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Salih M, Tan M, Lane T, Onida S, Davies AH. Tributary treatment: Foam or phlebectomy? Phlebology 2024:2683555241259638. [PMID: 38832584 DOI: 10.1177/02683555241259638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Affiliation(s)
- Marwah Salih
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Matthew Tan
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Tristan Lane
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, London, UK
| | - Sarah Onida
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Alun H Davies
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
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2
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Tan M, Bauza Moreno H, Thomis S, Canata V, Gianesini S, Parsi K, Davies AH. Truncal ablation: Techniques. Phlebology 2024; 39:132-134. [PMID: 37906199 PMCID: PMC10878002 DOI: 10.1177/02683555231211087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Affiliation(s)
- Matthew Tan
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Hernan Bauza Moreno
- Phlebolymphology Unit, General Surgery Department, Hospital Italiano de Buenos Aires, Argentina
| | - Sarah Thomis
- Department of Vascular Surgery, UZ Leuven - University Hospitals Leuven, Leuven, Belgium
| | - Victor Canata
- Hospital De Clinicas Universidad Nacional De Asuncion Paraguay, Paraguay
| | - Sergio Gianesini
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Kurosh Parsi
- Department of Dermatology, St. Vincent’s Hospital, Sydney, NSW, Australia
| | - Alun H Davies
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
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3
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Cleman J, Xia K, Haider M, Nikooie R, Scierka L, Romain G, Attaran RR, Grimshaw A, Mena-Hurtado C, Smolderen KG. A state-of-the-art review of quality-of-life assessment in venous disease. J Vasc Surg Venous Lymphat Disord 2023:101725. [PMID: 38128828 DOI: 10.1016/j.jvsv.2023.101725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 11/14/2023] [Accepted: 11/19/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE Chronic venous disease is a common condition and has a significant impact on patients' health status. Validated patient-reported outcome measures (PROMs) used to assess health status are needed to measure health status. This state-of-the-art review summarizes the current validation evidence for disease-specific PROMs for chronic venous disease and provides a framework for their use in the clinical setting. METHODS A literature search in OVID Embase and Medline was conducted to identify relevant English-language studies of chronic venous disease that used disease-specific PROMs between January 1, 1993, and June 30, 2022. Abstracts and titles from identified studies were screened by four investigators, and full-text articles were subsequently screened for eligibility. Data on validation of disease-specific PROMs was abstracted from each included article. Classical test theory was used as a framework to examine a priori defined validation criteria for content validity, reliability (construct validity, internal reliability, and test-retest reliability), responsiveness, and expansion of the validation evidence base (use in randomized controlled trials and comparative effectiveness research, cultural or linguistic translations, predictive validity, or establishing the minimal clinically important difference threshold, defined as smallest amount an outcome or measure is perceived as a meaningful change to patients). The PROMs were categorized into three groups based on the manifestations of disease of the population for which they were developed. The overall validity of each PROM was assessed across three stages of validation including content validity (phase 1); construct validity, reliability, and responsiveness (phase 2); and expansion of the validation evidence base (phase 3). RESULTS Of 2338 unique studies screened, 112 studies (4.8%) met inclusion criteria. The eight disease-specific PROMs identified were categorized into three groups: (1) overall chronic venous disease (C1 to C6); (2) C1 to C4 disease; and (3) C5 to C6 disease. Assessed by group, the Chronic Venous Insufficiency Questionnaire met criteria for validation at all three phases for patients with C1 to C4 disease, and the Charing Cross Venous Ulcer Questionnaire met criteria for validation at all three phases for patients with C5 to C6 disease. There were no PROMs that met all criteria for validation for use in overall chronic venous disease (C1 to C6). CONCLUSIONS Of the eight PROMs assessed in this review, only two met prespecified criteria at each phase for validation. The Chronic Venous Insufficiency Questionnaire and Charing Cross Venous Ulcer Questionnaire should be considered for use in patients with chronic venous disease without venous ulcers and with venous ulcers, respectively.
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Affiliation(s)
- Jacob Cleman
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT
| | - Kevin Xia
- Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, CT
| | - Moosa Haider
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT
| | - Roozbeh Nikooie
- Division of Cardiology, University of Massachusetts School of Medicine, Worcester, MA
| | - Lindsey Scierka
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT
| | - Gaëlle Romain
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT
| | | | - Alyssa Grimshaw
- Department of Library and Information Science, Yale University, New Haven, CT
| | | | - Kim G Smolderen
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT; Department of Psychiatry, Yale School of Medicine, New Haven, CT.
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4
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Carradice D. Lower Limb Superficial Venous Ablation: Does Tumescentless Axial Treatment Have a Future? Eur J Vasc Endovasc Surg 2023; 65:424. [PMID: 36436702 DOI: 10.1016/j.ejvs.2022.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 11/16/2022] [Accepted: 11/18/2022] [Indexed: 11/25/2022]
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5
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Gloviczki P, Lawrence PF, Wasan SM, Meissner MH, Almeida J, Brown KR, Bush RL, Di Iorio M, Fish J, Fukaya E, Gloviczki ML, Hingorani A, Jayaraj A, Kolluri R, Murad MH, Obi AT, Ozsvath KJ, Singh MJ, Vayuvegula S, Welch HJ. The 2022 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part I. Duplex Scanning and Treatment of Superficial Truncal Reflux: Endorsed by the Society for Vascular Medicine and the International Union of Phlebology. J Vasc Surg Venous Lymphat Disord 2023; 11:231-261.e6. [PMID: 36326210 DOI: 10.1016/j.jvsv.2022.09.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 09/23/2022] [Indexed: 11/06/2022]
Abstract
The Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society collaborated to update the 2011 Society for Vascular Surgery/American Venous Forum clinical practice guidelines and provide new evidence-based recommendations on critical issues affecting the care of patients with varicose veins. Each recommendation is based on a recent, independent systematic review and meta-analysis of the diagnostic tests and treatments options for patients with lower extremity varicose veins. Part I of the guidelines includes evidence-based recommendations for the evaluation of patients with CEAP (Clinical Class, Etiology, Anatomy, Pathology) class 2 varicose vein using duplex ultrasound scanning and other diagnostic tests, open surgical treatment (ligation and stripping) vs endovenous ablation techniques, thermal vs nonthermal ablation of the superficial truncal veins, and management of incompetent perforating veins in CEAP class 2 disease. We have also made recommendations on the concomitant vs staged treatment of varicose tributaries using phlebectomy or liquid or foam sclerotherapy (with physician-compounded foam or commercially prepared polidocanol endovenous microfoam) for patients undergoing ablation of incompetent superficial truncal veins.
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Affiliation(s)
- Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN.
