Thermal Ablation Of Saphenous Vein Research Articles

Update of the SFMV (French society of vascular medicine) guidelines on the conditions and safety measures necessary for thermal ablation of the saphenous veins and proposals for unresolved issues

Venous insufficiency is a very common disease affecting about 25% of the French population (if we combine all stages of its progression). It is a complex disease and its aetiology has not yet been fully elucidated. Some of its causes are well known, such as valvular dysfunction, vein wall defect, and the suctioning effect common to all varicose veins. These factors are generally associated and together lead to dysfunction of one or more of the saphenous veins. Saphenous vein dysfunction is revealed by ultrasound scan, a reflux lasting more than 0.5 seconds indicating venous incompetence. The potential consequences of saphenous vein dysfunction over time include: symptoms (heaviness, swellings, restlessness, cramps, itching of the lower limbs), acute complications (superficial venous thrombosis, varicose bleeding), chronic complications (changes in skin texture and colour, stasis dermatitis, eczema, vein atresia, leg ulcer), and appearance of unaesthetic varicose veins. It is not possible to repair an incompetent saphenous vein. The only therapeutic options at present are ultrasound-guided foam sclerotherapy, physical removal of the vein (saphenous stripping), or its thermal ablation (by laser or radiofrequency treatment), the latter strategy having now become the gold standard as recommended by international guidelines. Recommendations concerning thermal ablation of saphenous veins were published in 2014 by the Société française de médecine vasculaire. Our society has now decided to update these recommendations, taking this opportunity to discuss unresolved issues and issues not addressed in the original guidelines. Thermal ablation of an incompetent saphenous vein consists in destroying this by means of a heating element introduced via ultrasound-guided venous puncture. The heating element comprises either a laser fibre or a radiofrequency catheter. The practitioner must provide the patient with full information about the procedure and obtain his/her consent prior to its implementation. The checklist concerning the interventional procedure issued by the HAS should be validated for each patient (see the appended document).

Новый фактор послеоперационного венозного тромбоза в онкологии: миф или реальность?

Введение. Эндовенозная термическая абляция (ЭТА) поверхностных вен, включая лазерную абляцию или радиочастотную абляцию, широко применяется в лечении варикозной болезни нижних конечностей. Учитывая высокую частоту встречаемости варикозной болезни, частоту венозных тромбоэмболических осложнений (ВТЭО) после данного вмешательства, логично предположить, что выполнение ЭТА увеличит риск возникновения послеоперационного венозного тромбоза у онкологических больных. Существует недостаток данных о частоте ВТЭО в онкохирургии при ЭТА в анамнезе. Цель исследования: оценить влияние ранее проведенной ЭТА поверхностных вен нижних конечностей на послеоперационные ВТЭО в онкохирургии. Материалы и методы. Одноцентровое исследование с ретроспективным анализом онкологических больных на хирургическом этапе лечения злокачественных опухолей абдоминальной, гинекологической или урологической локализации проведено с мая 2013 г. по ноябрь 2018 г. В исследование были включены 36 пациентов, перенесших ЭТА более 3 мес назад (319 мес). Ультразвуковое дуплексное исследование вен нижних конечностей проводили перед операцией (за 110 дней) по поводу онкологического заболевания всем пациентам. Полная облитерация ствола большой подкожной вены (БПкВ) обнаружена в 66,7 случаев (n 24), реканализация в 33,3 (n 12). Все пациенты получали стандартную антикоагулянтную профилактику (надропарин по 0,4 мл/сут подкожно). Проведен морфологический анализ 3 случаев послеоперационного венозного тромбоза. Результаты. ВТЭО возникли в 20,8 (n 5) случаев при полной облитерации БПкВ, в 66,7 (n 8) с реканализацией ствола (95 ДИ 1,37,7) в послеоперационном периоде. Реканализация вены увеличила частоту развития послеоперационного венозного тромбоза в 3,2 раза. Заключение. ВТЭО часто возникают после неполной облитерации при ЭТА в отдаленном периоде при наличии дополнительных факторов риска. Учитывая широкое распространение данного типа операций во флебологии и возможность серьезных осложнений, необходимы дальнейшие исследования частоты венозного тромбоза при ЭТА в анамнезе у онкологических больных и определение стратегии профилактики ВТЭО. Introduction. Endovenous thermal ablation of saphenous vein (EVTA SV) including laser ablation or radiofrequency ablation widely used in varicose veins treatment of the lower extremities. EVTA SV can increase the risk of postoperative venous thrombosis in cancer patients. There is a deficiency of data examining rates of thrombotic events (VTE) in oncological patients. Aim: to assess influence of previously performed EVTA SV on postoperative VTE in oncosurgery. Materials and methods. This was a single centre study with retrospective analysis of consecutive oncological patients who underwent abdominal, gynecological or urological surgery from May 2013 to November 2018. 36 patients were included who underwent EVTA SV more than 3 month ago (319 months). Duplex ultrasound (DUS) was performed before oncological surgery (110 days). Complete SV obliteration was found in 66.7 of cases (n 24), recanalization in 33.3 (n 12). All patients had standard anticoagulant prophylaxis nadroparin 0.4 ml per day. We performed a morphologic analysis of 3 VTE cases. Results. Thrombotic complications occurred in 20.8 (n 5) of cases with complete SV obliteration, in 66.7 (n 8) with recanalization (95 CI 1.37.7). Recanalization of SV increased rate of postoperative cancer-associated VTE in 3.2 times. Conclusion. Thrombotic events occur frequently following incomplete obliteration after procedures EVTA SV. Taken account of the high rate of this procedures and the potential for serious consequences, further research is needed on VTE сomplications in oncology and their management.

