Treatment Options For Varicose Veins Research Articles

Varicose Veins: A Review and Management

Abstract: Twisted, swollen veins that are commonly found on the lower limbs can be deformative and incapacitating. Varicose vein prevalence varies. At least one-third of people are thought to have lower leg varicose veins. Family history, obesity, advanced age, pregnancy, and prolonged standing are risk factors. The pathogenesis includes weakening vascular walls, defective valves, and genetic factors. Treatment options for varicose veins include surgery, interventional therapy, and conservative measures like diet, lifestyle modifications, and hydrotherapy—all of which depend heavily on patient compliance to be effective. The symptoms, patient preferences, cost, and possible risks all influence the therapeutic selection. This review looks at varicose vein risk factors, symptoms, management (surgery and conservative measures), and complication avoidance

Foam-in-Vein: Characterisation of Blood Displacement Efficacy of Liquid Sclerosing Foams.

Sclerotherapy is among the least invasive and most commonly utilised treatment options for varicose veins. Nonetheless, it does not cure varicosities permanently and recurrence rates are of up to 64%. Although sclerosing foams have been extensively characterised with respect to their bench-top properties, such as bubble size distribution and half-life, little is known about their flow behaviour within the venous environment during treatment. Additionally, current methods of foam characterisation do not recapitulate the end-point administration conditions, hindering optimisation of therapeutic efficacy. Here, a therapeutically relevant apparatus has been used to obtain a clinically relevant rheological model of sclerosing foams. This model was then correlated with a therapeutically applicable parameter-i.e., the capability of foams to displace blood within a vein. A pipe viscometry apparatus was employed to obtain a rheological model of 1% polidocanol foams across shear rates of 6 s-1 to 400 s-1. Two different foam formulation techniques (double syringe system and Tessari) and three liquid-to-gas ratios (1:3, 1:4 and 1:5) were investigated. A power-law model was employed on the rheological data to obtain the apparent viscosity of foams. In a separate experiment, a finite volume of foam was injected into a PTFE tube to displace a blood surrogate solution (0.2% w/v carboxymethyl cellulose). The displaced blood surrogate was collected, weighed, and correlated with foam's apparent viscosity. Results showed a decreasing displacement efficacy with foam dryness and injection flowrate. Furthermore, an asymptotic model was formulated that may be used to predict the extent of blood displacement for a given foam formulation and volume. The developed model could guide clinicians in their selection of a foam formulation that exhibits the greatest blood displacement efficacy.

Myths and truths about varicose veins

Background: Varicose veins are a common chronic venous disorder that leads to a significantly reduced quality of life and high healthcare resource burden. There is a large amount of research-based data and opinions regarding varicose veins. There are also some common myths and misconceptions about the treatment options.Current Concepts: Management options include compression therapy, open venous surgery, and endovenous therapy. An appropriate treatment option must be selected on a case-by-case basis based on the symptoms, severity, and duplex ultrasonography findings. Venous intervention should be considered if the condition is symptomatic and often, there is no need for urgent surgery or endovenous therapy because the symptoms usually progress slowly and severe cardiac problems are rare. According to previous studies, there is no difference between the endovenous therapy modalities and the traditional surgical method (i.e., high ligation and stripping) in terms of recurrence rates. Therefore, case-specific factors, such as anatomy and economic factors, should be considered. When compression therapy is considered, graduated compression stocking with suitable pressure should be prescribed. Venoactive drugs can be suggested in addition to compression therapy for symptomatic varicose veins or venous ulcers.Discussion and Conclusion:. Correct information regarding treatment for varicose veins based on the best available evidence must be provided to patients. The treatment options for varicose veins should be selected on a case-by-case basis considering the patient`s symptoms, anatomy and economic factors.

