Treatment Of Saphenous Vein Incompetence Research Articles

Clinical outcomes after treatment of incompetent saphenous vein combined with segmental popliteal vein reflux

ObjectiveThis study aimed to evaluate whether differences exist in the quality of life changes and complication rates after treatment of incompetent saphenous vein (ISV) based on the presence of segmental popliteal vein reflux (SPVR). MethodsPatients who underwent treatment for ISV from July 2016 to July 2021 were included and divided into two groups: patients without deep venous reflux (DVR) and patients with SPVR. Patients with axial DVR, a history of deep vein thrombosis, a history of orthopedic surgery, previous venous treatment, and no postoperative follow-up were excluded from the study. Duplex ultrasound examination was performed preoperatively and at 6 and 12 months postoperatively. ResultsThe study included 233 patients (398 limbs), and 50 (64 limbs) had SPVR. Differences were not observed in gender, age, body mass index, distribution of clinical class according to Clinical-Etiology-Anatomy-Physiology classification, laterality, treatment method, and preoperative Venous Clinical Severity Score or Aberdeen Varicose Vein Questionnaire scores between the two groups with SPVR or without DVR. Furthermore, the Venous Clinical Severity Score and Aberdeen Varicose Vein Questionnaire scores at 6 and 12 months postoperatively were improved in both groups, although without significant differences. A significant difference was not observed in the rate of postoperative complications between the groups based on the presence of SPVR (1.8% vs 1.6%: P = .896). The SPVR improvement rate after ISV treatment was 25% (16/64), and patient-reported outcomes in patients combined with SPVR improved independent of treatment modality, saphenous vein treatment section, and postoperative SPVR improvement. ConclusionsComplication rates and clinical outcomes after ISV treatment did not differ in the presence of SPVR. In patients with SPVR, after ISV treatment, quality of life improved regardless of treatment modality, saphenous vein treatment section, and postoperative SPVR improvement.

The story of N-butyl cyanoacrylate saphenous vein ablation

In 2009, our group was approached by an experienced radiologist who proposed to close refluxing saphenous veins with glue; an idea based on his experience with N-butyl cyanoacrylate (TRUFILL) embolization of cerebral arterial venous malformations. We henceforth began with a swine model, 1 Almeida J.I. Min R.J. Rabe R. McLean D.J. Madsen M. Cyanoacrylate adhesive for the closure of truncal veins: 60-day swine model results. Vasc Endovascular Surg. 2011; 45: 631-635 Crossref PubMed Scopus (74) Google Scholar and then moved to first-in-human studies 2 Almeida J.I. Javier J.J. Mackay E. Bautista C. Proebstle T. One-year follow-up of first human use of cyanoacrylate adhesive for treatment of saphenous vein incompetence. J Vasc Surg Venous Lymphatic Disord. 2013; 1: 174-180 Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar for nonthermal ablation of the saphenous vein with their proprietary N-butyl cyanoacrylate glue. Of interest, during the regulatory development pathway, this product was approved as a device, not a drug. It's efficacy has proved excellent, and during the past decade cyanoacrylate closure (CAC) has been adopted widely worldwide. However, reports of hypersensitivity-related adverse events, and granulomas, have begun to surface. It is timely that Dr Athavale and his team have recently published an excellent systematic review on CAC. Based on the available literature, the adverse events related to cyanoacrylate glue can be divided into the following: phlebitis, hypersensitivity (type I and type IV), foreign body granuloma, endovenous glue induced thrombosis and infection. These adverse events may require prolonged steroid use or vein excision. Cyanoacrylate glue reactions: A systematic review, cases, and proposed mechanismsJournal of Vascular Surgery: Venous and Lymphatic DisordersVol. 11Issue 4PreviewCyanoacrylate glue closure was first used in humans 10 years ago to treat venous reflux of the axial veins. Studies have since shown its clinical efficacy in vein closure. However, great need exists to elucidate further the types of specific adverse reactions that cyanoacrylate glue can cause for better patient selection and to minimize these events. In the present study, we systematically reviewed the literature to identify the types of reported reactions. In addition, we explored the pathophysiology contributing to these reactions and proposed the mechanistic pathway with inclusion of actual cases. Full-Text PDF

Changes of stump length depending on starting position of glue injection related to venous diameter during cyanoacrylate closure for incompetent saphenous veins

