Treatment Of Superficial Venous Insufficiency Research Articles

The troubled course of the CHIVA Cure through clinical studies: a critical review

The treatment of Superficial Venous Insufficiency (SVI) encompasses a wide and disparate array of techniques, ranging from destructive procedures (endovascular ablation, stripping and sclerotherapy) to the conservative hemodynamic procedure (CHIVA). This variety of options betrays a wide degree of uncertainty on the recommended treatment, mainly due to technical biases in performing the CHIVA Cure that heavily affect the results from Randomized Controlled Trials (RCTs). In fact, the authors of the last Cochrane Review (CR) on the CHIVA Cure disowned its superiority based on the results from five RCTs in which more than 200 of the overall 419 participants allocated to the CHIVA arm had actually received treatments other than the CHIVA Cure. Further, the Guidelines (GLs) from both the American and the European Society for Vascular Surgery recommend the CHIVA Cure only to vascular surgeons experienced with this technique, contradicting what is expected of a specialist, i.e. mastery of the treatment of diseases in his or her specialty. Finally, CRs and GLs do not take into any account the ethically relevant issue that destructive procedures, recommended for vascular surgeons not experienced in the CHIVA Cure, will fatally deprive the patient of the Great Saphenous Vein (GSV), which is the first-choice infra-inguinal graft for the treatment of severe peripheral artery disease and to ward off the severely disabling condition resulting from limb loss, when angioplasty/stenting is not feasible. In this paper we review and discuss the RCTs, CRs, and GLs concerning the CHIVA Cure available at June 2023 on Medline and Cochrane Central databases.

Safety of Ultrasound Guided Endovenous Management of Varicose Veins and How to Avoid Potential Complications

Background Endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) have been used to treat superficial venous insufficiency, Ablation of veins has replaced operative saphenectomy as the procedure of choice for the treatment of superficial venous insufficiency. This change has likely taken place due to the minimally invasive nature and acceptable safety of endovenous ablation while remaining as efficacious and durable as saphenous ligation and stripping. Pattern of complications had been changed over the past decade, due to shifting from surgical stripping of varicose veins to endovenous procedures. The incidence of complications vary widely based on the level of operators as ecchymosis incidence post endovenous procedure range from (52-100%), parathesia (0.5 - 41.5%), phlebitis (0.5 – 5.5%), burn (0.46%), DVT (0.27%), and pulmonary embolism in 0.02% of cases. Aim of the Work assessing the incidence of complications during endovenous procedures of varicose veins and possible preventive measures. Assessing incidence of complications during Endovenous laser ablation (EVLA), radiofrequency ablation and injection sclerotherapy. Assessing the preventive measures that could be conducted to decrease the incidence of complications of endovenous surgeries. Patients and Methods Type of study retrospective cohort study study setting the study will be conducted at Ain Shams University Hospitals, interventional radiology department study period 2 years study population patients admitted in interventional radiology department during the past 2 years and scheduled for varicose veins treatment. Results was conducted on 20 patients, 70.0% were males and 30.0% were females with mean age of the study group was 45.35 ± 11.34 years ranged from 28 to 65 years. Most patients with no known medical or surgical history 65.5%, 25.0% were diabetic and 5.0% were hypertensive. Conclusion because most of the side effects are minor, and major complications are rare, EVLA is a safe and minimally invasive procedure with excellent efficacy in the treatment of varicose veins. Because optimizing laser parameters and the EVLA procedure may reduce the incidence and severity of complications associated with EVLA, additional research is warranted.

The impact of invasive treatment of superficial venous insufficiency of the lower extremities on cardiac functions.