VariClose® vein sealing system is inferior to endovenous laser ablation for the treatment of varicose veins

One of the three commercially available cyanoacrylate venous glues used for the treatment of saphenous vein insufficiency is the VariClose® vein sealing system. Previous studies have documented a high rate of occlusion and minimal postoperative complications. The aim of this study was to compare occlusion rates and clinical outcomes of endovenous laser treatment with the VariClose® vein sealing system in the treatment of truncal vein insufficiency. Retrospective non-randomized single center study with prospectively collected data comparing endovenous laser treatment and VariClose® procedures between April 2018 and November 2019. VariClose® was used in 27 patients (30 veins) and endovenous laser treatment in 42 patients (51 veins). The occlusion rate at one, three, and six months were 96%, 85%, and 65% for VariClose® procedures and 100%, 100%, and 97% for endovenous laser treatment procedures (p = 0.01), respectively. Reduction of VCSS scores before treatment and at the last postoperative follow-up visit in the VariClose® group dropped by an average of 1.8 ± 1.6 and in the endovenous laser treatment by an average of 3.3 ± 2.9 (p = 0.01). VariClose® vein sealing system is inferior to endovenous laser treatment as a treatment option for varicose veins as it has a higher recanalization rate.

Postoperative outcomes of microphlebectomy and Trendelenburg operation with stripping for saphenofemoral junction incompetence

Background: With more than 10 million cases occurring annually in India, varicose veins can sometimes result in severe discomfort and pain besides disfiguration of skin. The objective of the study was to assess the most viable treatment options for varicose veins between the traditional Trendelenburg procedure and microphlebectomy.Methods: This was an interventional study conducted at a tertiary center in South India. Patients above 18 years of age, presenting with varicose veins due to saphenofemoral junction (SFJ) incompetence and scheduled for surgical management, were included in a sample size of 46. Subjects were randomized into two groups – Group 1 underwent micro phlebectomy and Group 2 underwent Trendelenburg operation with stripping of great saphenous vein (GSV). Postoperative pain was assessed on day of surgery, day after, and postoperative day 7. A venous Doppler ultrasound was conducted 6 weeks after the surgical procedure, to look for reflux at SFJ.Results: Group 1 subjects reported lesser immediate postoperative pain and incurred significantly less cost as determined by an independent sample t-test. Chi-square test found no significant difference in the rate of occurrence of local complications (P > 0.05), and no recurrence was noted among both groups.Conclusion: Microphlebectomy is a more feasible treatment option than Trendelenburg operation with GSV stripping on account of lower costs. It is also a patient friendly alternative due to immediate reduction in pain.

Ultrasound-guided foam sclerotherapy for chronic venous disease with ulcer. A prospective multiple outcome cohort study.

BackgroundChronic Venous Disease (CVD) is the main cause of chronic leg ulcers. Varicose veins are the most frequent cause of venous leg ulcers (VLU). 50.9% of Brazilian women have varicose veins and ulcer prevalence is as high as 4%. Ultrasound-guided foam sclerotherapy (UGFS) is a low-cost treatment option for varicose veins.ObjectivesTo analyze UGFS outcomes in patients with VLU.MethodsProspective consecutive single center cohort study. Patients with great saphenous vein (GSV) reflux and VLU were treated and followed-up for 180 days. The following were studied: quality of life (QoL), disease severity, healing, and elimination of GSV reflux. The Aberdeen questionnaire, a venous clinical severity score, and Duplex scanning (DS) results were analyzed.Results22 patients aged 35 to 70 years were treated. There was improvement in quality of life, disease severity reduced, and ulcer diameter reduced (p < 0.001; ANOVA). 77.27% of VLU healed completely (95%CI: 59.76-94.78%). The dimensions of 20/22 VLU reduced (90.91%; 95%CI: 78.9-100%). GSV reflux was eliminated in 63.64% (95%CI: 43.54-83.74%). Men had greater QoL benefit and women had more complications. There were no severe complications. The VLU that had healed completely at the end of the study were smaller at baseline than those that did not completely heal. The GSV that were completely occluded at the end of the study were smaller at baseline than those that were not completely occluded (p < 0.05; Mann-Whitney).ConclusionThe results suggest that most patients benefited from UGFS.

