Treatment Of Saphenous Vein Reflux Research Articles

Long-term results of endovenous laser ablation of saphenous vein reflux: Up to nine years of follow-up.

Endovenous laser ablation (EVLA) has become the gold standard for the treatment of saphenous vein reflux. We report the long-term clinical and ultrasound results of EVLA. This study is a retrospective review of patients who underwent EVLA of saphenous vein over four years. Clinical results were assessed using venous clinical severity score (VCSS), and ultrasound results were classified according to Bush classification. Over a median follow-up time of 4.4 years, 168 EVLA-treated patients showed a drop in VCSS from 4.38 to 1.39. Ultrasound results of 140 treated great saphenous veins showed that 64% had one or more cause of recurrence. The presence of neovascularization correlated well with the lack of improvement of VCSS. EVLA resulted in drop in VCSS from 4.38 to 1.39. Among 140 treated great saphenous veins, reflux in the anterior accessory saphenous vein was the primary cause (23.5%) of recurrence.

The Efficacy of Endovenous Laser Ablation Alone as a Treatment for Varicose Veins

Introduction: Endovenous laser ablation (EVLA) of the saphenous vein has almost completely replaced surgical stripping for the treatment of saphenous vein reflux. In contrast to stripping that includes phlebectomy, EVLA is generally performed in two stages; ablation followed, when needed, by phlebectomy or sclerotherapy for branch varicose veins. However, there are several cosmetic complications after phlebectomy or sclerotherapy, such as surgical scar, haemorrhage and superficial thrombophlebitis. In our institution, a strategy is initiated to perform EVLA procedure without concomitant phlebectomy or sclerotherapy and to subsequently treat residual visible varicose veins with foam sclerotherapy if there are patients' request. This study assessed the efficacy of EVLA alone as a treatment for varicose veins. Methods: Patients undergoing EVLA alone (Radial 2Ring Fiber, ELVeS) as an initial treatment for varicose veins between September 2014 and December 2018 were enrolled. The clinical severity of venous insufficiency was graded according to CEAP classification. Patients were examined with duplex ultrasound imaging at two days, one month and one year after EVLA. Results: Seven hundred sixty-five limbs in 612 patients were included (400 females, 212 males, mean age 62 ± 13 years). Average follow-up time was 272 ± 8 days. By CEAP classification, 170 limbs were C2 (22.2 %), 348 were C3 (45.5 %), 220 were C4 (28.8 %), 10 were C5 (1.3 %) and 17 were C6 (2.2 %). Great saphenous veins (GSV) were treated in 624 extremities (81.6 %) and small saphenous veins (SSV) were treated in 141 (18.4 %) extremities. The mean diameter of GSV and SSV were 7.2 ± 0.1 mm and 6.0 ± 0.1 mm, respectively. The mean vein treatment length of GSV and SSV were 40.8 ± 0.3 cm and 16.6 ± 0.5 cm, respectively. A mean linear endovenous energy density was 57 ± 0.5 J/cm. There were no major complications such as pulmonary embolism or deep vein thrombosis. Concerning endovenous heat-induced thrombus (EHIT), class 1 were observed in 18 patients, class 2 in 26 patients and class 3 in seven patients, but no class 4. After EVLA, the rate of recanalization was 4.3%. Additional foam sclerotherapy for residual branch varicose veins was needed in 51 limbs (6.7%) for cosmetic reason. The mean time between initial treatment and subsequent procedure was 268 ± 33 days. Predictor of sclerotherapy after EVLA alone by multivariate analysis was female. Conclusion: After EVLA, only 6.7% of extremities required further treatment. Our results suggest that EVLA alone for the insufficient saphenous vein can result in improvement of symptoms and regression of visible varicosities, and the majority of patients undertaken EVLA alone might be spared unnecessary phlebectomy or sclerotherapy. Disclosure: Nothing to disclose