| | - Peter F Lawrence
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, CA
| | - Suman M Wasan
- Department of Medicine, University of North Carolina, Chapel Hill, and Rex Vascular Specialists, UNC Health, Raleigh, NC
| | | | - Jose Almeida
- Miller School of Medicine, University of Miami, Miami, FL
| | | | - Ruth L Bush
- Central Texas Veterans Affairs Healthcare System and Texas A&M University College of Medicine, Temple, TX
| | | | - John Fish
- Department of Medicine, Jobst Vascular Institute, University of Toledo, Toledo, OH
| | - Eri Fukaya
- Division of Vascular Surgery, Stanford University, Stanford, CA
| | | | | | - Arjun Jayaraj
- RANE Center for Venous and Lymphatic Diseases, Jackson, MS
| | - Raghu Kolluri
- Heart and Vascular Service, OhioHealth Riverside Methodist Hospital, Columbus, OH
| | - M Hassan Murad
- Evidence-Based Practice Research Program, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
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6
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Hitchman LH, Mohamed A, Smith GE, Pymer S, Chetter IC, Forsyth J, Carradice D. Provision of NICE-recommended varicose vein treatment in the NHS. Br J Surg 2023; 110:225-232. [PMID: 36448204 PMCID: PMC10364503 DOI: 10.1093/bjs/znac392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 10/18/2022] [Accepted: 10/22/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND Standardization of access to treatment and compliance with clinical guidelines are important to ensure the delivery of high-quality care to people with varicose veins. In the National Health Service (NHS) in England, commissioning of care for people with varicose veins is performed by Clinical Commissioning Groups (CCGs) and clinical guidelines have been developed by the National Institute for Health and Care Excellence (NICE CG168). The Evidence-Based Intervention (EBI) programme was introduced in the NHS with the aim of improving care quality and supporting implementation of NICE CG168. The aim of this study was to assess access to varicose vein treatments in the NHS and the impact of EBI. METHODS CCG policies for the delivery of varicose vein treatments in the NHS in England were obtained from 2017 (before EBI introduction) and 2019 (after EBI introduction) and categorized by two independent reviewers into levels of compliance with NICE CG168. Hospital Episode Statistics data were compared with the NICE commissioning model predictions. A quality-adjusted life-year was valued at £20 000 (Euro 23 000 15 November 2022). RESULTS Despite the introduction of the EBI programme, CCG compliance with NICE CG168 fell from 34.0 per cent (64 of 191) to 29.0 per cent (55 of 191). Some 33.0 per cent of CCG policies (63 of 191) became less compliant and only 7.3 per cent (14 of 191) changed to become fully compliant. Overall, 66.5 per cent of CCGs (127 of 191) provided less than the recommended intervention rate before EBI and this increased to 73.3 per cent (140 of191) after EBI. The overall proportion of patients estimated to require treatment annually who received treatment fell from 44.0 to 37.0 per cent. The associated estimated loss in net health benefit was between £164 and 174 million (Euro 188 million and 199 million 15 November 2022) over 3 years. A compliant policy was associated with a higher intervention rate; however, commissioning policy was associated with only 16.8 per cent of the variation in intervention rate (R2 = 0.168, P < 0.001). CONCLUSION Many local varicose vein commissioning policies in the NHS are not compliant with NICE CG168. More than half of patients who should be offered varicose vein treatment are not receiving it, and there is widespread geographical variation. The EBI programme has not been associated with any improvement in commissioning or access to varicose vein treatment.
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Affiliation(s)
| | - Abduraheem Mohamed
- Academic Vascular Surgery Unit, Hull York Medical School, Hull, UK.,Academic Vascular Surgery Unit, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - George E Smith
- Academic Vascular Surgery Unit, Hull York Medical School, Hull, UK.,Academic Vascular Surgery Unit, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Sean Pymer
- Academic Vascular Surgery Unit, Hull York Medical School, Hull, UK.,Academic Vascular Surgery Unit, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Ian C Chetter
- Academic Vascular Surgery Unit, Hull York Medical School, Hull, UK.,Academic Vascular Surgery Unit, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - James Forsyth
- Department of Vascular Surgery, Leeds University Teaching Hospital NHS Trust, Leeds, UK
| | - Daniel Carradice
- Academic Vascular Surgery Unit, Hull York Medical School, Hull, UK.,Academic Vascular Surgery Unit, Hull University Teaching Hospitals NHS Trust, Hull, UK
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7
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Danelyan BA, Manjikian HP, Adyrkhaev ZA, Sapelkin SV, Isaev AM. Combined microfoam sclerotherapy and miniphlebectomy as an optimal method of treating varicose vein tributaries after endovenous laser ablation. AMBULATORNAYA KHIRURGIYA = AMBULATORY SURGERY (RUSSIA) 2022. [DOI: 10.21518/1995-1477-2022-19-2-22-28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Introduction. The development of phlebology and mainstreaming of ultrasonic techniques has led to the emergence of microfoam sclerotherapy, which proved itself as a more effective technique. In the world literature, there are isolated publications that say about the effectiveness and safety of the microfoam sclerotherapy combined with mini-phlebectomy, but no specific studies comparing the combination treatment for the elimination of varicose syndrome with separate use of each of the techniques are described.Aim. To increase the effectiveness of invasive treatment and to reduce the rate of complications in patients with varicose veins using a combination of microfoam sclerotherapy and mini-phlebectomy of tributaries after endovenous laser ablation.Material and methods. Simple single- center, non-randomized, retrospective study was conducted at the A.K. Eramishantsev Moscow State Hospital. It included 52 patients with varicose veins (a total of 77 lower limbs, 22 patients had bilateral disease), who had no previous invasive treatment for this disease. They underwent endovenous laser ablation of truncal vein combined with microfoam sclerotherapy and mini-phlebectomy of tributaries. Microfoam sclerotherapy was performed with 0.5–2.0% of polidocanol foam, and mini-phlebectomy per Varady technique. The patients had a postprocedural follow-up clinical examination and duplex ultrasound the day after the intervention, then at 1, 6, and 12 months.Results. Endovenous laser ablation of truncal veins was acutely successful in all cases. No cases of great saphenous vein recanalization were detected in follow-up period. In the early postprocedural period, the combined microfoam sclerotherapy and miniphlebectomy also showed 100% success rate, however redo sclerotherapy was required in 4 (5.2%) cases for new varicose tributaries developed in late postprocedural period.Conclusion. Combined microfoam sclerotherapy and mini-phlebectomy, as a method of treatment for various veins syndrome, can provide additional benefit such as reducing the volume of mini-phlebectomy and the resultant tissue damage, the varicosity recurrence rate, the number of subcutaneous hematomas and ecchymoses, the discomfort of the tumescent anesthesia, the risk of postprocedural varicose veins thrombosis and pigmentation rate.
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Affiliation(s)
| | - H. P. Manjikian
- Eramishantsev Moscow State Hospital; Vishnevsky National Medical Research Center of Surgery
| | - Z. A. Adyrkhaev
- Vishnevsky National Medical Research Center of Surgery; Russian Medical Academy of Continuous Professional Education
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8
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Pannier F, Noppeney T, Alm J, Breu FX, Bruning G, Flessenkämper I, Gerlach H, Hartmann K, Kahle B, Kluess H, Mendoza E, Mühlberger D, Mumme A, Nüllen H, Rass K, Reich-Schupke S, Stenger D, Stücker M, Schmedt CG, Schwarz T, Tesmann J, Teßarek J, Werth S, Valesky E. S2k guidelines: diagnosis and treatment of varicose veins. DER HAUTARZT; ZEITSCHRIFT FUR DERMATOLOGIE, VENEROLOGIE, UND VERWANDTE GEBIETE 2022; 73:1-44. [PMID: 35438355 PMCID: PMC9358954 DOI: 10.1007/s00105-022-04977-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/23/2022] [Indexed: 11/29/2022]
Affiliation(s)
- F Pannier
- Praxis für Dermatologie und Phlebologie, Helmholtzstr. 4-6, 53123, Bonn, Germany.