PMD4 - Systematic Review and Network Meta-Analysis of Randomized Trials of Surgery and Minimally Invasive Techniques Versus Cyanoacrylate Embolization for Varicose Veins

Cyanoacrylate embolization (CAE) with the VenaSeal™ Closure System is a relatively new technique for varicose vein treatment. There is paucity of data on the performance of CAE relative to other available treatments. Therefore, this study aimed to establish the safety and efficacy of CAE compared to multiple treatment options for varicose veins through a network meta-analysis (NMA). A systematic literature review of RCTs comparing two or more of the available treatments (surgery, foam sclerotherapy, laser, RFA, and cyanoacrylate) was considered for the analysis. Two independent reviewers determined study eligibility and extracted descriptive, methodologic, and outcome data. Frequentist NMA conducted in accordance with the general principles of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and the ISPOR guidelines, was applied to synthesize the direct and indirect evidence between VenaSeal™ and all other treatment arms. The literature review identified 3,225 studies, among which 19 RCTs were finally included for the NMA based on the inclusion criteria. As there were no direct studies comparing CAE with surgery and other treatment modalities for varicose veins, a network was created with 1-7 studies included in each network. The anatomic success of CAE at follow-up was the highest (predicted means estimate 0.99; 95% CI, 0.92-1.00) followed by RFA (0.96; 95 % CI, 0.89-1.00), which was higher than all other treatment arms including surgery (0.76; 95% CI, 0.71-0.81). CAE led to significant improvement in other clinical outcomes including venous clinical severity score (P<0.0001), pain reduction (P<0.0088) and quality of life measures (P<0.0001) compared to surgery. CAE was not associated with any serious adverse events. In the absence of head-to-head trials comparing CAE with other techniques except RFA, this NMA indicates that CAE is superior to surgery and non-inferior to other treatment modalities for varicose veins.

Vein diameter is a predictive factor for recanalization in treatment with ultrasound-guided foam sclerotherapy

ObjectiveUltrasound-guided foam sclerotherapy (UGFS) is a low-cost and minimally invasive treatment option for varicose veins. There is a relative paucity of outcome reports. MethodsUGFS procedures at a tertiary public hospital between 2010 and 2017 were studied. Either the great saphenous vein (GSV) or small saphenous vein (SSV) was treated. Pretreatment, in-treatment, 6-week, and 1-year post-treatment ultrasound reports were analyzed. The primary outcome was to determine whether vein diameter predicts obliteration failure. ResultsThere were 457 treatments completed in 290 patients. The GSV was targeted in 372 (81%). Mean vein diameters of the GSV were not different from those of the SSV (GSV, 5.7 mm; SSV, 6.2 mm; P = .18); 109 (24%) had a Clinical, Etiology, Anatomy, and Pathophysiology score of at least 4. Of the 457 UGFS procedures, 360 (78.8%) were for primary veins. Baseline information, including vein diameter, was not different between primary and recurrent veins. At 6 weeks, complete obliteration, partial recanalization, and complete recanalization rates were 54.9%, 29.1%, and 16%, respectively. Of those with complete obliteration at 6 weeks, the recanalization rate at 1 year was 25%. Increasing vein diameter was associated with recanalization at 1 year (obliteration, 4.9 mm; recanalization, 5.7 mm; P = .03), especially for primary veins (4.8 vs 5.8 mm; P = .009). Multivariate analysis showed similar outcome. Vein diameter of >6 mm had good specificity (88%) but poor sensitivity (43%) for predicting obliteration failure. There were 15 (3%) new-onset deep venous thromboses reported on follow-up, all of which were from treatment of primary veins (P = .049). ConclusionsOnly 44% of UGFS procedures were observed to have complete obliteration at 1 year after a single intervention. Significant recanalization developed at 1 year. Increased vein diameter was associated with recanalization. The impact on clinical recurrence is unknown.

RFA vs EVLT: A Comparison of Treatment Options for Varicose Veins

RFA vs EVLT: A Comparison of Treatment Options for Varicose Veins

YouTube as a source of patient information for varicose vein treatment options.