EHIT after thermoablation

SummaryAim: After 10 years of experience, we evaluated the incidence and management of endothermal heat-induced-thrombosis (EHIT), i.e. saphenous vein thrombosis following endothermic treatment of saphenous vein re-flux.Methods: From 2006 to 2016 data were retrospectively collected on 840 patients undergoing saphenous vein treatment by laser and radiofrequency technique. All patients were treated with tumescent local anaesthesia in an ambulatory setting to promote early mobilization. Class II compression stockings and heparin were recommended for 5 days post-operatively.Results: EHIT was observed in 15 patients from a total of 992 saphenous veins which were evaluated (1,5 %). 14 patients treated by EVLA had EHIT 1, one patient by RFA had EHIT 2, complicated by pulmonary embolism. All EHIT patients were treated by low weight molecular heparin. 980 nm laser and bare-tip fibres had been used in EVLA-EHIT patients. EHIT was not observed in patients treated by 1470 nm laser and radial fibres.Conclusions: Latest generation technology, the ambulatory setting and local anaesthesia probably contributed to the low incidence of EHIT reported. Further studies are necessary for a better acquaintance of these complications and to facilitate the development of specific guidelines.

Comment to: Combined endovenous laser therapy and pinhole high ligation in the treatment of symptomatic great saphenous varicose veins, by Zhu H-P, Zhou Y-L, Zhang X, Yan J-L, Xu Z-Y, Wang H, Zhao Q-M, Jing Z-P. Ann Vasc Surg 2013. [Epub ahead of print

Recanalization and DVT/PE are two major complications of ELTV, To prevent them minimally invasive pinhole high ligation (PHL) has been added to EVLT for the treatment of saphenous vein reflux in 200 patients (254 limbs) from February 2011 to May 2012. Sixty-eight of them had concurrent TriVex suction for clusters of varicose veins (VV). After conscious sedation and local anesthesia, venous access puncture was made using a Seldinger needle under US guidance. The tip of the sheath was placed approximately 1 cm distal to SFJ, and the location was marked on the skin. A 600-mm laser fiber was introduced through the sheath and advanced to the skin mark. Local anesthesia was achieved by injecting 1% lidocaine around the proximal GSV under US guidance with laser beam marking of the skin. Two 2-mm pinholes 1 cm distal to SFJ using an ophthalmic scalpel, approximately 5 mm from the laser fiber on each side were performed. A cutting needle with a 2-0 silk suture was passed through the pinholes underneath the GSV, but superficial to the femoral vein, which was confirmed by US. The needle and suture were then passed backward through the original two needle holes, but stayed in the subcutaneous space between the GSV and the skin.. A single knot was made first. Reinsertion of the laser fiber was gently attempted, and resistance indicated that ligation of the GSV was satisfactory. US was performed to confirm femoral vein patency, and then two more knots were tied down and buried in the subcutaneous space. If US showed that the femoral vein was captured, the needle and suture were removed and direct pressure was applied for 5 minutes to prevent bleeding. Then high ligation of GSV was performed again. EVLT was started immediately distal to the pinhole ligation, which was approximately 1 cm distal to the SFJ. An 810- nm diode laser system was used. In the 68 patients with venous clusters, transilluminated powered phlebectomy (TIPP) was performed using a TriVex system. After the procedures, compression pads were applied over the treated GSV and venous cluster areas. Elastic bandages were placed starting from the foot to the upper thigh. The technical success rate was 100%. Total occlusion of GSV was achieved in all treated limbs. There was no GSV recanalization during the 3 - 20 months of follow-up. No reintervention was needed for any patient. There were no cases of DVT. Use of PHL avoids the complications after open high ligation, and can be performed within 5-10 min in >90% of patients.

Endovenous Ablation plus Microphlebectomy/Sclerotherapy for the Treatment of Varicose Veins: A Single or Two-Stage Procedure?