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9
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De Maeseneer MG, Kakkos SK, Aherne T, Baekgaard N, Black S, Blomgren L, Giannoukas A, Gohel M, de Graaf R, Hamel-Desnos C, Jawien A, Jaworucka-Kaczorowska A, Lattimer CR, Mosti G, Noppeney T, van Rijn MJ, Stansby G, Esvs Guidelines Committee, Kolh P, Bastos Goncalves F, Chakfé N, Coscas R, de Borst GJ, Dias NV, Hinchliffe RJ, Koncar IB, Lindholt JS, Trimarchi S, Tulamo R, Twine CP, Vermassen F, Wanhainen A, Document Reviewers, Björck M, Labropoulos N, Lurie F, Mansilha A, Nyamekye IK, Ramirez Ortega M, Ulloa JH, Urbanek T, van Rij AM, Vuylsteke ME. Editor's Choice - European Society for Vascular Surgery (ESVS) 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs. Eur J Vasc Endovasc Surg 2022; 63:184-267. [PMID: 35027279 DOI: 10.1016/j.ejvs.2021.12.024] [Citation(s) in RCA: 203] [Impact Index Per Article: 101.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 11/12/2021] [Indexed: 01/12/2023]
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10
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OUP accepted manuscript. Br J Surg 2022; 109:679-685. [DOI: 10.1093/bjs/znac116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 02/08/2022] [Accepted: 03/21/2022] [Indexed: 11/13/2022]
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11
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Hicks CW, Vavra AK, Goldsborough E, Rebuffatti M, Almeida J, Duwayri YM, Haurani M, Ross CB, Shah SK, Shireman PK, Smolock CJ, Yi J, Woo K. Current status of patient-reported outcome measures in vascular surgery. J Vasc Surg 2021; 74:1693-1706.e1. [PMID: 34688398 PMCID: PMC9834908 DOI: 10.1016/j.jvs.2021.05.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 05/26/2021] [Indexed: 01/14/2023]
Abstract
A previously published review focused on generic and disease-specific patient-reported outcome measures (PROMs) relevant to vascular surgery but limited to arterial conditions. The objective of this project was to identify all available PROMs relevant to diseases treated by vascular surgeons and to evaluate vascular surgeon perceptions, barriers to widespread implementation, and concerns regarding PROMs. We provide an overview of what a PROM is and how they are developed, and summarize currently available PROMs specific to vascular surgeons. We also report results from a survey of 78 Society for Vascular Surgery members serving on committees within the Policy and Advocacy Council addressing the barriers and facilitators to using PROMs in clinical practice. Finally, we report the qualitative results of two focus groups conducted to assess granular perceptions of PROMS and preparedness of vascular surgeons for widespread implementation of PROMs. These focus groups identified a lack of awareness of existing PROMs, knowledge of how PROMs are developed and validated, and clarity around how PROMs should be used by the clinician as main subthemes for barriers to PROM implementation in clinical practice.
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Affiliation(s)
- Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Ashley K Vavra
- Division of Vascular Surgery, Department of Surgery, Northwestern Feinberg School of Medicine, Chicago, Ill
| | | | - Michelle Rebuffatti
- Division of Vascular Surgery, Department of Surgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, Calif
| | - Jose Almeida
- Miami Vein and Division of Vascular and Endovascular Surgery, University of Miami Miller School of Medicine, Miami, Fl
| | - Yazan M Duwayri
- Division of Vascular Surgery and Endovascular Therapy, Emory University, Atlanta, Ga
| | - Mounir Haurani
- Division of Vascular Diseases and Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Charles B Ross
- Vascular Center of Excellence, Piedmont Heart and Vascular Institute, Piedmont Healthcare, Atlanta, Ga
| | - Samir K Shah
- Division of Vascular Surgery, University of Florida, Gainesville, Fl
| | - Paula K Shireman
- Division of Vascular and Endovascular Surgery, Long School of Medicine, University of Texas Health San Antonio, Tex; Department of Surgery, South Texas Veterans Health Care System, San Antonio, Tex
| | - Christopher J Smolock
- Department of Vascular Surgery, Sydell and Arnold Miller Family Heart, Vascular, and Thoracic Institute, The Cleveland Clinic, Cleveland, Ohio
| | - Jeniann Yi
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Colorado, Aurora, Colo
| | - Karen Woo
- Division of Vascular Surgery, Department of Surgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, Calif.
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Sharmila DN. Surgery for Varicose Veins. Indian J Surg 2021. [DOI: 10.1007/s12262-021-03044-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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13
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Farah MH, Nayfeh T, Urtecho M, Hasan B, Amin M, Sen I, Wang Z, Prokop LJ, Lawrence PF, Gloviczki P, Murad MH. A systematic review supporting the Society for Vascular Surgery, the American Venous Forum, and the American Vein and Lymphatic Society guidelines on the management of varicose veins. J Vasc Surg Venous Lymphat Disord 2021; 10:1155-1171. [PMID: 34450355 DOI: 10.1016/j.jvsv.2021.08.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/13/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Several diagnostic tests and treatment options for patients with lower extremity varicose veins have existed for decades. The purpose of this systematic review was to summarize the latest evidence to support the forthcoming updates of the clinical practice guidelines on the management of varicose veins for the Society for Vascular Surgery (SVS), the American Venous Forum (AVF) and the American Vein and Lymphatic Society. METHODS We searched multiple databases for studies that addressed four clinical questions identified by the AVF and the SVS guideline committee about evaluating and treating patients with varicose veins. Studies were selected and appraised by pairs of independent reviewers. A meta-analysis was conducted when feasible. RESULTS We included 73 original studies (45 were randomized controlled trials) and 1 systematic review from 12,915 candidate references. Moderate certainty of evidence supported the usefulness of duplex ultrasound (DUS) examination as the gold standard test for diagnosing saphenous vein incompetence in patients with varicose veins and chronic venous insufficiency (clinical, etiological, anatomic, pathophysiological classification [CEAP] class C2-C6). High ligation and stripping (HL/S) was associated with higher anatomic closure rates at 30 days and 5 years when compared with radiofrequency ablation and ultrasound-guided foam sclerotherapy (UGFS) (moderate certainty), while no significant difference was seen when compared with endovenous laser ablation (EVLA) at 5 years. UGFS was associated with an increased risk of recurrence compared with HL/S. EVLA was associated with lower anatomic closure rates at 30 days than cyanoacrylate closure (CAC) and higher rates at one and 5 years when compared with UGFS. Thermal interventions were associated with lower generic quality of life scores and an increased risk of adverse events when compared with CAC or n-butyl cyanoacrylate (low certainty). Thermal interventions were associated with a lower risk of recurrent incompetence when compared with UGFS and an increased risk of recurrent incompetence than CAC. The evidence for great saphenous vein ablation alone to manage perforator disease was inconclusive. CONCLUSIONS The current systematic review summarizes the evidence to develop and support forthcoming updated SVS/AVF/American Vein and Lymphatic Society clinical practice guideline recommendations. The evidence supports duplex scanning for evaluating patients with varicose veins and confirms that HL/S resulted in similar long-term saphenous vein closure rates as EVLA and in better rates than radiofrequency ablation and UGFS. Thermal interventions were associated with inferior generic quality of life scores than nonthermal interventions, but had a lower risk of recurrent incompetence than UGFS. The recommendations in the guidelines should consider this information as well as other factors such as patients' values and preferences, anatomic considerations of individual patients, and surgical expertise.
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Affiliation(s)
- Magdoleen H Farah
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn
| | - Tarek Nayfeh
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn
| | - Meritxell Urtecho
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn
| | - Bashar Hasan
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn
| | - Mustapha Amin
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn
| | - Indrani Sen
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Zhen Wang
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn
| | | | - Peter F Lawrence
- Division of Vascular Surgery, Department of Surgery, University of California, Los Angeles, Calif
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - M Hassan Murad
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn.
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14
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Andrews RH, Dixon RG. Ambulatory Phlebectomy and Sclerotherapy as Tools for the Treatment of Varicose Veins and Telangiectasias. Semin Intervent Radiol 2021; 38:160-166. [PMID: 34108801 DOI: 10.1055/s-0041-1727151] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Treatment of chronic venous disease is a fascinating and rewarding undertaking. Once the truncal reflux is addressed, several options are available that can be used to treat the associated ulcers, varicosities, reticular veins, and telangiectasias. This review will focus on two widely employed procedures: ambulatory phlebectomy and sclerotherapy.
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Affiliation(s)
- R Hampton Andrews
- Department of Radiology, University of North Carolina, Chapel Hill, North Carolina
| | - Robert G Dixon
- Interventional Radiology Program, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Management of Lower Extremity Pain from Chronic Venous Insufficiency: A Comprehensive Review. Cardiol Ther 2021; 10:111-140. [PMID: 33704678 PMCID: PMC8126535 DOI: 10.1007/s40119-021-00213-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Indexed: 02/08/2023] Open
Abstract
PURPOSE OF REVIEW Chronic venous insufficiency is found to some extent in a large proportion of the world's population, especially in the elderly and obese. Despite its prevalence, little research has been pursued into this pathology when compared to similarly common conditions. Pain is often the presenting symptom of chronic venous insufficiency and has significant deleterious effects on quality of life. This manuscript will describe the development of pain in chronic venous insufficiency, and will also review both traditional methods of pain management and novel advances in both medical and surgical therapy for this disease. RECENT FINDINGS Pain in chronic venous insufficiency is a common complication which remains poorly correlated in recent studies with the clinically observable extent of disease. Although lifestyle modification remains the foundation of treatment for pain associated with chronic venous sufficiency, compression devices and various pharmacologic agents have emerged as safe and effective treatments for pain in these patients. In patients for whom these measures are insufficient, recently developed minimally invasive vascular surgical techniques have been shown to reduce postsurgical complications and recovery time, although additional research is necessary to characterize long-term outcomes of these procedures. This review discusses the latest findings concerning the pathophysiology of pain in chronic venous insufficiency, conservative and medical management, and surgical strategies for pain relief, including minimally invasive treatment strategies.