The purpose of this study was to analyze the quality of content and potential sources of bias in videos available on YouTube pertaining to interventional treatment for varicose veins. Searches were performed on YouTube to identify videos pertaining to interventional treatment for varicose veins. Videos that met eligibility criteria were analyzed and rated according to predetermined criteria by two independent assessors, with a third independent assessor to resolve any discrepancy. Each video was rated for its informational quality (good, fair, poor) and stance (for, neutral, against, unclear) toward the treatment option discussed. A total of 284 videos were extracted, of which 228 met eligibility criteria and were analyzed. The largest group of videos (47.3%) received a quality rating of fair, meaning that they discussed one or two aspects of a treatment option, such as procedural technique and indications. Among those videos rated poor (25.0%), nearly all videos (98.2%) failed to mention a specific treatment. Most videos (71.1%) were in favor of the treatment discussed without presenting balanced discussion of alternatives. Private companies represented the most frequent source of videos analyzed (73.2%). There was a statistically significant correlation between quality and video source (χ2= 9.308; df= 2; P= .010), with videos from private companies generally receiving poorer quality ratings than other videos. There was no association between quality and viewing frequency of videos (P= .379). On the whole, the videos available on YouTube are neither sufficiently comprehensive nor adequately balanced to be recommended as patient education material regarding interventional treatment options for varicose veins.

Endovenous radiofrequency ablation for the treatment of varicose veins.

Varicose veins are a common condition that can be treated surgically. Available operative modalities include saphenous venous ligation and stripping, phlebectomy, endovenous laser therapy and radiofrequency ablation. Radiofrequency ablation is the newest of these technologies, and to our knowledge our group was the first to use it in Canada. Our experience suggests that it is a safe and effective treatment for varicose veins, with high levels of patient satisfaction reported at short-term follow-up. More studies are needed to assess long-term effectiveness and compare the various available treatment options for varicose veins.

Cost-effectiveness analysis: role and implications

Cost-effectiveness analysis (CEA) is often misperceived to be a cost-cutting exercise. The intention of CEA is not to identify and implement cheap technologies, but rather those which offer maximum health gain, subject to available funds. Such analysis is crucial for decision making in health care, as tight budget constraints mean spending in one area of healthcare displaces spending elsewhere. Therefore in order to achieve the greatest health gain for the overall population, treatments must be selected which provide the greatest health gain within the available funds. The relevance of CEA in health care systems is explained, using varicose vein treatment in the UK NHS as an example. Treatment for varicose veins is often not commissioned to at a local level, most likely because it is misperceived to be a cosmetic problem. However, this view does not take into account the impact of quality of life. CEA balances costs against a quantitative measure of health related quality of life, and could therefore be used to determine whether it is cost-effective to provide varicose vein treatment. The current literature on the cost-effectiveness of varicose vein treatment is reviewed, and an overview of cost-effectiveness principles is provided. Concepts such as economic modelling, incremental cost-effectiveness ratios (ICERs), net monetary benefit (NMB) and sensitivity analysis are explained, using examples relevant to varicose veins where appropriate. This article explains how, far from cutting costs and sacrificing patient health, CEA provides a useful tool to maximise the health of the population in the face of ever tightening budget constraints. CEA could be used to compare the cost-effectiveness of the various treatment options for varicose veins, and efficiencies realised.

Endovenous laser ablation of varicose perforating veins with the 1470-nm diode laser using the radial fibre slim

Endovenous Laser Ablation (EVLA) is one of the most accepted treatment options for varicose veins. The aim of this study was to investigate the efficacy and safety of the new radial fiber slim (ELVeS-radial-slim kit™) for the 1470 nm diode laser in perforator veins with a 1 month follow-up. Our prospective observational cohort study comprised 69 perforating veins in 55 patients. Ninety percent of all patients were in the CEAP-stage C3-C6. The radial fiber slim was used to occlude the perforating vein and the great or small saphenous vein in the same procedure. The primary efficacy endpoint of the study was ultrasonographically proven elimination of venous reflux in the perforating vein after at least one month. Secondary efficacy and further safety end points after one month were as follows: (1) sonographic exclusion of recanalization of the treated vein segments, (2) deep vein thrombosis (DVT), clinical pulmonary embolism (PE), or superficial vein thrombosis (SVT) as defined by objective testing, (3) death from any cause, (4) persistent clinical complaints such as pain and paresthesia. Follow-up could be completed in all patients. In all treated perforating varicose veins, occlusion with elimination of reflux could be demonstrated immediately after the procedure. After one month 95.6% of the treated veins were still occluded (67/69). During follow-up, we did not diagnose any DVT, PE or SVT in the area related to the treated perforating vein. No patient died. One patient reported paresthesia distally of the puncture site. Endovenous laser treatment of varicose perforating veins with 1470 nm diode laser using the radial fiber slim is effective and safe with low recanalization rates during 1-month follow-up.