Endovenous ablation (EVA) of the saphenous vein has almost completely replaced surgical stripping for the treatment of saphenous vein reflux. In contrast to stripping that includes microphlebectomy, EVA is generally performed in two stages (ablation followed, when needed, by microphlebectomy or sclerotherapy). The purpose of this study was to determine how often second stage procedures are required after EVA. All consecutive patients undergoing laser EVA between March 2007 and December 2008 were enrolled. At presentation, the clinical severity of venous insufficiency was graded according to CEAP classification. Patients were examined clinically/ultrasound at one week, and clinically at one month. Varicose vein resolution following EVA was classified as excellent (no varicosities), good (major reduction in size), and poor (no change). Need for further intervention was determined at the one month follow-up. During the study period, 86 lower extremities in 76 patients were treated with laser EVA (50 females, 26 males, mean age 50 ± 15 years). By CEAP classification, 75 extremities were C2 (87.2%), five were C4 (5.8%), two were C5 (3.5%), and two were C6 (3.5%). Greater saphenous veins were treated in 72 extremities (83.7%), small saphenous veins in 10 extremities (11.6%), anterior branch of the greater saphenous vein in two extremities (2.3%), and both the greater saphenous vein and anterior branch in two extremities (2.3%). The mean vein treatment length was 26.3 ± 9.7 cm with a mean energy delivery of 64 ± 11.3 Joules. At one week, all 86 extremities had the treated segment of vein closed and one of them had partial extension of clot to the common femoral vein (1.16% incidence of deep vein thrombosis [DVT]). At one month, complete resolution of varicosities was found in 36 extremities (41.8%), reduction in size in 48 extremities (55.8%), and no improvement in two extremities (2.3%). Of the patients with remaining varicosities, 15 extremities (17.4%) had small persistent asymptomatic varicose veins of no concern to the patient. The remaining 35 extremities (40.7%) required a second stage procedure. After EVA, 59.3% of extremities did not require any further treatment. These results justify the performance of EVA alone as a first stage, as the majority of patients will be spared unnecessary microphlebectomy or sclerotherapy.

Foam Sclerotherapy in the Treatment of Saphenous Vein Reflux

伏在型静脈瘤に対するフォーム硬化療法（FS）は，近年良好な成績が報告され，血管内治療の選択肢の一つとして注目されている．本論文ではFSの初期治療成績を検討することを目的とした．【対象】2007年1月から2009年7月までに，38例47肢の伏在型静脈瘤に対してFSを施行した．高位結紮術併用本幹硬化療法（H群）が25肢，カテーテル本幹硬化療法（D群）が16肢，分枝からの本幹硬化療法（B群）が6肢であった．D群では超音波ガイド下に伏在静脈を直接穿刺しカテーテルを本幹内に挿入し硬化剤の注入を行った．B群では，分枝から硬化剤を注入し超音波ガイド下に本幹内に入っていることを確認した．【結果】平均10.8mlのフォーム硬化剤の注入を行った．本幹閉塞率はH群で100%，D群で81.5%，B群で66.7%であった．重篤な合併症は認めなかった．2例で無症候性のdeep vein thrombosisを認めたが，1カ月以内に消失した．【結論】FSは，重篤な合併症がなく治療成績も良好であった．今後さらなる検討が期待される．

Endovenous Laser Treatment of Saphenous Vein Reflux: How Much Energy Do We Need to Prevent Recanalizations?

The aim of this study was to report the results of high-energy endovenous laser treatment to measure the relationship between the fluence and the outcome in terms of recanalization. In 97 patients, 129 great saphenous veins were treated with endovenous laser treatment, using a 980-nm diode laser. Follow-up visits were done at 3 days, 1 month, and 6 months. The best results were noted 1 month postoperative, but at 6 months, control late recanalizations occurred decreasing occlusion rate to 90.6%. Patients were divided into 2 groups according to the outcome (occlusion or recanalization) at 6 months, and statistical analysis was done. The authors found 52 J/cm(2) mean fluence in the occlusion group and 43.7 J/cm(2) in the nonocclusion group. This was a statistical significant difference (P < .01). The occlusion rate on long term is fluence dependent. But recanalizations might occur even in these higher fluence treatment groups. A fluence of 52 J/cm(2) is advised.