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Randomized Controlled Trial of Compression After Endovenous Thermal Ablation of Varicose Veins (COMETA Trial). Ann Surg 2021; 273:232-239. [PMID: 31850976 DOI: 10.1097/sla.0000000000003626] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The 21st century has witnessed a rise in the use of endovenous thermal ablation. Being highly clinically and cost-effective and improving the quality of life of patients, they are now considered to be the "gold-standard" treatment for varicose veins. Post-intervention management, especially in terms of postoperative compression, however, remains unclear. As a result, a randomized study was undertaken to investigate the effects of wearing compression stockings after varicose vein treatment. METHOD Patients with saphenous vein reflux undergoing treatment with endothermal ablation (with or without concurrent phlebectomies) were randomized to receive either 7 days of compression stockings or no stockings. The primary outcome measure for this study was the pain score over the first 10 postoperative days. The pain scores, clinical score, time to return to normal activities, and ecchymosis were assessed. Patients were followed-up at 2 weeks and 6 months post-ablation. RESULTS In total, 206 patients were randomized, 49% of them to the compression group. The mean age was 49.7 (±16) years and approximately 51% of the population was male. The median pain score in the compression group using a visual analog scale was significantly lower on days 2-5, compared to the no compression group. Those having concurrent phlebectomies and compression stockings also had significantly better pain scores on days 1-3, day 5, and day 7. Improvement in the median venous clinical severity score was noted at 6-month follow-up, but this was not significant. No difference in the generic- or disease-specific quality of life was observed and the time to return to activities was similar. There were no differences in the degree of ecchymosis between the 2 groups and both groups had similar occlusion rates. CONCLUSIONS These results indicate that wearing compression stockings after endothermal ablation is advantageous in the first few days after treatment and is especially beneficial for those having concurrent phlebectomies.
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Park I, Kim JY, Lee H, Park G, Park J, Hwang H, Yun S, Ohe H, Hong KP, Park JK, Jang JH, Yun SS. Draft Revision of Clinical Practice Guidelines for Varicose Veins -Treatment-. Phlebology 2020. [DOI: 10.37923/phle.2020.18.2.29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - Jang Yong Kim
- Division of Vascular and Transplant Surgery, Department of Surgery, The Catholic University of Korea, Seoul St. Mary’s Hospital, Seoul, Korea
| | - Hogyun Lee
- Division of Vascular and Transplant Surgery, Department of Surgery, Chonnam National University Hospital, Gwangju, Korea
| | - Geunmyeong Park
- Division of Vascular and Transplant Surgery, Department of Surgery, Inha University Hospital, Inchon, Korea
| | - Junho Park
- Happy Varicose Vein Clinic, Seoul, Korea
| | - Hongpil Hwang
- Division of Vascular and Transplant Surgery, Department of Surgery, Jeonbuk National University Hospital, Jeonju, Korea
| | - Sangchul Yun
- Department of Surgery, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Haengjin Ohe
- Division of Vascular and Transplant, Department of Surgery, Inje University Seoul Paik Hospital, Seoul, Korea
| | - Ki-Pyo Hong
- Department of Thoracic and Cardiovascular Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jong Kwon Park
- Division of Vascular and Transplant, Department of Surgery, Inje University Haeundae Paik Hospital, Busan, Korea
| | | | - Sang Seob Yun
- Division of Vascular and Transplant Surgery, Department of Surgery, The Catholic University of Korea, Seoul St. Mary’s Hospital, Seoul, Korea
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Mosquera-Rey V, Del Castro Madrazo JA, Ángeles M Herrero M, Cordeu RA, Azofra EA, Pérez MA. Mechanochemical ablation for great and small saphenous veins insufficiency in patients with type III shunt. Phlebology 2020; 36:145-151. [PMID: 32847473 DOI: 10.1177/0268355520951695] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE the aim of this study was to assess the results of mechanochemical endovenous ablation either in the primary or recurrent saphenous vein insufficiency, including only patients with veno-venous shunt type III. METHODS retrospective analysis of a prospective study of patients with symptomatic chronic venous insufficiency who underwent ClariVein® technique. A total of 134 saphenous veins were included between August 2017 and August 2018. Follow-up was performed by Duplex ultrasound at 1, 6 and 12 months. Primary endpoints were technical and anatomical success. Secondary endpoints were the need for further treatment of varicose collateral veins by sclerotherapy, outcomes regarding recurrent insufficiency and clinical success. RESULTS A total of 111 great saphenous veins and 23 small saphenous veins were treated with a technical success of 95.6%. The overall anatomical success rates at 1, 6 and 12 month were 96.2%, 88.8% and 84.4%, respectively, without differences between primary and recurrent insufficiency. Deferred sclerotherapy over varicose collaterals was carried out in 28% of the patients with anatomical success. Clinical improvement was achieved in 87.3%. CONCLUSIONS MOCA technique has proven to be an effective technique, although additional treatment over varicose collaterals could be necessary in up to one-third. Atrophy of the saphenous vein and the lack of persistent varicose collateral veins during follow-up seem to be indicators of successful therapy.
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Affiliation(s)
- Vicente Mosquera-Rey
- Department of Angiology and Vascular Surgery, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - José A Del Castro Madrazo
- Department of Angiology and Vascular Surgery, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - María Ángeles M Herrero
- Department of Angiology and Vascular Surgery, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Rubén A Cordeu
- Department of Angiology and Vascular Surgery, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Ernesto A Azofra
- Department of Angiology and Vascular Surgery, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Manuel A Pérez
- Department of Angiology and Vascular Surgery, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
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Aherne TM, Ryan ÉJ, Boland MR, McKevitt K, Hassanin A, Tubassam M, Tang TY, Walsh S. Concomitant vs. Staged Treatment of Varicose Tributaries as an Adjunct to Endovenous Ablation: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2020; 60:430-442. [PMID: 32771286 DOI: 10.1016/j.ejvs.2020.05.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 04/16/2020] [Accepted: 05/19/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVE This review compares the outcomes of both concomitant and staged superficial varicose tributary (SVT) interventions as an adjunct to endovenous truncal ablation. METHODS A systematic search of Medline through Pubmed, Embase, and the Cochrane Central Register of Controlled Trials was last performed in November 2019. All studies comparing the outcomes of both concomitant and staged treatments for SVT as an adjunct to endovenous truncal ablation were included. Each included study was subject to an evaluation of methodological quality using the Downs and Black assessment tool. Outcomes assessed included rates of re-intervention, complications, and thrombotic events. Quality of life (QOL) and disease severity were also analysed. Data were pooled with a random effects model. RESULTS Fifteen studies (6 915 limbs) were included for analysis. Included studies were of reasonable methodological quality. Re-intervention rates were significantly lower in the concomitant group (6.3% vs. 36.1%) when compared with staged intervention (relative risk [RR] 0.21 [95% CI 0.07-0.62], p = .004, I2 = 90%, p ≤ .001). Reported complications (RR 1.14 [95% CI 0.67-1.93], p = .64) and rates of deep venous thrombosis (RR 1.41 [95% CI 0.72-2.77] p = .31) were similar in each group. Overall disease severity (Venous Clinical Severity Score) was lower in the concomitant group (-1.16 [95% CI, -1.97- -0.35] p = .005), while QOL, assessed using the Aberdeen Varicose Vein Questionnaire, favoured concomitant treatment when measured at less than three months (weighted mean difference [WMD] -3.6 [95% CI, -7.17- -0.03] p = .050) and between three and 12 months (WMD -1.61 [95% CI, -2.99- -0.23] p = .020). CONCLUSION Concomitant and staged treatments are safe and effective. Improvements in early disease severity and QOL scores were better in the concomitant group. While meta-analysis suggests that concomitant intervention offers significantly lower rates of re-intervention, studies assessing its merits are subject to some biases. This benefit was not reflected by the randomised trial subgroup analysis, which identified no difference in re-intervention.