ObjectiveA common pattern of recurrence after cyanoacrylate treatment of incompetent saphenous veins has been associated with reflux from the residual stump. The purpose of this study was to analyze the starting point of cyanoacrylate glue injection from the junction to decrease the stump length. MethodsA retrospective review was performed using prospectively collected data of patients with cyanoacrylate closure (CAC). Preoperatively, the diameter of the saphenous vein was measured. CAC was performed according to the manufacturer's instructions. After the procedure, clinical outcomes including pain, Venous Clinical Severity Score, and quality of life using the Aberdeen Varicose Vein Questionnaire were evaluated. Postoperative duplex scanning was performed to evaluate the occlusion rate of the target vein, stump length, and presence of endovenous glue-induced thrombosis. The stump length was analyzed according to the preoperative venous diameter to determine the proper point of glue injection to decrease the stump length. ResultsDuring the study period, CAC was performed in 408 patients. The mean age was 56.2 ± 11.5 years (range, 19-84 years). A total of 279 patients (68.4%) were women. Occlusion of the target vein was achieved in all patients. After the procedure, pain, Venous Clinical Severity Score, and quality of life were improved (P < .001). Endovenous glue-induced thrombosis developed in 5.8% of patients. There was a 1.53-fold linear increase in the stump length for every 1-mm increment of the preoperative venous diameter. In 20 patients with a venous diameter ≥5 mm, glue injection was performed safely 4 cm distal to the junction to decrease the stump length. ConclusionsThe stump length linearly increased with an increase in the saphenous vein diameter. If the diameter of the saphenous vein is more than 5 mm, cyanoacrylate glue may be injected 4 cm distal to the junction to decrease the stump length.

A systematic review and meta-analysis comparing the efficacy of cyanoacrylate ablation over endovenous thermal ablation for treating incompetent saphenous veins.

The aim of this study was to systemically review and analyze the efficacy of cyanoacrylate ablation (CA) in comparison with endovenous thermal ablation (ETA) for the treatment of incompetent saphenous veins. A systematic literature search was conducted using databases of Pubmed, Embase, and Cochrane Library from the times of their inception to April 2020. Studies were selected based on inclusion and exclusion criteria after assessing the risk of bias in comparative studies with Cochrane and rating quality of evidence with the GRADE methodology. The meta-analysis was carried out using the Review Manager 5.4 program to conduct homogeneity tests. One cohort study and three randomized controlled trials (RCT), including a total of 1457 participants were included in the meta-analysis. ETA included endovenous laser ablation (ELVA) and radiofrequency ablation (RFA) in the selected studies. Comparison between CA and a combination of EVLA and RFA or RFA alone were carried out in two of RCTs, while comparison between CA with EVLA was conducted in one RCT and the cohort study. There was no statistical difference in closure rates between CA and ETA after pooled analysis. Similar symptom alleviation observed between different groups. However, the CA group showed a lower ecchymosis rate than RFA and a significantly lower incidence of adverse events, such as ecchymosis, phlebitis and paresthesia, than EVLA. Compared with ETA, the patients received CA treatment exhibited lower pain scores in a shorter procedure duration without needing compression stocking, returned to normal life sooner, and had significantly better quality of care. There was no significant difference in the number needed to treat for additional therapy after three months of follow-up between groups. This meta-analysis indicates that CA has better overall outcomes than ETA and offers superior clinical benefits in the treatment of incompetent saphenous veins.

Automatic Sclerosant Injection Technique of Mechanochemical Ablation with ClariVein Using a Syringe Pump for the Treatment of Varicose Veins.

Mechanochemical ablation (MOCA) is a non-thermal, non-tumescent technique for the treatment of incompetent saphenous vein. It is sometimes difficult to maintain consistency when simultaneously implementing wire rotation, sclerosant injection, and wire pullback. Here, we report a simple technique for achieving constant injection during MOCA with the help of a syringe pump; thus, the operator can focus on wire pullback only with convenience and consistency.

Proper Position of the Catheter Tip to Decrease Stump Length During Cyanoacrylate Closure for Incompetent Saphenous Vein