Recommended reporting standards for endovenous ablation for the treatment of venous insufficiency: Joint Statement of the American Venous Forum and the Society of Interventional Radiology

Sanjoy Kundu, MD, FRCPC, FCIRSE, FASA, Fedor Lurie, MD, Steven F. Millward, MD, FRCPC, FSIR, Frank Padberg Jr, MD, Suresh Vedantham, MD, Steven Elias, MD, Neil M. Khilnani, MD, William Marston, MD, John F. Cardella, MD, FSIR, FACR, Mark H. Meissner, MD, Michael C. Dalsing, MD, Timothy W.I. Clark, MD, FSIR, and Robert J. Min, MD, MBA, FSIR, Toronto and Peterborough, Ontario, Canada; Honolulu, Hawaii; Newark and Englewood, NJ; Saint Louis, Mo; New York, NY; Chapel Hill, NC; Springfield, Mass; Seattle, Wash; and Indianapolis, Ind

The utility of the venous clinical severity score in 682 limbs treated by radiofrequency saphenous vein ablation

The goal of endovenous ablation is to reduce the symptoms associated with chronic venous insufficiency. This prospective study was designed to apply the venous clinical severity score to limbs before and after endovenous saphenous vein radiofrequency ablation and to identify risk factors associated with treatment failure. Between September 2003 and March 2005, 499 patients underwent 682 saphenous vein radiofrequency ablation procedures. Preoperative venous clinical severity scores were documented. Follow-up clinical and duplex examinations were performed at 4 days, 4 weeks, and 4 months after saphenous vein radiofrequency ablation and at > or=6 months thereafter. Venous clinical severity scoring was repeated at follow-up visits, and patients were asked to evaluate their level of satisfaction with the procedure. The mean +/- standard deviation age of the patients was 53.5 +/- 13.3 years (range, 28 to 86 years), and 68% were women. Pretreatment CEAP clinical class C3/C4 comprised 80% of limbs (520/682). Preoperative, 4-day, 4-week, and 4-month venous clinical severity scores were, respectively, 8.8 +/- 3.7 in 648 limbs, 5.2 +/- 3.0 in 629, 4.1 +/- 2.4 in 530, and 3.3 +/- 1.6 in 479 limbs. Saphenous vein radiofrequency ablation significantly reduced pain related to lower extremity venous disease from 95.7% to 15.2% (P < .0001) and edema from 92.4% to 17.0% (P < .0001). Before treatment, venous stasis ulcers were present in 52 limbs and healed at a rate of 86%. Complications in 633 limbs at last follow-up included superficial thrombophlebitis in 12.0%, paresthesia in 0.3%, and nonocclusive thrombus extension in 0.2%. No skin thermal injury was observed. Fewer than 2% of patients reported dissatisfaction with their procedural outcome. Age (relative risk, 0.98; P = .06), female sex (relative risk, 0.19; P < .0001), and tumescent volume >250 mL (relative risk, 0.59; P = .06) were associated with higher rates of occlusion. The overall occlusion rate was 87.1%. As determined by the venous clinical severity score, treatment of saphenous vein reflux with endovenous radiofrequency ablation results in the clinical improvement of symptoms and aids in the healing of venous ulcers. Age, female sex, and tumescent volume are associated with high success rates of occlusion. We found the venous clinical severity score to be an excellent stand-alone tool for assessing outcomes after saphenous vein radiofrequency ablation.

Diffuse phlegmonous phlebitis after endovenous laser treatment of the greater saphenous vein

Endovenous laser treatment (EVLT) has become a valuable and safe option in the treatment of varicose veins. Although long-term results are lacking, most patients seem to benefit in the short-term from EVLT. Reported postoperative complications are limited, consisting usually of pain, ecchymosis, induration, phlebitis, or spot skin burn injuries. The most feared complication is an extension of the saphenous thrombus into the femoral vein, with possible pulmonary embolism. Here we report a septic thrombophlebitis after EVLT resulting in a phlegmonous infection of the whole leg that was treated by surgical drainage. Aggressive local therapy and antibiotic treatment resulted in complete resolution of symptoms and eventual satisfactory healing.