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Affiliation(s)
- Thomas M Aherne
- Department of Vascular Surgery, University Hospital Galway, Ireland; Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland.
| | - Éanna J Ryan
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Michael R Boland
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Kevin McKevitt
- Department of Vascular Surgery, University Hospital Galway, Ireland
| | - Ahmed Hassanin
- Department of Vascular Surgery, University Hospital Galway, Ireland; Department of Surgery, University of Sohag, Egypt
| | - Muhammad Tubassam
- Department of Vascular Surgery, University Hospital Galway, Ireland; Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland
| | - Tjun Y Tang
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Stewart Walsh
- Department of Vascular Surgery, University Hospital Galway, Ireland; Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland
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Brown CS, Obi AT, Cronenwett JL, Kabnick L, Wakefield TW, Osborne NH. Outcomes after truncal ablation with or without concomitant phlebectomy for isolated symptomatic varicose veins (C2 disease). J Vasc Surg Venous Lymphat Disord 2020; 9:369-376. [PMID: 32502731 DOI: 10.1016/j.jvsv.2020.05.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 05/22/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Many insurance payers are hesitating to cover interventional treatments in patients with isolated symptomatic varicose veins. In this study, we sought to determine the outcomes of patients with varicose veins who were treated with venous ablation alone or ablation plus phlebectomy using the Vascular Quality Initiative Varicose Vein Registry. METHODS Using data from the Varicose Vein Registry between January 2015 and March 2019, we investigated immediate postoperative as well as long-term clinical and patient-reported outcomes among patients with documented symptomatic C2 disease undergoing truncal endovenous ablations alone and combined ablation and phlebectomy. Preprocedural and postprocedural comparisons were performed using t-test, χ2 test, or nonparametric tests when appropriate. Multivariable ordinal logistic regression was performed on ordinal outcome variables. RESULTS Among 3375 patients with symptomatic C2 disease, 40.1% of patients (1376) underwent isolated truncal ablation and 59.9% (1999) underwent ablation and phlebectomy. Complications overall were low (8.6%) and varied between 8.4% and 8.7% in patients undergoing ablation alone and ablation plus phlebectomy, respectively (P = .820). The most common complication noted was paresthesia, 3.4% overall, which occurred more commonly after ablation and phlebectomy (4.5%) than after ablation alone (1.3%; P < .001). An improvement in Venous Clinical Severity Score (VCSS) was experienced by 87.4% of patients; median change in VCSS was 4 points (interquartile range [IQR], 2-5 points), with an improvement of 3 points among patients undergoing ablation alone (IQR, 1-5 points) and 5 points among patients undergoing ablation and phlebectomy (IQR, 3-5 points; P < .001). An improvement in overall symptoms was experienced by 94.4% of patients (median improvement, 11 points; (maximum, 30 points), with more significant decreases among patients undergoing ablation and phlebectomy (median, 12 points; IQR, 8-17 points) compared with ablation alone (median, 9 points; IQR, 5-13 points; P < .001). CONCLUSIONS Among patients with isolated symptomatic varicose veins (C2 disease), ablation and ablation with phlebectomy are safe and effective in improving both patient-reported outcomes and clinical severity (VCSS). Given these data, payers should continue to cover these treatments.
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Affiliation(s)
- Craig S Brown
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich.
| | - Andrea T Obi
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Jack L Cronenwett
- Section of Vascular Surgery, Department of Surgery, Dartmouth Institute and Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Lowell Kabnick
- Atlantic Health System (Morristown Medical Center), Kabnick Vein Center, Morristown, NJ
| | - Thomas W Wakefield
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Nicholas H Osborne
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
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Campbell B, J Franklin I, Gohel M. The choice of treatments for varicose veins: A study in trade-offs. Phlebology 2020; 35:647-649. [DOI: 10.1177/0268355520922708] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Bruce Campbell
- University of Exeter Medical School, Exeter, UK
- Royal Devon and Exeter Hospital, Exeter, UK
| | | | - Manj Gohel
- Cambridge University Hospitals NHS Healthcare Trust, Cambridge, UK
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Clinical response to combination therapy in the treatment of varicose veins. J Vasc Surg Venous Lymphat Disord 2020; 8:216-223. [DOI: 10.1016/j.jvsv.2019.10.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 10/13/2019] [Indexed: 01/06/2023]
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Residual incompetent tributaries after varicose vein surgery increased the need for reintervention after 8 years. J Vasc Surg Venous Lymphat Disord 2020; 8:378-382.e1. [PMID: 31992538 DOI: 10.1016/j.jvsv.2019.11.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 11/03/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The aim of this study was to determine whether residual incompetent tributaries after varicose vein surgery affected the reintervention rate after longer follow-up. METHODS The study is a retrospective review of data from a cohort of a previous randomized controlled study comparing surgery with and without preoperative duplex ultrasound, with follow-up after 2 months, 2 years, and 5 to 9 years clinically and with duplex ultrasound. The cohort was subdivided according to the duplex ultrasound findings 2 months after surgery: no venous incompetence, residual incompetent tributaries only, truncal incompetence, and combined truncal and tributary incompetence. Reintervention rates were compared between groups. RESULTS There were 280 patients (326 legs) who attended follow-up 2 months postoperatively and 164 patients (190 legs) after a median of 8 years (5-9 years). Another 53 patients (62 legs) were interviewed by telephone or had been reoperated on earlier during follow-up; thus, information was available for 217 patients (252 legs). Of the 252 legs, 56 (22%) were reoperated on during follow-up. In the subgroup with no venous incompetence at all 2 months postoperatively, 4 of 74 legs (5%) were reoperated on; and in the group with residual incompetent tributaries without truncal incompetence, 16 of 56 legs (29%) were reoperated on (P = .000). There was no significant difference in reintervention rate of the group with incompetent tributaries only compared with those with truncal incompetence without incompetent tributaries (12/42 legs [29%]; P = 1) or with combined incompetence of truncal vein and tributaries (22/64 legs [34%]; P = .495). The presence of perforating vein incompetence at 2 months postoperatively did not significantly alter the rate of reoperations (P = .159). In legs that had not been reoperated on, more incompetent veins could be seen progressively. In the group without any incompetent veins postoperatively, 37% still had normal findings at 8 years. CONCLUSIONS Residual incompetent tributaries after treatment of varicose veins will increase the reintervention rate in the long term, as much as leaving a trunk vein untreated. Patients should be informed about the increased risk of reintervention if not all incompetent veins are targeted.