The cyanoacrylate closure (CAC) procedure is a safe and effective modality for treatment of incompetent saphenous veins. The common pattern of recurrence is associated with reflux from the residual stump. The purpose of this study was to analyze the proper point of glue injection from the junction to decrease stump length. A retrospective review was performed from prospectively collected data of CAC patients. Preoperatively, the diameter of the saphenous vein was measured. The CAC procedure was performed with the instruction for use. Postoperative duplex ultrasound scanning was performed to evaluate the occlusion rate of target vein, stump length, and presence of endovenous glue-induced thrombosis (EGIT). Stump length was analyzed according to the preoperative venous diameter to evaluate the proper injection point of glue to decrease stump length. All statistical analysis was performed using SPSS 22.0 software (IBM, Armonk, NY). P value < .05 was considered statistically significant. During the study period, the CAC procedure was performed in 348 patients. The mean age was 55.7 ± 11.7 years (range, 19-84 years); 240 patients (68.9%) were female. The occlusion rate of the target vein was 91.2% at 12 months. After the procedure, pain, Venous Clinical Severity Score, and quality of life score were improved with statistical significance (P < .001). EGIT developed in 5.8% of patients. Small diameter of the saphenous vein (<5 mm) is a risk factor for the development of EGIT. The stump length was increased 1.5 times for every 1-mm increment of preoperative venous diameter (Fig). The Table shows the expected stump length if the glue is injected 4 cm distal from the junction. Venous diameter ≥8 mm is the cutoff value for injection of glue 4 cm distal from the junction to decrease stump length with safety. Small diameter of the saphenous vein (<5 mm) is a risk factor for the development of EGIT. If the diameter of the saphenous vein is >8 mm, the glue can be injected 4 cm distal from the junction for acceptable stump length and safety as well.TableCorrelation between venous diameter and stump lengthInterval of venous diameter (mm)Mean venous diameter (mm)Stump length (mm)Expected stump lengtha (mm)<2.01.8 ± 0.2––2.0 ∼ 2.92.5 ± 0.2––3.0 ∼ 3.93.4 ± 0.322.5 ± 13.1–4.0 ∼ 4.94.5 ± 0.223.7 ± 11.2–5.0 ∼ 5.95.4 ± 0.226.4 ± 9.916.46.0 ∼ 6.96.4 ± 0.227.9 ± 9.417.97.0 ∼ 7.97.4 ± 0.227.1 ± 11.518.48.0 ∼ 8.98.5 ± 0.330.4 ± 9.619.99.0 ∼ 9.99.4 ± 0.333.8 ± 10.521.4≥1011.5 ± 1.636.9 ± 7.222.9P valueb<.001<.001<.001Values are mean ± standard deviation.aIf the glue is injected 4 cm distal from the junction, the stump length can be expected as following. (The values are added 1.5 mm with the increment of venous diameter 1 mm from 5.0∼5.9 mm as a reference diameter.bAnalyzed by one way ANOVA. Open table in a new tab

CASS (CyanoAcrylate closure versus Surgical Stripping for incompetent saphenous veins) study: a randomized controlled trial comparing clinical outcomes after cyanoacrylate closure and surgical stripping for the treatment of incompetent saphenous veins

BackgroundSeveral modalities are used for the treatment of varicose veins. Open surgical treatment with ligation and stripping of the saphenous vein has been the standard of care for many years. Endovenous thermal ablation has been shown to be a safe and effective alternative with high, long-term, target-vein closure rates. Despite this, there is the possibility of thermal injury to surrounding structures. The recently introduced cyanoacrylate closure is also considered to be a good alternative and the risk of injury to surrounding structures is minimal. The purpose of this study is to demonstrate the non-inferiority of cyanoacrylate closure with the VenaSeal™ closure system compared to surgical stripping in terms of clinical outcomes for the treatment of incompetent great saphenous veins.Methods/designThis is an open-label, multicenter, prospective, randomized controlled trial evaluating the non-inferior clinical outcomes of cyanoacrylate closure compared to surgical stripping for the treatment of incompetent saphenous veins. After baseline measurements, participants will be randomly allocated into either the cyanoacrylate closure group or the surgical-stripping group. The primary endpoint of the study is the complete closure rate of the target vein in the cyanoacrylate closure group, and the absence of venous reflux or residual venous tissue after surgical stripping in the surgical-stripping group. These endpoints will be measured by Doppler ultrasound performed by qualified vascular technologists or investigators at 3 months after treatment. Secondary outcomes include perioperative pain, postoperative ecchymosis, clinical assessment (including general and disease-specific quality of life evaluations), complete closure rate, and absence of venous reflux or residual venous tissue at the 12- and 24-month follow-ups, as well as all adverse event rates during the 24-month follow-up period.DiscussionThis multicenter randomized controlled trial is designed to show non-inferiority in terms of complete closure rate of cyanoacrylate compared to surgical stripping for the treatment of incompetent saphenous veins.Trial registrationClinical Research Information Service (CRIS), ID: KCT0003203. Registered on 20 September 2018.

Effect of saphenous vein diameter and reflux time on stump length after cyanoacrylate closure.

