77% of stented patients compared with 58% and 32% of nonstented patients. Complete symptom resolution was achieved in 48% of patients overall, or 64% of stented patients and only 21% of nonstented patients. Complications included two early reocclusions. Primary and secondary 2-year patency rates were 93% and 97% (mean follow-up, 20.3 months) for stented patients. Venography-guided treatment of MTS is associated with excellent 1-year patency rates and a significant reduction in symptoms and CEAP score. Treating symptomatic MTS patients on the basis of physiologically relevant venographic findings rather than by intravascular ultrasound imaging alone results in excellent long-term patency and clinical outcomes but may result in undertreatment of some patients who could benefit from stent implantation.

Aneurysms of the superficial venous system: classification and treatment

Superficial venous aneurysms are rarely described and they may remain indolent or become the source for pulmonary emboli. A system of classification and treatment protocol according to size and location is proposed. Three hundred thirty patients were evaluated for symptomatic venous disease (C2-C6) over a 2-year period. A proposed designation for venous aneurysm is described. Patients fulfilling this criterion are described in reference to site of involvement, histologic findings, and method of treatment. Five percent of patients met the criteria for venous aneurysm. Nine aneurysms of the greater saphenous vein were identified. Three aneurysms were proximal to the subterminal valve and the rest were distal. Six aneurysms of the anterior accessory greater saphenous vein (AAGSV) were identified. Three aneurysms of the AAGSV spontaneously thrombosed. Two patients presented with aneurysms of the small saphenous vein. Histology revealed thickened intima, smooth muscle and adventitia. Aneurysm designation relates to diameter of normal and contiguous vein. All superficial venous aneurysms in close proximity to the junction of the femoral or popliteal vein should be ligated. Classification of venous aneurysms should include the AAGSV, which may present with spontaneous thrombosis.

Importance of Phasicity in Detection of Proximal Iliac Vein Thrombosis with Venous Duplex Examination

Superficial venous reflux is commonly the cause of symptomatic venous disease, but proximal venous obstruction may also play a role. A duplex ultrasound evaluating bilateral common femoral veins can detect differences in phasicity, which may be due to pelvic venous obstruction. We report a case of a patient with recurrent symptomatic varicose veins after treatment of superficial venous reflux. Based the duplex ultrasound results of damped respiratory phasicity, the patient was diagnosed with deep venous obstruction which was confirmed on MRV.

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.

Measurement of Health-related Quality of Life with the Dutch Translated Aberdeen Varicose Vein Questionnaire before and after Treatment

This clinical trial evaluated the use of the Dutch translated Aberdeen Varicose Vein Questionnaire (AVVQ) and SF-36 before and after treatment in patients with clinical-severity classes 1-6 venous disease of the lower limb. A total of 145 patients with symptomatic venous disease of the leg were included. Numbers of patients were evenly distributed among the six clinical-severity classes 1-6 (clinical, aetiology, anatomy and pathophysiology; CEAP). Patients completed two preoperative AVVQ questionnaires and one short-form health survey with 36 items (SF-36) questionnaire to evaluate test-re-test reliability of the AVVQ. Patients completed one postoperative AVVQ and SF-36 to evaluate the effect of treatment. The test (99%) and re-test responses (97%) of the AVVQ were sufficient. Internal consistency of the Dutch translated AVVQ showed a Cronbach's alpha of 0.76. Correlation of test and re-test of the AVVQ was high (rho=0.86, P<0.001). A significant negative association, by Spearman's correlation coefficient, was found between the preoperative baseline Dutch translated AVVQ score and all eight domains of the preoperative SF-36 (P<0.001). These significant associations were also found in the postoperative scores. The mean preoperative AVVQ score of 19.5 (SD 11.8) and mean postoperative AVVQ score of 16.1 (SD 12.0) differed significantly (P<0.01). Analysis of three subgroups of clinical-severity classes (C1-2, C3-4 and C5-6) showed significant score changes before and after surgery (P<0.01). Preoperative and postoperative SF-36 scores were not significantly different. This study established the use of the Dutch translated AVVQ as a valid, health-related quality of life (QOL) questionnaire for measuring QOL before and after treatment in patients with clinical-severity classes 1-6 venous disease of the leg.

Toxicité cardiaque du polidocanol : rapport d’un cas et revue de la littérature

Polidocanol foam sclerotherapy is a treatment of symptomatic venous disease. This solution is highly valued by clinicians because of its high efficacy and excellent safety profile. Systemic adverse effects are rare. Some life-threatening reactions have been reported. We report a case of respiratory and cardiac arrest, and a literature review on the cardiac toxicity of polidocanol used within and outside their licensed indications. A 48-year-old woman, with a symptomatic venous disorder, CEAP grade C2, was treated by echosclerotherapy for a great saphenous vein. She developed a malaise and respiratory and cardiac arrest occurred within minutes after a 7 ml foam polidocanol injection. Cardiopulmonary resuscitation was immediately started before restoration of pulses. A literature search was done using the Medline database. Five cases of cardiac toxicity were reported with polidocanol, but four of them were used outside their licensed indications. Because of the very suggestive chronology and the lack of any other obvious etiology, this cardiac arrest was attributed to polidocanol. Initial ST-segment elevation and negativity of anaphylaxis markers suggest a direct myocardial toxicity. Clinicians should be aware of the possibility of little-known but potentially serious cardiac adverse reaction with polidacanol injection and be prepared to initiate cardiopulmonary resuscitation if needed.