The aim of the study was to investigate the effect of invasive treatment for chronic venous insufficiency (CVI) on cardiac hemodynamics. Fifty three patients diagnosed with saphenofemoral junction or great saphenous vein insufficiency in a level above C3 according to Clinical-Etiology-Anatomy-Pathophysiology classification were included in the study. All the patients underwent 2D echocardiography before and 3months after the invasive treatment. In postinvasive treatment echocardiographic assessment, significant decreases in right ventricular end-diastolic diameter (p = 0.006), TAPSE (p = 0.006), tricuspid E wave velocity (p = 0.004), tricuspid E/A ratio (p < 0.001), sPAB (p = 0.017), tricuspid lateral s' wave velocity (p = 0.004), and right ventricular free wall longitudinal strain rate (p = 0.011) were observed. The invasive treatment of superficial venous insufficiency of the lower extremities may lead to reduction in the increased venous return in the supine position subclinically.

Comparison of endovenous laser ablation and cyanoacrylate embolization in the non-invasive treatment of superficial venous insufficiency in terms of patient satisfaction.

Ablation with n-butyl cyanoacrylate is a clinically newer technique than endovenous laser ablation and other interventional techniques in the treatment of chronic venous insufficiency (CVI). The aim of this study was to compare the endovenous laser ablation (EVLA) and n-butyl cyanoacrylate (NBCA) interventional techniques in terms of benefit, effectiveness, and patient satisfaction. The study was conducted at Yozgat City Hospital and Bozok University Research Hospital Cardiovascular Surgery clinics between November 2016 and February 2021. A total of 260 symptomatic patients with 130 randomized cases in each intervention group were included. NBCA patients constituted Group 1 and EVLA patients Group 2. The saphenous vein was evaluated by color Doppler ultrasonography (CDUS) of the lower extremity. Patients with saphenous veins over 5.5mm in diameter and a saphenous-femoral reflux time of 2s or longer were included in the study. The patients were asked about their satisfaction and symptoms in the first postoperative week during an outpatient clinic follow-up with CDUS investigation at the first and sixth months. Although vena saphenous magna (VSM) closure results were similar with the two methods, satisfaction rates were found to be higher with the NBCA procedure. Comparison of the new methods used in the treatment of CVI revealed similar VSM closure rates in the two methods, but the satisfaction rate was higher with the NBCA technique in this study.

A pictorial essay of ultrasound findings after endovascular procedures for superficial chronic venous disease

To date endovascular surgical techniques represent an effective and widely used choice in the treatment of superficial venous insufficiency. In recent years, tumescent ablative techniques (endovenous laser ablation, radiofrequency ablation) have been joined by non-tumescent ablative techniques (mechanical-chemical ablation and cyanoacrylate glue embolization). The Duplex ultrasound (DUS) is the survey mostly used to evaluate the outcome of these procedures. The aim of this work was to provide an updated overview of the ultrasound aspects that can be found in the follow-up of patients undergoing endovascular procedures. Specifically, the characteristic imaging pictures will be described in the immediate and short/medium term follow-up. The DUS is a fundamental element of the investigation of venous system of the lower limbs after the surgical and endovascular treatment of varicose veins. Therefore, it is necessary to update one’s knowledge regarding ultrasound patterns related to new endovascular procedures.

Randomized controlled trial comparing immediate and delayed treatment of varicose veins following mechanochemical ablation