Cyanoacrylate closure (CAC) has recently been introduced for the treatment of incompetent saphenous veins. The purpose of the present study is to investigate the correlation of the saphenous vein diameter and reflux time (RT) with the stump length after CAC. A retrospective review was performed using prospectively collected data of CAC patients. The pre-operative saphenous vein diameter and RT were measured. The stump length was measured immediately after the procedure and at 1 week. Pearson's correlation analysis was applied to determine the correlation between the saphenous vein diameter or RT and stump length. A total of 32 saphenous veins were closed in 21 patients, 15 of whom were female. The mean age was 56.9±12.6 years (range, 31-73 years). Complete closure was achieved in all patients. The pre-operative mean diameter was 7.0±2.2 mm. The mean stump lengths were 26.1±10.2 and 28.1±13.6 mm on post-operative days 0 and 7, respectively (P=0.002). The Pearson coefficients for the correlation between the saphenous vein diameter and stump length on post-operative days 0 and 7 were 0.528 (P=0.005) and 0.177 (P=0.430), respectively. Furthermore, the Pearson coefficients for the correlation between the RT and stump length on post-operative days 0 and 7 were -0.215 (P=0.282) and 0.019 (P=0.938), respectively. In conclusion, CAC is effective modality for the treatment of saphenous vein insufficiency. The stump length increased with the diameter of the saphenous veins, while the RT had no marked effect on the stump length. Therefore, the glue injection should be initiated from the instructed position to avoid glue extension into deep veins and to prevent elongating the stump length.

Safety and Effectiveness of Endovenous Thermal Ablation for Incompetent Saphenous Veins with an Aneurysm Close to the Junction

The aim was to evaluate the safety and effectiveness of endovenous thermal ablation (EVTA) with or without adding high ligation (HL) for the treatment of incompetent saphenous veins with an aneurysm (>20mm for the great saphenous vein, >15mm for the small saphenous vein) close to the junction. This was a prospective observational cohort study in a single centre. All patients presenting with saphenous aneurysms close to the junction were included. Those with a venous aneurysm more distally, at >2cm from the junction, or with associated deep venous aneurysms were excluded. Patients were treated with EVTA alone or combined with HL in cases of an aneurysm with a diameter >30mm. Phlebectomies were performed during the same treatment session. Patients were followed up one and six weeks, and one year after treatment. Duplex ultrasound (DUS) was performed to evaluate occlusion of the vein and aneurysm as well as possible complications such as endovenous heat induced thrombosis (EHIT) or deep vein thrombosis (DVT). Venous clinical severity scores (VCSS) were registered before and one year after treatment. Thirteen patients (15 limbs) were included between February 2012 and January 2015. Eleven limbs were treated with EVTA alone, the remaining four limbs with EVTA and HL. No severe adverse events occurred (no EHIT, no DVT). After one year none of the aneurysms was still visible on DUS and the truncal obliteration rate was 80% (two partial, one segmental recanalisation). Both treatment strategies showed significant improvement of the VCSS at the one year follow up, from a median score of 6 (interquartile range [IQR] 5-7) to 2 (IQR 1-3) (p=.001). EVTA with or without HL appeared to be a safe and effective treatment for patients presenting with incompetent saphenous veins with an aneurysm close to the junction.

VESS08. Incidence, Classification, and Risk Factors of Endovenous Glue-Induced Thrombosis After Cyanoacrylate Closure of Varicose Vein