Endovenous laser ablation of varicose veins with the 1470-nm diode laser

Endovenous laser ablation (EVLA) is one of the most accepted treatment options for varicose veins. In previous studies conducted with a laser at 810 to 1320 nm, paresthesia, pain, and ecchymosis were common adverse effects. We hypothesized that a lower linear endovenous energy density (LEED), as used with 1470-nm diode laser fibers, would lead to a reduction in adverse events. We conducted a prospective, nonrandomized observational cohort study of 312 consecutively treated lower limbs legs in 286 patients. Of these, a bare laser fiber (ELVeS-plus kit) was used to treat 168 legs in 150 patients (group 1), and a radial fiber (ELVeS-radial kit) was used in 144 legs in 136 patients (group 2). Laser treatment was performed in the great saphenous vein. Follow-up for all patients was 3 months. The primary end point was the occurrence of ecchymosis and bruising. This was correlated to the reduced LEED needed with the 1470-nm diode laser. Laser fiber (odds ratio [OR], 22.3; 95% confidence interval [CI], 20.2-24.5) and body mass index (OR, 0.35; 95% CI, 0.15-0.55) were identified as independent parameters for LEED. In group 2 compared with group 1, LEED in the great saphenous vein could be reduced from 79.4 +/- 9.1 to 57.4 +/- 10 J/cm (P < .0001). LEED was an independent parameter for skin bleeding (OR, 1.04; 95% CI, 1.017-1.058). Ecchymosis and bruising were significantly less frequent in group 2 than in group 1 (P < .0001). The need for analgesia was low, with 103.08 +/- 15.34 mg diclofenac-sodium in group 1 vs 82.08 +/- 18.86 mg in group 2 (P < .04). Occlusion with elimination of reflux was achieved in 100% of group 1 and group 2 (P < 1). No recanalization occurred at follow-up. Endovenous laser treatment of varicose veins in the great saphenous vein with the 1470-nm diode laser is safe and highly effective. The lower energy level needed using the radial laser fiber significantly minimized adverse effects compared with the bare laser fiber.

A rare cause of foot drop after radiofrequency ablation for varicose veins: Case report and review of the literature

The treatment option for varicose veins (VV) is mainly surgery both open and minimally invasive. Even though mortality and major morbidity are rare with surgery, minor neurological complications like cutaneous nerve injuries remain a common problem. Involvement of major branches of sciatic nerve is extremely a rare complication of radiofrequency ablation (RFA), the other treatment option for VV. To the best of our knowledge, injury to both peroneal and tibial nerves has not been reported following RFA procedure. We report a very rare complication of sudden onset foot drop after RFA for VV. Lack of knowledge of such symptoms may lead to misdiagnosis and electrodiagnostic and magnetic resonance imaging studies can help in correct diagnosis.

Follow-up of varicose veins with incompetent great saphenous veintreated with ultrasound guided foam sclerotherapy

Objective To assess the clinical outcome of varicose veins with incompetent great saphenous vein(GSV) treated with ultrasound guided foam sclerotherapy. Methods Forty limbs with moderate to severe symptomatic varicose veins with incompetent GSV in 38 patients were injected with foam sclerosing agent (Fibro-Vein) under ultrasound guidance. There were 36 patients with unilateral varicose veins and 2 with bilateral varicose veins. No of them suffered from deep vein incompetence or perforating vein incompetence. Second injection was performed one month after the initial injection in 7 limbs. Thirty-eight of 40 limbs were followed up with clinical examination and duplex ultrasound scan 30-47 months (mean 40 months) after the treatment. Results Among 38 limbs with follow-up mild debilitation was found in two limbs(5. 3%). There were no other symptoms or complications. Duplex ultrasound demonstrated four type of results: type I, sclerosed GSV trunk with no detectable venous flow in 32 of 38 limbs (84. 2%) ;type II,patent GSV trunk in 3 limbs (7. 9%) ,two of them had mild reflux in the GSV trunk;type III,sclerosed GSV trunk and mild reflux in the GSV tributaries, 1/38(2. 6%) ; type IV,sclerosed proximal GSV trunk,patent distal GSV communicated with a superficial vein and mild reflux in the veins, 2/38 (5. 3% ). Conclusions Clinical examination and duplex ultrasound scan demonstrated excellent results of varicose veins with incompetent GSV treated with ultrasound guided foam sclerotherapy 40 months after the treatment. Sclerotherapy is less invasive treatment option for varicose veins with incompetent GSV with satisfactory clinical and cosmetic outcome. Key words: Ultrasonography,Doppler,color; Saphenous vein; Varicose veins; Sclerotherapy