ObjectiveThe standard treatment of superficial venous insufficiency consists of endovenous thermal ablation of the refluxing main trunk, combined with side branch treatment, if needed. Side branches are often treated with phlebectomy concurrently or as a staged procedure. Whether the delayed treatment is justifiable, taking into consideration the long-term outcomes of the treatment and the need for later interventions, remains an open question. The objective of this study is to evaluate the necessity of immediate treatment of varicosities and to compare it with delayed treatment after mechanochemical ablation of the main trunk of the great saphenous vein (GSV). MethodsVenous outpatient clinic patients with varicosities (clinical classification C2-C4) resulting from GSV insufficiency were randomized to receive mechanochemical ablation only or mechanochemical ablation with concurrent phlebectomies at a ratio of 1:1. After eligibility assessment of 1149 patients, 85 met the inclusion criteria, which were age 20 to 70 years, ultrasound-verified GSV insufficiency, mean GSV diameter of 5 to 10 mm in the thigh, and provision of written informed consent. The exclusion criteria were deep venous reflux, peripheral arterial disease, pregnancy, lymphedema, body mass index of >40 kg/m2, an allergy to the sclerosant, a history of deep vein thrombosis, and/or any form of coagulopathy. The primary outcome was the need for sclerotherapy at 3 months after treatment. The secondary outcome measures, which were assessed at 3 months and 1 year, were complications, duration of sick leave, overall patient satisfaction, and GSV occlusion rate. ResultsAt 3 months, 13.2% of the patients randomized to delayed treatment needed sclerotherapy. No statistically significant difference was found in the occlusion rate of the GSV at either 3 months (mechanochemical ablation only group, 94.7%; mechanochemical ablation with phlebectomy group, 100%; P = 1.000) or 1 year (mechanochemical ablation only group, 89.7%; mechanochemical ablation with phlebectomy group, 94.4%; P = 1.000). The groups were also similar in terms of disease-specific quality of life (P = .964), health-related quality of life (P = .337), and the other outcome measures within the study period. ConclusionsThe need for reintervention did not increase and the patients' quality of life and satisfaction with the procedure were similar at 1 year when mechanochemical ablation only was compared with mechanochemical ablation plus phlebectomy.

Specific management of lipodermatosclerosis (sclerotic hypodermitis) in acute and chronic phase.

Lipodermatosclerosis or sclerotic hypodermitis is presented as a complication of venous insufficiency and in particular of post-thrombotic syndrome with a high risk of progression to leg ulcers. However, it has also been described in obese patients without venous insufficiency, and even in the course of various systemic diseases including scleroderma. It most often affects middle-aged women and is usually bilateral, with a typically "inverted champagne bottle" leg appearance. The pathogenic role of venous hypertension explains why compression with bands or stockings is the basis of treatment. In acute phase, which may precede or complicate chronic forms, the pain is so severe that compression is not tolerated. In acute phase, non-steroidal anti-inflammatory drugs, intra-lesional use of triamcinolone, and capsaicin transdermal patches indicated for neuropathic pain have been proposed. In chronic forms, the treatment of superficial venous insufficiency and/or incontinent perforating veins, documented during a Duplex ultrasound scan, is usually proposed, whenever possible. In association with elastic compression, pentoxifylline and colchicine have been used without clear evidence of clinical efficacy. Finally, in the most advanced clinical presentation with the appearance of a sclerotic gaiter associated with ulcerations, surgical treatment with excision-cutaneous grafting associated or not with perforating veins ligation and a fasciotomy may be discussed as a last resort for treatment.

Treatment of superficial venous insufficiency in a large patient cohort with retrograde administration of ultrasound-guided polidocanol endovenous microfoam versus endovenous laser ablation

Treatment of superficial venous insufficiency in a large patient cohort with retrograde administration of ultrasound-guided polidocanol endovenous microfoam versus endovenous laser ablation

Treatment of superficial venous insufficiency in a large patient cohort with retrograde administration of ultrasound-guided polidocanol endovenous microfoam versus endovenous laser ablation