Cyanoacrylate closure (CAC) is a safe and effective modality for the treatment of incompetent saphenous vein. The glue extension into the deep vein, so-called endovenous glue-induced thrombosis (EGIT) may be a worrisome complication. However, the incidence, classification, and risk factors of EGIT have not been elucidated. We report the incidence after CAC for an incompetent saphenous vein. A retrospective review was performed from prospectively collected data of CAC patients (Table I). Preoperatively, the diameter, reflux time, and peak reflux velocity of saphenous veins were measured. CAC was performed following the instructions for use. Postoperative follow-up was done at 1 week, 3 months, 6months, and 1 year after procedure. Postoperative duplex scanning was performed to evaluate the presence of glue extension into the deep vein. We classified it as four grades. The risk factor for the development of EGIT was analyzed (Table II). The paired t-test, independent t-test, Fisher’s exact test and one-way analysis of variance were used for statistical analysis. A P value of less than .05 was considered statistically significant. During the study period, CAC was performed in 191 patients. The mean age was 56.1 ± 11.7 years with a range of 19 to 84 years. The 126 patients were female. EGIT developed in 11 patients (5.8%). EGIT grades I and II developed in seven (63.6%) and four (36.4%) patients, respectively. All patients with EGIT did not use an anticoagulant. After the procedure, pain, venous clinical severity score, and quality of lift score were improved with statistical significance (P < .001). On the analysis of risk factor for the development of EGIT, a preoperative saphenous vein diameter of less than 5 mm was the only risk factor (P < .001). EGIT is not uncommon complication. A small diameter of saphenous vein less than 5 mm is a risk factor for the development of EGIT. The clinical course of EGIT was benign.Table IPatient demographics (N = 191)DemographicsAge, years56.1 ± 11.7 (19-84)Sex Male65 (34.0) Female126 (66.0)Indication for treatment Discomfort168 (88.0) Heaviness152 (79.6) Night cramping129 (67.5) Pain23 (12.0) Itching10 (5.2) Swelling5 (2.6)Limbs286 Right47 (24.6) Left49 (25.7) Bilateral95 (49.7)Truncal veins332 179 (41.4) 287 (45.5) 321 (11.0) 44 (2.1)Anesthesia Local190 (99.5) General1 (0.5)Operation time, minutes67.7 ± 29.8EGIT11 (5.8)Gradea 17 (63.6) 24 (36.4) 30 (0) 40 (0)Truncal vein (GSV : SSV)7 (63.6) : 4 (36.4) : 0 (0) : 0 (0)Pain scoreb Immediate after procedure1.6 ± 1.0 Postoperative 7 days0.8 ± 1.1Venous clinical severity scorec Immediate after procedure (n = 145)4.25 ± 2.35 Postoperative 7 days (n = 167)1.25 ± 1.31 Postoperative 90 days (n = 96)0.95 ± 1.34Quality of lift scored Immediate after procedure (n = 145)11.51 ± 8.24 Postoperative 7 days (n = 167)7.89 ± 5.50 Postoperative 90 days2.65 ± 4.01EGIT, Endovenous glue-induced thrombosis; GSV, great saphenous vein; SSV, small saphenous vein.Values are mean ± standard deviation (range) or number (%).aGrade was classified with the occupied area of common femoral or popliteal vein of glue extension.bPain score was measured with via visual analog scale (P < .001 by paired t-test).cThe venous clinical severity score was improved after procedure (P < .001 by one-way analysis of variance).dQuality of lift score was calculated with Aberdeen Varicose Veins Questionnaire (P < .001 by one way analysis of variance). Open table in a new tab Table IIRisk factors of endovenous glue-induced thrombosis (EGIT)Risk factorsNo EGITEGITP valueNo. (%)180 (94.2)11 (5.8)Age, years, mean ± SD55.9 ± 11.923.7 ± 4.9.573aBMI, mean ± SD25.1 ± 4.856.1 ± 11.7.456aSex, no. (%).189b Male59 (90.8)6 (9.2) Female121 (96.0)5 (4.0)Side, no. (%).577b Right43 (91.5)4 (8.5) Left47 (95.9)2 (4.1) Bilateral90 (94.7)5 (5.3)Treated vein, no. (%).860b GSV99 (95.2)5 (4.8) SSV30 (90.9)3 (9.1) Both51 (94.4)3 (5.6)Comorbidity, no. (%) Hypertension (yes:no)22:1582:9.632b Diabetes (yes:no)15:1650:111.00b Hypercholesterolemia (yes:no)7:1731:10.384b Smoking (yes:no)4:1761:10.259b Cancer (yes:no)1:1790:111.00b Previous DVT (yes:no)1:1791:10.112bPresence of symptom (yes:no)178:211:01.00bVein diameter <5 mm (yes:no)10:1708:3<.001bBMI, Body mass index; DVT, deep vein thrombosis; GSV, great saphenous vein; SD, standard deviation; SSV, small saphenous vein.aIndependent t-test.bFisher’s exact test. Open table in a new tab

Clinical Features and Management of “Phlebitis-like Abnormal Reaction” After Cyanoacrylate Closure for the Treatment of Incompetent Saphenous Veins

Cyanoacrylate closure for the treatment of incompetent saphenous veins does not cause thermal damage and demonstrates satisfactory outcomes with rapid recovery. However, the characteristics of phlebitis-like abnormal reaction (PLAR), the most common adverse event after cyanoacrylate closure, have not been clarified. Moreover, it differs from typical phlebitis after thermal ablation. The objective of our study is to investigate the clinical features of PLAR after cyanoacrylate closure and to report its management. A total of 160 patients with 271 incompetent saphenous veins (great saphenous veins, 201; small saphenous veins, 70) underwent cyanoacrylate closure with the VenaSeal™ system. We defined PLAR as any unusual skin condition that develops suddenly, such as erythema, itching, swelling, and pain/tenderness, over the treated veins several days after cyanoacrylate closure. Oral antihistamines and intravenous dexamethasone were administered to manage PLAR. Of the 271 treated veins, 69 experienced PLAR (25.4%). The mean time of occurrence was 13.6±4.6days after treatment. The rate of occurrence of erythema, itching, swelling, and pain/tenderness were 92.2%, 91.2%, 66.2%, and 48.5%, respectively. The occurrence of PLAR was significantly higher for great saphenous veins than for small saphenous veins (P<0.001). Occurrences were more frequent in cases with a suprafascial great saphenous vein of length >10cm than in cases with a subfascial great saphenous vein (P=0.001). The proportion of patients who reported swelling decreased by more than half after the administration of oral antihistamine. The pain score on the 10th day also decreased significantly after the administration of antihistamine (P=0.006). PLAR must be distinguished from classic phlebitis. We believe that PLAR is a type IV hypersensitivity reaction due to a foreign body, and in our experience, antihistamines or steroids are effective for the prevention and management of PLAR.