Treatment of Varicose Veins: The Present and the Future – A Questionnaire Survey

The treatment options for varicose veins have increased over the last few years. Despite a lack of randomised trials comparing the various modalities, many surgeons are changing their practice. The aim of this study was to assess the current practice of surgeons in Great Britain and Ireland. A postal questionnaire survey was sent to surgical members of the Vascular Society of Great Britain and Ireland and the Venous Forum of The Royal Society of Medicine. Of 561 questionnaires sent, 349 were returned completed (62%). The types of varicose vein treatments offered by each surgeon varied widely in both NHS and private practice. The vast majority (96%) offered conventional surgery (CS) on the NHS. Foam sclerotherapy (FS) endovenous laser (EVL) and radiofrequency ablation (RF) were more likely to be offered in private practice than in NHS practice. Overall, 38% of respondents for NHS practice and 45% of respondents for private practice offered two or more modalities. Of the respondents who were not yet performing FS, EVL, or RF, 19% were considering or had undertaken training in FS, 26% in EVL and 9% in RF. When asked to consider future practice, 70% surgeons felt that surgery would remain the most commonly used treatment. This was followed by FS (17%), EVL (11%) and RF (2%). Over one-third of respondents are now offering more than one treatment modality for the treatment of varicose veins. Whilst there is movement towards endovascular treatments, the problem of cost has yet to be solved. At present, surgery remains the most popular modality in both the NHS and private practice; however, improved outcomes and patient preference may lead to a change in practice.

Endovenous procedures in varicose veins

SummaryOver the past ten years endoveous treatment options for varicose veins have evovled considerably, offering clinicians a multitude of options to meet the needs of their patients. The endothermal ablation procedures have moved to the forefront as the choice modality for treating truncal reflux. Both radiofrequency ablation and endovenous laser ablation are widely accepted and interchangeable, showing comparable efficacy and safety. Although numerous endovenous laser wavelengths exist, the data indicates that the differences do not affect the efficacy or postoperative recovery of the procedure. The endovenous laser innovation that has shown early evidence of improved patient outcome is the jacket-tip fiber. The versatility of sclerotherapy makes it a critical component in the endovenous treatment of varicosities. Although not approved by the Food and Drug Administration (USA), the use of a foamed sclerosing agent is the fastest growing segment of sclerotherapy and an important treatment modality in the future of varicose vein treatment. Cutaneous lasers and intense pulse light devices contribute a crucial element, enabling clinicians to treat minute veins that may be impossible to treat with other therapies.

Muller's ambulatory phlebectomy for varicose veins of the foot.

Ambulatory phlebectomy is an accepted therapy for varicose veins. It has also been used for ankle and foot varicosities with success although the anatomy of the venous system of the foot is poorly described in the literature. To review the relevant literature on the anatomy of the veins of the foot. Also to form an opinion on safe possibilities for the treatment of foot varicosis. The English, French, German, and Dutch language literature was reviewed for anatomy and treatment of varicose veins of the foot. Fourteen patients (19 feet) were treated for varicose veins of the foot with ambulatory phlebectomy. Literature concerning the venous anatomy of the foot is very limited. Venous surgery, sclerotherapy, and ambulatory phlebectomy have all been used for the treatment of varicose veins of the foot. The former two have resulted in serious complications. All treated patients showed excellent results with ambulatory phlebectomy. No serious side effects were seen. The venous anatomy of the foot does not indicate major restrictions in the treatment of its varicosities. Ambulatory phlebectomy is the safest and most elegant treatment option for varicose veins of the foot. Venous surgery and sclerotherapy may be used successfully in special cases only.