Endovenous laser treatment of saphenous vein reflux

Readily available noninvasive diagnostic tests now allow physicians to accurately map out abnormal venous pathways and identify sources of reflux. In recent years, minimally invasive alternatives to surgical treatment of saphenous vein reflux, the main contributor to most cases of symptomatic varicose veins, have been developed with promising results. 1-8 The latest percutaneous technique developed to treat incompetent saphenous veins is endovenous laser, which allows delivery of laser energy directly into the vein lumen to cause collagen contraction and denudation of endothelium. This stimulates vein-wall thickening with eventual fibrosis of the vein. These modern percutaneous techniques now provide patients with alternatives to ligation and stripping for treatment of significant sources of venous reflux without many of the potential complications associated with surgery. © 2003 Elsevier Inc. All rights reserved.

Endovenous Laser Treatment of Saphenous Vein Reflux: Long-Term Results

To report long-term follow-up results of endovenous laser treatment for great saphenous vein (GSV) reflux caused by saphenofemoral junction (SFJ) incompetence. Four hundred ninety-nine GSVs in 423 subjects with varicose veins were treated over a 3-year period with 810-nm diode laser energy delivered percutaneously into the GSV via a 600- micro m fiber. Tumescent anesthesia (100-200 mL of 0.2% lidocaine) was delivered perivenously under ultrasound (US) guidance. Patients were evaluated clinically and with duplex US at 1 week, 1 month, 3 months, 6 months, 1 year, and yearly thereafter to assess treatment efficacy and adverse reactions. Compression sclerotherapy was performed in nearly all patients at follow-up for treatment of associated tributary varicose veins and secondary telangiectasia. Successful occlusion of the GSV, defined as absence of flow on color Doppler imaging, was noted in 490 of 499 GSVs (98.2%) after initial treatment. One hundred thirteen of 121 limbs (93.4%) followed for 2 years have remained closed, with the treated portions of the GSVs not visible on duplex imaging. Of note, all recurrences have occurred before 9 months, with the majority noted before 3 months. Bruising was noted in 24% of patients and tightness along the course of the treated vein was present in 90% of limbs. There have been no skin burns, paresthesias, or cases of deep vein thrombosis. Long-term results available in 499 limbs treated with endovenous laser demonstrate a recurrence rate of less than 7% at 2-year follow-up. These results are comparable or superior to those reported for the other options available for treatment of GSV reflux, including surgery, US-guided sclerotherapy, and radiofrequency ablation. Endovenous laser appears to offer these benefits with lower rates of complication and avoidance of general anesthesia.

Percutaneous Techniques for Treatment of Saphenous Vein Reflux: Radiofrequency

Introduction The development of superficial varicosities is a consequence of valvular dysfunction within the superficial venous system. When valves fail, high venous pressure leaks into the superficial venous system causing the thin waJled superficial veins to dilate and become varicose. The partern of varicosities follows well-defined anatomical pathways. These patterns provide important clues to the precise origin of high-pressure Jeaks into the superficial venous system. Appropriate treatment is directed towards eradicating these leaks. Traditionally, surgical ligation Ol' vein stripping has been performed to eliminate these leaks. These treatments can be very painful and often require a prolonged recovery. Recently, new percutaneous endovenous techniques have been introduced that permit noninvasive treatment of superficial venous insufficiency. These procedures are far less painful and recovery is quite rapid. The reduced invasiveness of these techniques is a consequence of image guidance. Ultrasound is used almost exclusively to guide these procedures. However, f1uoroscopy, which is rarely used, can be a very useful adjunct. This syllabus will initially and primarily review superficial venous anatomy of the lower extremity because its' understanding is essential for appropriate diagnosis and subsequent treatment of superficial venous insufficiency. Subsequently, noninvasive treatment modalities will be briefly reviewed.