Initial outcomes of endovenous laser ablation with 1940 nm diode laser in the treatment of incompetent saphenous veins

To investigate the initial outcomes of 1940 nm diode laser in the treatment of incompetent saphenous veins. This was a prospective observational study. We treated 89 patients with 160 incompetent saphenous veins using a 1940 nm diode laser and bare fiber. The laser's power was set to 4.5 W with a mean linear endovenous energy density of 50.4 J/cm. The one-month closure rate was 100%. The post-procedural pain score at 6 h, 1 day, 10 days, and 1 month was 0.85 ± 1.04, 0.65 ± 1.01, 0.82 ± 1.25, and 0.47 ± 0.82, respectively. Complications encountered included paresthesia (3.8%) and thrombophlebitis (4.4%), whereas no cases of endovenous heat-induced thrombosis were observed. The 1940 nm laser and bare fiber at 50.4 J/cm showed satisfactory initial outcomes with less pain and fewer complications, in the treatment of incompetent saphenous veins.

Feasibility and Safety of Catheter Directed Foam Sclerotherapy Combined with Tumescent Local Anesthesia for Treatment of Axial Varicose Vein

Background: Varicose veins is a common health problem, with an estimated prevalence of greater than 20% (range 21.8% to 29.4%). Approximately 5% (range 3.6% to 8.6%) have venous oedema, skin changes or ulceration. Chronic venous disease (CVD) is the most common venous disorder. It is caused by venous hypertension due to either reflux, outflow obstruction or both. Aim of the Work: The aim of the work was to review the feasibility and efficacy of catheter-directed foam sclerotherapy in treatment of saphenous vein incompetence. Patients and Methods: This clinical trial was conducted at vascular surgery department at Al Azhar University Hospital. The study included 25 patients suffering from primary varicose vein. All patients were belonging to class C2 to C4 Ep as Pr according to CEAP classification. This mean: C2 to C4 clinically stage to stage venous disease in which there were uncomplicated, moderate to severe varicosities. Ep etiologically the disease was primary with well functioning deep system. Anatomically, the varicosities affected the superficial system mainly the great saphenous vein. Results: Between March 2017 and March 2018, 25 patients (25 limbs) were treated with CDFS at vascular department – Al-Azhar University hospitals. Demographic data and severity of venous disease are shown in Table below. Conclusion: The use of this catheter based technique facilitated foam sclerotherapy with a high primary and acceptable short-term occlusion rates, and low numbers of complications. Further studies are required to evaluate how the migration of foam into the common femoral vein can be diminished and whether the techniques used in this study of leg elevation and manual compression provide any advantage.

Endovascular laser treatment of incompetent saphenous veins using the 1470 nm diode laser and radial fiber

ObjectivesTo assess the technical success, complications, and patients' quality of life (QoL) after treatment of chronic venous disease (CVD) using the 1470 nm radial fiber laser.MethodsA total of 170 patients with chronic venous disease, classified as C2 to C4 according to CEAP classification, were treated for incompetent greater (GSV) and small (SSV) saphenous veins, using the 1470 nm radial fiber laser and application of tumescent anesthesia. Additional phlebectomies were performed through stab microincisions, while 11 patients further underwent sclerotherapy intraoperatively. Patients' QoL was recorded using a CIVIQ-20 questionnaire pre and post-operatively.ResultsTechnical success regarding GSV vein occlusion was recorded at 100% and 98% during 12 and 24 month follow up respectively. SSV occlusion rates were recorded at 100% for the same period. 55% of patients were classified as C2. Mean laser application time was 401.1 ± 92.6 s and 169.4 ± 56.8 s, while an average of 3986.6 ± 934.9 and 1643.5 ± 534.1 J were applied during ablation of GSV and SSV respectively. Three incidents of postoperative pain were recorded. Two patients exhibited partial proximal GSV recanalization, while two patients reported mild post-operative temporal paresthesia. No major complications were observed post-operatively. A significant improvement in patients' QoL was demonstrated through the CIVIQ-20 questionnaires. Mean pre-operative CIVIQ-20 total score was recorded at 77 ± 3.9, with a total score of 32.8 ± 2.8 being observed during 12 month follow-up.ConclusionsEndovascular laser treatment using the 1470 nm radial fiber laser constitutes an effective and safe modality for treatment of CVD.