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Kawai Y, Sugimoto M, Aikawa K, Komori K. Endovenous Laser Ablation with and Without Concomitant Phlebectomy for the Treatment of Varicose Veins: A Retrospective Analysis of 954 Limbs. Ann Vasc Surg 2020; 66:344-350. [PMID: 31917221 DOI: 10.1016/j.avsg.2019.12.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 12/30/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND Endovenous laser ablation (EVLA) with concomitant phlebectomy is commonly performed in many institutions. However, phlebectomy is associated with cosmetic complications such as surgical scarring, hemorrhage, and hematoma. This study aims to compare the need for additional sclerotherapy during follow-up after EVLA with and without concomitant phlebectomy. METHODS Between November 2013 and December 2018, we performed EVLA on 1,363 limbs in 1,009 patients with symptomatic primary varicose veins, of which 954 limbs in 771 patients with great saphenous vein (GSV) or small saphenous vein (SSV) insufficiency were included in this study. Data were collected prospectively and supplemented with retrospective medical record review. Demographic and clinical characteristic profiles were collected. The outcomes of EVLA with or without concomitant phlebectomy were compared. Logistic regression was used to assess predictors for additional sclerotherapy after EVLA. RESULTS CEAP classification (P < 0.001), operative time (P < 0.001), laser device type (P < 0.001), length of the treated vein (P < 0.001), linear endovenous energy density (P < 0.001), and tumescent local anesthesia volume (P < 0.001) differed significantly. Pain after EVLA was significantly more frequent in the nonphlebectomy group than in the phlebectomy group (P = 0.005). During follow-up, 34 of 954 limbs (3.6%) underwent additional sclerotherapy for residual visible varicose veins after EVLA. No statistical difference was found in the rate of additional sclerotherapy between the groups (P = 0.849). Logistic regression showed that female sex (odds ratio [OR], 6.18; 95% confidence interval [CI], 1.86-20.6; P = 0.003) is significantly associated with additional sclerotherapy, and concomitant phlebectomy is not a significant predictor of additional sclerotherapy (OR, 0.844; 95% CI, 0.375-1.90; P = 0.682). CONCLUSIONS Patient preference for additional sclerotherapy was comparable between those who underwent EVLA with and without concomitant phlebectomy. This result supports our present strategy of avoiding simultaneous phlebectomy at the time of primary EVLA.
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Affiliation(s)
- Yohei Kawai
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Masayuki Sugimoto
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | | | - Kimihiro Komori
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Belramman A, Bootun R, Lane TRA, Davies AH. Foam sclerotherapy versus ambulatory phlebectomy for the treatment of varicose vein tributaries: study protocol for a randomised controlled trial. Trials 2019; 20:392. [PMID: 31269978 PMCID: PMC6610823 DOI: 10.1186/s13063-019-3398-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 05/06/2019] [Indexed: 11/19/2022] Open
Abstract
Background Ambulatory phlebectomies and foam sclerotherapy are two of the most common treatments for varicose vein tributaries. Many studies have been published on these treatments, but few comparative studies have attempted to determine their relative effectiveness. Methods/design This is a prospective single-centre randomised clinical trial. Patients with primary truncal vein incompetence and varicose vein tributaries requiring treatment will be assigned randomly to either ambulatory phlebectomies or foam sclerotherapy. The primary outcome measure is the re-intervention rate for the varicose vein tributaries during the study period. The secondary outcomes include the degree of pain during the first two post-operative weeks and the time to return to usual activities or work. Improvements in clinical scores, quality of life scores, occlusion rates and cost-effectiveness for each intervention are other secondary outcomes. The re-intervention rate will be considered from the third month. Discussion This study compares ambulatory phlebectomies and foam sclerotherapy in the treatment of varicose vein tributaries. The re-intervention rates, safety, patient experience and the cost-effectiveness of each intervention will be assessed. This study aims to recruit 160 patients and is expected to be completed by the end of 2019. Trial registration ClinicalTrials.gov, NCT03416413. Registered on 31 January 2018. Electronic supplementary material The online version of this article (10.1186/s13063-019-3398-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Amjad Belramman
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
| | - Roshan Bootun
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK.,Specialty Training Registrar in Vascular Surgery, East of England Deanery, UK
| | - Tristan R A Lane
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK. .,Specialty Training Registrar in Vascular Surgery, London Deanery, UK. .,Imperial College Healthcare NHS Trust, London, UK.
| | - Alun H Davies
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK.,Imperial College Healthcare NHS Trust, London, UK
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Delineating the durability outcome differences after saphenous ablation with laser versus radiofrequency. J Vasc Surg Venous Lymphat Disord 2019; 7:486-492. [DOI: 10.1016/j.jvsv.2018.11.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 11/20/2018] [Indexed: 11/19/2022]
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Kürşat Bozkurt A, Lawaetz M, Danielsson G, Lazaris AM, Pavlovic M, Olariu S, Rasmussen L. European College of Phlebology guideline for truncal ablation. Phlebology 2019; 35:73-83. [DOI: 10.1177/0268355519857362] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background The purpose of the guideline was to achieve consensus in the care and treatment of patients with chronic venous disease, based on current evidence. Method A systematic literature search was performed in PubMed, Embase, Cinahl, and the Cochrane library up until 1 February 2019. Additional relevant literature were added through checking of references. Level of evidence was graded through the GRADE scale and recommendations were concluded. Results For the treatment of great and small saphenous vein reflux, endovenous ablation with laser or radiofrequency was recommended in preference to surgery or foam sclerotherapy. If tributaries are to be treated it should be done in the same procedure. Treatment with mecanicochemical ablation and glue can be used but we still need long term follow up results. Conclusion For the treatment of truncal varicosities, endovenous ablation with laser or radiofrequency combined with phlebectomies is recommended before surgery or foam.
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Affiliation(s)
- A Kürşat Bozkurt
- Department of Cardiovascular Surgery, Istanbul University – Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Martin Lawaetz
- Rigshospitalet, Department of Vascular Surgery, Copenhagen, Denmark
- The Danish Vein Centers, Naestved, Denmark
| | | | - Andreas M Lazaris
- Department of Vascular Surgery, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Milos Pavlovic
- Infinity Family Medicine Clinic, Dubai, United Arab Emirates
| | - Sorin Olariu
- Victor Babes University of Medicine and Pharmacy of Timisoara
- UMFT, Surgery 1st, Timişoara, Romania
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Commonly Used Endovenous Laser Ablation (EVLA) Parameters Do Not Influence Efficacy: Results of a Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2019; 58:230-242. [PMID: 31230868 DOI: 10.1016/j.ejvs.2018.10.036] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 10/17/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVES The objective of this systematic review and meta-analysis was to summarise available randomised controlled trials (RCTs) of EVLA efficacy, and to define the differences in success rate of variations in wavelength, administered energy, outcome definition, and follow up period. METHODS A literature search was conducted in Embase, Medline (Ovid-SP), Cochrane Central Database, and Web of Science from inception to November 2017. RCTs with follow up of more than three months were included. The studied outcome was the proportion of patients with EVLA treatment success, defined as absence of reflux or occlusion of the great saphenous vein (GSV). Pooled proportions of anatomical success were compared. Subgroup and meta-regression analysis included wavelengths (short [810, 940, and 980 nm], long [1470, 1500, and 1920 nm]), amount of energy (≤50 J/cm, > 50 J/cm), follow up (≤1 year, > 1 year), outcome definition (occlusion, no reflux), and quality of the studies (low risk of bias, unclear/high risk of bias). RESULTS Twenty-eight RCTs, with a total of 2829 GSVs were included. The overall success rate of EVLA was 92% (95% CI 90-94%, I2 = 68%). In subgroup analysis, no statistically significant differences were found for long or short wavelengths (95% [95% CI 91-97%] vs. 92% [95% CI 89-94%], p = .15), high or low administered energy (93% [95% CI 89-95%] vs. 92% [95% CI 90-94%], p = .99), long or short follow up (89% [95% CI 84-93%] vs. 93% [95% CI 91-95%], p = .13) and outcome definition (occlusion group 94% [95% CI 91-96%] vs. absence of reflux group 91% [95% CI 87-94%], p = .26). Studies with low risk of bias reported a significantly higher success rate than high or unclear risk of bias (93% [95% CI 90-95%] vs. 89% [95% CI 83-93%], p = .04). CONCLUSIONS The overall success rate of EVLA is high (92%), even with increasing follow up. Commonly used parameters of EVLA (wavelength, administered energy, and outcome definition) have no influence on the treatment success rate.