ObjectiveTo evaluate outcomes among symptomatic patients with superficial chronic venous insufficiency treated with retrograde ultrasound-guided polidocanol endovenous microfoam 1% (PEM) or endovenous laser ablation (EVLA). MethodsThis study is a retrospective chart review from a single vein center between October 2013 and June 2019. Procedures were performed on 1070 patients with Clinical, Etiologic, Anatomic, and Pathophysiologic class 2 to 6 disease and symptomatic superficial venous reflux of the great saphenous vein or anterior accessory saphenous vein. ResultsPEM was used for 550 procedures and patients were followed for 43 ± 13 months; EVLA was used for 520 procedures and patients were followed for 57 ± 18 months. After complete treatment, the elimination of reflux was documented in 93.5% (514/550) and 92.8% (482/520) of the PEM and EVLA procedures, respectively. During the follow-up period, 18% of patients treated with EVLA returned for additional treatment to address residual symptoms in the affected leg. In C6 patients treated with PEM, 69% of ulcers (11/16) healed in less than 1 month, compared with 5% of patients (1/21) treated with EVLA. In C4 patients with lesions, resolution of spontaneous bleeding was 100% in both groups. There were no neurological or cardiac adverse events in the PEM group. Minor complications included asymptomatic deep vein thrombosis (0.5%), one common femoral vein thrombus extension, and superficial venous thrombosis (4%) in the PEM group and asymptomatic deep vein thrombosis (0.8%) and two endovenous heat-induced thromboses in the EVLA group. ConclusionsPEM is comparable in safety and efficacy with EVLA for the treatment of saphenous reflux and associated symptoms. PEM was an effective intervention for most patients with C6 disease. Closure rates in both groups were maintained 36 months after treatment.

Influence of Superficial Venous Ablation on Deep Venous Dilation and Reflux in Patients With Saphenous Varicose Veins

This study is a single-center retrospective review of 223 legs treated with radiofrequency ablation of the great saphenous vein in 154 patients. Patients were evaluated before and after radiofrequency ablation. The treatment of superficial venous insufficiency with endovenous ablation improves deep venous hemodynamics. In patients with concomitant deep venous reflux, there was a statistically significant improvement as well as a decrease in the diameter of both the common femoral and popliteal veins. There were also improvements in the functional venous volume (decrease) and venous filling index (decrease, which correlated with the deep venous diameters. The “old” teaching that one cannot improve deep venous insufficiency has been shown not to be the case in many studies, including this one. By taking the refluxing superficial system out of the circuit, the hemodynamics and dilatation improve in the deep system. It may not return to normal or baseline, but the patients may have symptomatic improvement. And improved quality of life is the ultimate goal!!

Effects of diosmin-hesperidin and low pressure compression stocking combination in superficial venous insufficiency

Aim: The main aim of the study is to investigate the efficacy and patient tolerance of Daflon 1000mg/day and low-pressure compression stocking combination in the treatment of superficial venous insufficiency. Materials and Methods: This prospective study included 112 patients diagnosed with superficial venous insufficiency and reflux in saphenofemoral junction during March 2018 and 2019 at our center. All the patients received 1000 mg micronized purified flavonoid fractions containing 90% diosmin-10% hesperidin and low-pressure venous compression stockings (15-20 mmHg) throughout the study. Patients superficial, perforator, and deep venous systems were evaluated by Doppler US at the beginning and average of 5.3 ± 3.7 months after treatment. Results: A total of 99 (88.4%) patients out of 112 eligible patients completed the investigation. The mean age was 41±12.6, the female was 66 (58.9%), the mean follow-up was 5.3±3.7 months. Pre-treatment and post-treatment diameters of SFJ were 6.27±2.9 and 5.68±1.8 mm, respectively, this was statistically significant (P=0.033). All of the patients have SFJ reflux initially, after the treatment, patients with SFJ reflux were decreased to 44 (44.4%), this was also statistically significant (P0.001, OR:0.004, 95% CI: 0.0002-0.07). We also found significant improvement in grade III and grade IV reflux (P0.05) after treatment. The symptomatic patients decreased from 63 to 16 after treatment, this was statistically severely significant (P0.001, OR:0.11, 95% CI: 0.056-0.216). During the follow-up period, 6 (5.4%) patients were worsened and underwent surgical intervention, this was not statistically significant (P=0.076). Conclusion: Daflon 1000mg/day with a combination of low- pressure CS well tolerates by venous insufficiency patients. Six months of continuous application may reduce the reflux of SFJ and VSM, and causes marked symptomatic relief.

Frequency and Severity of Hypersensitivity Reactions in Patients After VenaSeal Cyanoacrylate Treatment of Superficial Venous Insufficiency

ObjectiveHypersensitivity reaction presenting as a distinctive erythematous rash has been reported following VenaSeal™ cyanoacrylate adhesive closure. We report the frequency of hypersensitivity re...