Initial Outcomes of Cyanoacrylate Closure, VenaSeal System, for the Treatment of the Incompetent Great and Small Saphenous Veins.

Cyanoacrylate closure of the saphenous vein with the VenaSeal system is a new technique just approved on December 2016 in Korea. Therefore, there are seldom reports about postprocedural outcomes of VenaSeal system in Asian countries. We report the initial outcomes of VenaSeal system for the treatment of great saphenous veins (GSVs) and small saphenous veins (SSVs) as a first report in Korea. Thirty-four patients with incompetent saphenous veins (47 GSVs and 16 SSVs) were treated at a single session. Concomitant phlebectomy was performed in 15 (44.1%) of 34 patients. All procedures were started with local anesthesia with music therapy and switched to intravenous sedation if patient requested. Patients revisited the clinic on 10 days, 1 month, and 3 months after surgery. Postprocedural evaluations including numerical pain rating score, revised Venous Clinical Severity Scores (rVCSS), and Aberdeen Varicose Vein Questionnaires were checked. Duplex ultrasound was performed on 10 days, 1 month, and 3 months. All treated veins (47 GSVs and 16 SSVs; 100%) had complete closure by duplex ultrasound during the follow-up period. Mean numerical pain rating scale of 6 hours after procedure was 2.7. The rVCSS was improved during the follow-up period. Phlebitis-like "abnormal skin reaction" in the treatment area was occurred in 8 (23.5%) of 34 patients and recovered fully in 2 weeks. Cyanoacrylate closure, VenaSeal system, is safe and effective for the treatment of incompetent saphenous veins.

A review of endothermal laser ablative treatment of incompetent saphenous veins

SummaryEndovenous treatment of incompetent great and small saphenous veins has become firmly established as an alternative to cross-ectomy and stripping operations. Among other thermal and non-thermal procedures, endovenous laser ablation (EVLA) is one of the most frequently used methods. Development of the procedure has continued since its introduction in 1998: the low wavelengths used at first (810 nm) resulted in a high rate of complications (ecchymosis, pain), and over the years systems using longer wavelengths have been developed with increasingly fewer side effects. The effectiveness of the wavelength most frequently used today (1470 nm) has been reported in numerous studies. The most frequent side effects include endovenous heat-induced thrombosis (EHIT), nerve damage and ecchymosis; major complications like lung embolism are reported very rarely.

Current clinical evidence on endovenous laser ablation (EVLA) from randomised trials

SummaryBackground Endovenous laser ablation (EVLA) is globally counted among the most frequently administered methods to treat saphenous vein incompetence. Technical development proceeded in three particular steps: EVLA #1 – Diode lasers linearly emitting wavelengths from 810 to 980 nm through optical bare fibres; EVLA #2 – Diode or Nd:YAG lasers emitting wavelengths from 1064 to 1500 nm; EVLA #3 – Modified optical fibres warranting an optimised emission geometry by centralisation of the fibre tip (Tulip-fibre, Jacket-tip) or radial emission of the laser beam. Due to the number of different EVLA techniques their value compared with standard surgery (high ligation and stripping, HLS) and other endovascular approaches has to be questioned.Methods Selective literature analysis based on a systematic PubMed search focussed on randomised controlled trials (RCT) comparing EVLA with HLS and other thermal or nonthermal ablation techniques – radiofrequency ablation (RFA), ultrasound guided foam sclerotherapy (UGFS), endothermal steam ablation (EStA).Results The search terms “endovenous”, “laser”, “varicose vein” resulted in 509 publications, hereof 57 RCTs, hereof 24 randomised studies comparing EVLA with other treatment approaches: 15 studies comprise comparisons with standard surgery and further 9 studies with other endovenous techniques. 6 RCTs contain long-term followup data on EVLA #1 vs. HLS suggesting superiority of HLS in terms of same site clinical and duplex detected recurrence from the groin. 15 RCTs are reporting short-term results clearly demonstrating inferiority of EVLA #1 against EVLA #2, EVLA #3, and RFA with respect to postoperative complaints and patients’ quality of life.Conclusions The first generation endovenous laser systems are disadvantageous or even harmful as compared with more advanced EVLA techniques and RFA in terms of patients’ complaints and side effects. Furthermore, evidence is rising that EVLA #1 is inferior to standard surgery regarding long-term treatment efficacy. Therefore, the application of EVLA #1 in the treatment of saphenous vein incompetence cannot be recommended any longer. In view of the more recently published RCTs reporting long-term superiority of standard surgery, HLS should still be implemented as control group in studies investigating endovenous treatment approaches.