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Mohamed A, Leung C, Hitchman L, Wallace T, Smith G, Carradice D, Chetter I. A prospective observational cohort study of concomitant versus sequential phlebectomy for tributary varicosities following axial mechanochemical ablation. Phlebology 2019; 34:627-635. [DOI: 10.1177/0268355519835625] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Introduction Endovenous mechanochemical ablation (MOCA) is an increasingly popular non-thermal non-tumescent technique used to treat axial reflux in patients with superficial venous incompetence. However, the optimal management of varicose tributaries following this technique is unknown and may impact on patient outcomes. This study compares MOCA with concomitant phlebectomy (MOCAP) versus ablation with sequential phlebectomy if required (MOCAS). Methods Patients with symptomatic Comprehensive Classification System for Chronic Venous Disorders (CEAP C2–C6) unilateral axial reflux were studied. Patient choice determined whether concomitant treatment of varicosities was carried out. The primary outcome was the Aberdeen Varicose Veins Questionnaire (AVVQ) at one year. Secondary outcomes included: Venous Clinical Severity Scores (VCSS), EuroQol 5-Domain quality of life scores, complications, procedure duration, procedural and post-operative pain scores and need for secondary procedures. Outcomes were assessed at baseline and then one week, six weeks, six months and one year post intervention. Results Fifty patients underwent MOCAP and 33 patients MOCAS. The two groups were comparable at baseline. MOCAP was associated with lower (better) AVVQ scores at six weeks (3.4 (0.5–6.0) vs. 6.1 (1.8–12.1); P = 0.009) and at six months (1.6 (0.0–4.5) vs. 3.34 (1.8–8.4); P = 0.009) but by one year the difference was no longer statistically significant (1.81 (0.0–4.5) vs. 3.81 (0.2–5.3); P = 0.099). MOCAP was associated with longer procedural duration (45 min (36–56) vs. 30 min (25–37); P < 0.001) and higher maximal periprocedural pain (31 (21–59) vs. 18 (7–25); P = 0.001). VCSS at all time points were lower in favour of MOCAP (0 (0–1) vs. 1 (0–3); P < 0.001). MOCAP was associated with fewer episodes of clinically significant thrombophlebitis (6 of 50 (12%) vs. 10 of 33 (30%); P = 0.039) and lower numbers of secondary procedures (2 (4%) vs. 6 (18%); P = 0.032). Conclusion Concomitant treatment of tributary varicosities following MOCA improves quality of life and clinical severity, while reducing rates of re-intervention and post-operative thrombophlebitis compared to sequential treatment. The penalty is a modest increase in procedural duration and discomfort. Further evidence from longer-term follow-up is needed.
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Affiliation(s)
| | - Clement Leung
- Academic Vascular Surgical Unit, Hull York Medical School, Hull, UK
| | - Louise Hitchman
- Academic Vascular Surgical Unit, Hull York Medical School, Hull, UK
| | - Tom Wallace
- Academic Vascular Surgical Unit, Hull York Medical School, Hull, UK
| | - George Smith
- Academic Vascular Surgical Unit, Hull York Medical School, Hull, UK
| | - Daniel Carradice
- Academic Vascular Surgical Unit, Hull York Medical School, Hull, UK
| | - Ian Chetter
- Academic Vascular Surgical Unit, Hull York Medical School, Hull, UK
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Shutze W, Shutze R, Dhot P, Ogola GO. Patient-reported outcomes of endovenous superficial venous ablation for lower extremity swelling. Phlebology 2018; 34:391-398. [PMID: 30466354 DOI: 10.1177/0268355518814130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective To evaluate the effect of endovenous ablation in patients presenting with leg swelling. Methods We identified Clinical, Etiology, Anatomy, Pathophysiology (CEAP) clinical class 3 (C3) patients undergoing endovenous ablation from 21 January 2005 to 19 March 2015 with an 810-nm or 1470-nm laser. Patients were surveyed regarding the degree of edema, use of compression stockings, and satisfaction with the procedure. Results A total of 1634 limbs were treated by endovenous ablation for incompetent saphenous veins with or without adjunctive segmental varicose vein microphlebectomy. Of these, 528 limbs were treated for CEAP C3. The average time period from the procedure date until the survey date was 1494 days (range, 562–2795 days). Ninety-two respondents accounted for 130 ablations in 128 limbs with an average venous segmental disease score of 2.7. Ninety-seven limbs (75.8%) had reduced or resolved swelling, 29 limbs (22.6%) were unchanged, and 2 limbs (1.6%) had increased swelling. The vast majority (81%) were satisfied with their decision to have the procedure. Conclusions Endovenous ablation for edema secondary to superficial venous insufficiency is effective and has high patient satisfaction. Further investigation is needed regarding risk factors for immediate failure and delayed recurrence of edema.
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Affiliation(s)
- William Shutze
- 1 Texas Vascular Associates, Dallas, Texas, USA.,2 The Heart Hospital Baylor Plano, Dallas, Texas, USA
| | - Ryan Shutze
- 1 Texas Vascular Associates, Dallas, Texas, USA
| | - Paul Dhot
- 1 Texas Vascular Associates, Dallas, Texas, USA.,2 The Heart Hospital Baylor Plano, Dallas, Texas, USA
| | - Gerald O Ogola
- 3 Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas, Texas, USA
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Nandhra S, Wallace T, El-Sheikha J, Leung C, Carradice D, Chetter I. A Randomised Clinical Trial of Buffered Tumescent Local Anaesthesia During Endothermal Ablation for Superficial Venous Incompetence. Eur J Vasc Endovasc Surg 2018; 56:699-708. [DOI: 10.1016/j.ejvs.2018.05.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Accepted: 05/13/2018] [Indexed: 11/25/2022]
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Wang JC, Li Y, Li GY, Xiao Y, Li WM, Ma Q, Liu JL, Lu SY. A Comparison of Concomitant Tributary Laser Ablation and Foam Sclerotherapy in Patients Undergoing Truncal Endovenous Laser Ablation for Lower Limb Varicose Veins. J Vasc Interv Radiol 2018; 29:781-789. [DOI: 10.1016/j.jvir.2018.01.774] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 12/20/2017] [Accepted: 01/16/2018] [Indexed: 10/17/2022] Open
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Thirty-sixth-month follow-up of first-in-human use of cyanoacrylate adhesive for treatment of saphenous vein incompetence. J Vasc Surg Venous Lymphat Disord 2017; 5:658-666. [DOI: 10.1016/j.jvsv.2017.03.016] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 03/22/2017] [Indexed: 12/14/2022]
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Evidence summary of combined saphenous ablation and treatment of varicosities versus staged phlebectomy. J Vasc Surg Venous Lymphat Disord 2017; 5:134-137. [DOI: 10.1016/j.jvsv.2016.07.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 07/28/2016] [Indexed: 11/19/2022]
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Lane T, Bootun R, Dharmarajah B, Lim CS, Najem M, Renton S, Sritharan K, Davies AH. A multi-centre randomised controlled trial comparing radiofrequency and mechanical occlusion chemically assisted ablation of varicose veins - Final results of the Venefit versus Clarivein for varicose veins trial. Phlebology 2016; 32:89-98. [PMID: 27221810 DOI: 10.1177/0268355516651026] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Endovenous thermal ablation has revolutionised varicose vein treatment. New non-thermal techniques such as mechanical occlusion chemically assisted endovenous ablation (MOCA) allow treatment of entire trunks with single anaesthetic injections. Previous non-randomised work has shown reduced pain post-operatively with MOCA. This study presents a multi-centre randomised controlled trial assessing the difference in pain during truncal ablation using MOCA and radiofrequency endovenous ablation (RFA) with six months' follow-up. Methods Patients undergoing local anaesthetic endovenous ablation for primary varicose veins were randomised to either MOCA or RFA. Pain scores using Visual Analogue Scale and number scale (0-10) during truncal ablation were recorded. Adjunctive procedures were completed subsequently. Pain after phlebectomy was not assessed. Patients were reviewed at one and six months with clinical scores, quality of life scores and duplex ultrasound assessment of the treated leg. Results A total of 170 patients were recruited over a 21-month period from 240 screened. Patients in the MOCA group experienced significantly less maximum pain during the procedure by Visual Analogue Scale (MOCA median 15 mm (interquartile range 7-36 mm) versus RFA 34 mm (interquartile range 16-53 mm), p = 0.003) and number scale (MOCA median 3 (interquartile range 1-5) versus RFA 4 mm (interquartile range 3-6.5), p = 0.002). ' Average' pain scores were also significantly less in the MOCA group; 74% underwent simultaneous phlebectomy. Occlusion rates, clinical severity scores, disease specific and generic quality of life scores were similar between groups at one and six months. There were two deep vein thromboses, one in each group. Conclusion Pain secondary to truncal ablation is less painful with MOCA than RFA with similar short-term technical, quality of life and safety outcomes.