Using radiofrequency ablation for the treatment of lower limb varicose veins

Lower limb chronic venous insufficiency is a commonly seen disease which accounted for 40.5% of people over the age of 50 years old with females having 4.25 higher prevalence compared with males [23]. The lesions could be observed in superficial, perforating, deep veins or all three venous systems in the lower extremities [2]. Superficial veins in particular could be classified in 3 groups: chronic venous insufficiency, varicose veins, and thrombophlebitis. The treatment options of lower limb chronic venous insufficiency in general and chronic venous insufficiency – varicose veins are grouped in two major categories: medication/intervention and surgery. Since 1980s-1990s, endovascular interventions for the treatment of superficial venous insufficiency – varicose veins were introduced and were the new advancement in the treatment of lower limb venous insufficiency disorders [3, 7, 11, 12, 16] .

Patient injuries in the treatment of superficial venous insufficiency registered in Finland between 2004 and 2017.

This study aimed to identify the unintended incidents that led to patient injuries (PIs) in the treatment of superficial venous insufficiency (SVI). PI claims filed with the Finnish Patient Insurance Centre between 2004 and 2017 involving SVI were reviewed. Factors contributing to PI were identified and classified. Eighteen (13.2%) of 136 compensated PIs in the specialty of vascular surgery were related to SVI. Only 4.7% of 383 SVI claims were compensated. The incidence of PIs was 9.9 per 100 000 patients. Fifteen patients had open surgery (83.3%) and three (16.7%) endovenous treatment. Two (11.1%) patients had necrotising fasciitis, four (22.1%) had deep vein injuries and two (11.1%) had a permanent nerve injury. Two (11.1%) patients had retained endovenous material that required surgical removal. PIs were identifiable during all stages of care, perioperative injuries related to open surgery being the most common.

Which antidote to the undue injections of hypertonic bicarbonate solution during tumescence for surgery of superficial venous insufficiency?

The generalization of local anesthesia by tumescence during the thermal endovenous treatment of superficial venous insufficiency transferred the management of sedation to the surgeons. The recommended preferential use of a 1.4/100 bicarbonate solution with 1% of adrenalined lidocaine requires the compliance with certain rules, with the risk of side effects and of potentially serious complications, and possible medico-legal issues. Apart from an overdose in lidocaine, the injection by error of a hypertonic solution can induce extensive subcutaneous and cutaneous necroses in the treated zone leading to many weeks of treatment with surgical debridement, directed healing, and skin grafting, with esthetic even functional important sequelae, leading to medico-legal procedures.

Use of a Novel Device in Reconstructive Venous Surgery: Preliminary Results.

Evaluation of the outcomes of OSES (oval-shaped external support), a novel device for external valvuloplasty of the great saphenous vein (GSV) for the conservative treatment of superficial venous insufficiency. Between 2012 and 2015, 30 patients underwent external valvuloplasty of the GSV for a total of 32 limbs. Patients were subjected to clinical and instrumental follow-up by a half-year ultrasound for a minimum of 36 months. The main endpoints were the recurrence of varicose disease, persistent or recurrent venous reflux, and venous thrombosis. Varicose recurrence was verified in six limbs on 32 (18.75%). Four limbs (12.5%) presented a recurrence of the reflux even in the absence of varicose veins. Two limbs (6.25%) underwent saphenectomy after the valvuloplasty intervention at 12 and 18 months, respectively, because of the presence of saphenofemoral reflux and varicose recurrences. No case of venous thrombosis of the saphenous trunk was observed. The external valvuloplasty of the GSV is a well-known technique that used to treat the superficial venous insufficiency. The newly introduced OSES device seems to show better midterm results, due to a better alignment of the valve flaps. In our experience, the use of this device gives better long-term results and allowed to extend the indication to patients with saphenic diameters that were considered not eligible for repair. In conclusion, although our data needs further confirmation, OSES device might represents a new interesting opportunity for reconstructive venous surgery.