Management of perforator vein aneurysms in the lower extremities.

Perforator vein aneurysms (PVAs) of the lower extremity have not been defined or reported. This study reports the clinical presentation of patients, the PVA characteristics, and the clinical outcome of their management. Patients with signs and symptoms of chronic venous disease who had a PVA were included. Diagnosis of a PVA was made with duplex ultrasound. Normal perforator veins have a diameter of<3mm. A PVA was defined as a diameter dilation of >9mm, and it was always found below the deep fascia. The topography and morphology of the aneurysms were described in detail. All PVAs were treated with subfascial ligation with or without aneurysm excision. All patients were followed up for a minimum of 3months with clinical examination and duplex ultrasound, and complications were noted. There were 21 aneurysms identified in 19 patients. Fourteen (73.7%) patients were female. The mean age at diagnosis was 49years with a standard deviation of 9. Aneurysm size ranged from 9.8 to 22.2mm, with a mean diameter of 15.7mm and a standard deviation of 3.8. Seventeen aneurysms were fusiform, one was saccular, and one was multilobar. The perforators of the great saphenous vein distribution were most frequently involved, whereas only one involved deep vein disease. Few patients had symptoms, such as pressure and pain directly over the affected perforator. There was no association between the location and size of the PVA and the severity of chronic venous disease. Fourteen patients were treated surgically; fivepatients preferred conservative treatment with elastic compression stockings. Fourteen patients (73.7%) had ligation with (n= 9) or without (n= 5) excision of the aneurysm. All underwent concomitant phlebectomies, and eight of them also had ultrasound-guided foam sclerotherapy. Endovenous thermal ablation of saphenous veins was performed in seven patients, whereas two had ligation and stripping. There were four minor postoperative complications in four patients, all of which resolved within 6weeks. The median follow-up was 21months, ranging from 3 to 52months. There were no recurrences of a PVA. Five patients preferred conservative treatment. The diameter changed from 0 to 13mm during the follow-up, and the patients' symptoms remained the same or had mild worsening. PVAs are rare without causing significant symptoms locally. Diagnosis is made with duplex ultrasound because the affected vein is located below the deep fascia. As only one case in our series of 19 involved the deep veins, we believe that PVAs originate from superficial veins. The condition is relatively benign, and the treatment outcomes are very good with limited complications experienced. However, selective treatment of PVAs may not be needed for most of them as treatment of the superficial veins connecting with the PVA may be sufficient.