Three-Year Follow-Up of First Human Use of Cyanoacrylate Adhesive for Treatment of Saphenous Vein Incompetence.

Severity score improvement was better in overweight and obese patients (P 1⁄4 .019). There was no difference in satisfaction across groups. More obese patients than normal-weight patients had recanalization of treated veins at 5 years (60% vs 29%; P < .0005, c trend). They were also more likely to have required re-treatment by 5 years (28% vs 7%; P 1⁄4 .026). Conclusions: Despite more severe venous disease at baseline, overweight and obese patients had greater symptomatic improvement after UGFS than normal-weight patients did. Although they were more likely to have recanalization and recurrence, their long-term satisfaction remainedhigh.

The 1,470-nm Bare-Fiber Diode Laser Ablation of the Great Saphenous Vein and Small Saphenous Vein at 1-Year Follow-up Using 8–12 W and a Mean Linear Endovenous Energy Density of 72 J/cm

PurposeTo demonstrate 1-year outcomes after low-energy endovenous laser ablation (EVLA) of incompetent saphenous veins with linear endovenous energy density (LEED) of 80 J/cm or lower with the use of a 1,470-nm diode laser. Materials and MethodsIncompetent saphenous veins in 236 patients (355 limbs; Clinical/Etiology/Anatomy/Pathophysiology classifications of C2–C4) were treated by EVLA with a bare-tipped 1,470-nm laser with LEED no greater than 80 J/cm (mean, 72.4 J/cm) and laser power of 8–12 W. Patients were evaluated clinically and with duplex ultrasonography at 1 week and 1, 3, 6, and 12 months after EVLA to assess the technical and clinical success and complication rates. ResultsIn the 355 limbs, the technical success rate was 100%. The great saphenous vein (GSV) remained occluded in all 229 limbs (100%) after 1 week, 202 of 203 limbs (99.5%) after 1 month, 157 of 158 limbs after 3 months (99.3%), all 99 limbs after 6 months (100%), and all 41 limbs after 1 year (100%). The small saphenous vein (SSV) remained occluded in all 103 limbs (100%) after 1 week, all 94 limbs (100%) after 1 month, 68 of 69 limbs (98.5%) after 3 months, 40 of 41 limbs (97.5%) after 6 months, and all 14 limbs after 1 year (100%). Two GSVs and two SSVs were recanalized and underwent repeated EVLA. No major complications occurred, although bruising (21% of cases), pain (15%), and paresthesia (4%) were observed. ConclusionsLow-energy EVLA with the use of a 1,470-nm laser with LEED of 80 J/cm or lower is an effective, safe, and technically successful option for the treatment of incompetent saphenous veins.

Comment to: Laser assisted foam sclerotherapy (LAFOS): a new approach to the treatment of incompetent saphenous veins, by Frullini A, Fortuna B. Phlébologie 2013;66:51-4.

For veins exceeding 1 cm of diameter, poorer outcome is expected as the occlusion rate of great or small saphenous veins (GSVs and SSVs, respectively). Reducing the diameter of the vein prior to sclerotherapy could improve the results, also requiring a limited volume of foam. A holmium:YAG (Ho:YAG) laser was employed to produce significant shrinkage on the vein media. This laser has been designed to avoid endothelium damaging while inducing coarctation of the vein wall by accumulating heat in the media (5 W, 500 mj, 350 µs max, 10 Hz max). The procedure under consideration – laser assisted foam sclerotherapy (LAFOS) – was applied in 50 patients (38 GSVs, mean diameter 9.17; 12 SSVs, mean diameter 7.91). Veins were accessed by a 17 G short catheter with ultrasound (US) assistance. The laser fiber was placed 1-2 cm below the junction and manually retracted applying fluency from 150 to 400 mj without infiltration anesthesia. At the end of the laser phase, sclerosing foam (polidocanol: 3% GSV-5 mL mean; 2% SSV- 2 mL mean) was injected through the same catheter. One month of compression stockings was prescribed, with a 48-h-thigh eccentric compression by means of a pad. Patients were invited to walk daily for at least 1 h. Vein shrinkage was constantly achieved and complete occlusion was always observed at 1 month. No patient referred extreme pain during laser procedure, while in 8 cases energy adjustment was required to avoid discomfort.