The Effectiveness of Endovenous Radiofrequency Ablation Application in Varicose Vein Diseases of the Lower Extremity.

We aimed to determine the outcome, complications, and quality of life effects of radiofrequency ablation (RFA) in the treatment of superficial venous insufficiency.A total of 134 extremities from 100 patients were evaluated in this retrospective study performed at the Cardiovascular Surgery Department of Atatürk University Faculty of Medicine. Treatment success was determined by occlusion. The clinical, etiologic, anatomic, and pathophysiologic (CEAP) and venous clinical severity score (VCSS) scores of patients were assessed pre- and postoperatively to evaluate clinical outcome and quality of life. The pain was assessed with the Wong-Baker score. Complications and their frequency were assessed and recorded.Treatment success, as measured by occlusion rate, was 99% percent. Prior to treatment, the CEAP clinical score was C2 (81.0%), while after treatment, it was C0 (54.0%) (p<0.001). The pretreatment median VCSS score was 5 (min-max: 1-9) while the post-treatment median was 1 (min-max: 1-3) (p<0.001). The mean pain score was 1.34; only one patient reported a score of 6 while the minimum score was 1. A total of 15 complications occurred; only one was a major complication (deep vein thrombosis or DVT) while the remaining 14 were minor complications.While longstanding surgical treatments still provide significant success, the RFA technique not only surpasses them in success rate but also in terms of pain, complications, and better patient satisfaction. The results of our study indicate that RFA is an effective and safe option for the treatment of superficial venous insufficiency.

3:18 PM Abstract No. 74 Feasibility of implementing medical chatbot technology into the postoperative care for patients undergoing treatment for superficial venous insufficiency

We report our early experience in implementing medical chatbot technology into the care of patients undergoing treatment for lower extremity (LE) superficial venous reflux disease. We conducted a pilot study to assess whether a medical chatbot can be used to facilitate and reinforce postoperative monitoring, care coordination, and communication for venous insufficiency patients. This is a prospective, observational study design using survey and utilization data for 168 patients (146 female, 22 male) with a mean age of 48.5 years (range, 22 to 79 years), who underwent treatment for LE superficial venous reflux disease at our center. Pre procedure consultation included a detailed medical history, pertinent physical examination and performance of a thorough LE venous duplex evaluation. Treatment included a variable combination of endovascular ablation, ultrasound-guided sclerotherapy and ambulatory phlebectomy. All patients were followed at one week, one month and three to months post procedure(s). In addition to providing each patient with our standard verbal and written post procedure care instructions, we provided access to an automated post procedure medical chatbot platform. Of the 168 patients who initially enrolled, 10 (6%) opted out. Among the remaining volunteer participants, there was an engagement rate of 83.3%. 60.1% reported a high degree of satisfaction and found the chatbot to be helpful or very helpful in their care. The chatbot facilitated follow-up appointments, communication with our clinic for questions or concerns, and reinforced post procedure instructions for activity, wound care, compression, and awareness of potential complications. We successfully piloted the use of a chatbot messaging platform to supplement education and monitoring for a group of postoperative venous insufficiency patients. This study highlights the potential for broader integration into established best-practice workflows. Broader adoption will likely necessitate seamless integration into the electronic medical record.

Retrograde Administration of Ultrasound-Guided Endovenous Microfoam Chemical Ablation Versus Endovenous Laser Ablation for the Treatment of Superficial Venous Insufficiency

Retrograde Administration of Ultrasound-Guided Endovenous Microfoam Chemical Ablation Versus Endovenous Laser Ablation for the Treatment of Superficial Venous Insufficiency

The Discord Outcome Analysis (DOA) as a Reporting Standard at Three Months and Five Years in Randomised Varicose Vein Treatment Trials

In patients undergoing endovenous treatment for superficial venous insufficiency, a combined approach to outcome reporting may provide a more accurate representation of the degree of improvement experienced by patients.