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Affiliation(s)
- Tristan Lane
- 1 Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK.,2 Department of Vascular Surgery, Imperial College Healthcare NHS Trust, London, UK.,3 Department of Vascular Surgery, London North West Hospitals NHS Trust, London, UK
| | - Roshan Bootun
- 1 Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK.,2 Department of Vascular Surgery, Imperial College Healthcare NHS Trust, London, UK
| | - Brahman Dharmarajah
- 1 Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK.,2 Department of Vascular Surgery, Imperial College Healthcare NHS Trust, London, UK.,3 Department of Vascular Surgery, London North West Hospitals NHS Trust, London, UK
| | - Chung S Lim
- 1 Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK.,2 Department of Vascular Surgery, Imperial College Healthcare NHS Trust, London, UK.,3 Department of Vascular Surgery, London North West Hospitals NHS Trust, London, UK
| | - Mojahid Najem
- 3 Department of Vascular Surgery, London North West Hospitals NHS Trust, London, UK
| | - Sophie Renton
- 3 Department of Vascular Surgery, London North West Hospitals NHS Trust, London, UK
| | - Kaji Sritharan
- 1 Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK.,2 Department of Vascular Surgery, Imperial College Healthcare NHS Trust, London, UK
| | - Alun H Davies
- 1 Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK.,2 Department of Vascular Surgery, Imperial College Healthcare NHS Trust, London, UK
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El-Sheikha J, Carradice D, Nandhra S, Leung C, Smith GE, Wallace T, Campbell B, Chetter IC. A systematic review of the compression regimes used in randomised clinical trials following endovenous ablation. Phlebology 2016; 32:256-271. [DOI: 10.1177/0268355516648497] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives There is insufficient evidence to inform guidelines on the optimal compression strategy following ablation for varicose veins. This study aimed to identify the practice of key opinion leaders performing randomised clinical trials involving endovenous ablation. Method A systematic review of MEDLINE/EMBASE/CENTRAL was performed identifying the compression strategies used in randomised clinical trials where at least one comparator arm underwent endovenous ablation. Results Thirty-four randomised clinical trials were identified. At least 14 different compression products were used, with at least 6 different pressures in 7 different regimes with durations from 2 to 84 days. There was no evidence of any convergence of practice over time. Conclusions A lack of evidence as to the optimal strategy for compression has resulted in a marked variation in clinical practice. There is no suggestion that this variation is becoming less over time indicating that experience is not helping to form a consensus and, therefore, further research is required.
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Affiliation(s)
- Joseph El-Sheikha
- Hull York Medical School, Academic Vascular Surgery Unit, Hull Royal Infirmary, UK
| | - Daniel Carradice
- Hull York Medical School, Academic Vascular Surgery Unit, Hull Royal Infirmary, UK
| | - Sandip Nandhra
- Hull York Medical School, Academic Vascular Surgery Unit, Hull Royal Infirmary, UK
| | - Clement Leung
- Hull York Medical School, Academic Vascular Surgery Unit, Hull Royal Infirmary, UK
| | - George E Smith
- Hull York Medical School, Academic Vascular Surgery Unit, Hull Royal Infirmary, UK
| | - Tom Wallace
- Hull York Medical School, Academic Vascular Surgery Unit, Hull Royal Infirmary, UK
| | - Bruce Campbell
- Royal Devon and Exeter Hospital and University of Exeter Medical School, Exeter, UK
| | - Ian C Chetter
- Hull York Medical School, Academic Vascular Surgery Unit, Hull Royal Infirmary, UK
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Brittenden J, Cotton SC, Elders A, Tassie E, Scotland G, Ramsay CR, Norrie J, Burr J, Francis J, Wileman S, Campbell B, Bachoo P, Chetter I, Gough M, Earnshaw J, Lees T, Scott J, Baker SA, MacLennan G, Prior M, Bolsover D, Campbell MK. Clinical effectiveness and cost-effectiveness of foam sclerotherapy, endovenous laser ablation and surgery for varicose veins: results from the Comparison of LAser, Surgery and foam Sclerotherapy (CLASS) randomised controlled trial. Health Technol Assess 2015; 19:1-342. [PMID: 25858333 DOI: 10.3310/hta19270] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Foam sclerotherapy (foam) and endovenous laser ablation (EVLA) have emerged as alternative treatments to surgery for patients with varicose veins, but uncertainty exists regarding their effectiveness in the medium to longer term. OBJECTIVES To assess the clinical effectiveness and cost-effectiveness of foam, EVLA and surgery for the treatment of varicose veins. DESIGN A parallel-group randomised controlled trial (RCT) without blinding, and economic modelling evaluation. SETTING Eleven UK specialist vascular centres. PARTICIPANTS Seven hundred and ninety-eight patients with primary varicose veins (foam, n = 292; surgery, n = 294; EVLA, n = 212). INTERVENTIONS Patients were randomised between all three treatment options (eight centres) or between foam and surgery (three centres). PRIMARY OUTCOME MEASURES Disease-specific [Aberdeen Varicose Vein Questionnaire (AVVQ)] and generic [European Quality of Life-5 Dimensions (EQ-5D), Short Form questionnaire-36 items (SF-36) physical and mental component scores] quality of life (QoL) at 6 months. Cost-effectiveness as cost per quality-adjusted life-year (QALY) gained. SECONDARY OUTCOME MEASURES Quality of life at 6 weeks; residual varicose veins; Venous Clinical Severity Score (VCSS); complication rates; return to normal activity; truncal vein ablation rates; and costs. RESULTS The results appear generalisable in that participants' baseline characteristics (apart from a lower-than-expected proportion of females) and post-treatment improvement in outcomes were comparable with those in other RCTs. The health gain achieved in the AVVQ with foam was significantly lower than with surgery at 6 months [effect size -1.74, 95% confidence interval (CI) -2.97 to -0.50; p = 0.006], but was similar to that achieved with EVLA. The health gain in SF-36 mental component score for foam was worse than that for EVLA (effect size 1.54, 95% CI 0.01 to 3.06; p = 0.048) but similar to that for surgery. There were no differences in EQ-5D or SF-36 component scores in the surgery versus foam or surgery versus EVLA comparisons at 6 months. The trial-based cost-effectiveness analysis showed that, at 6 months, foam had the highest probability of being considered cost-effective at a ceiling willingness-to-pay ratio of £20,000 per QALY. EVLA was found to cost £26,107 per QALY gained versus foam, and was less costly and generated slightly more QALYs than surgery. Markov modelling using trial costs and the limited recurrence data available suggested that, at 5 years, EVLA had the highest probability (≈ 79%) of being cost-effective at conventional thresholds, followed by foam (≈ 17%) and surgery (≈ 5%). With regard to secondary outcomes, health gains at 6 weeks (p < 0.005) were greater for EVLA than for foam (EQ-5D, p = 0.004). There were fewer procedural complications in the EVLA group (1%) than after foam (7%) and surgery (8%) (p < 0.001). Participants returned to a wide range of behaviours more quickly following foam or EVLA than following surgery (p < 0.05). There were no differences in VCSS between the three treatments. Truncal ablation rates were higher for surgery (p < 0.001) and EVLA (p < 0.001) than for foam, and were similar for surgery and EVLA. CONCLUSIONS Considerations of both the 6-month clinical outcomes and the estimated 5-year cost-effectiveness suggest that EVLA should be considered as the treatment of choice for suitable patients. FUTURE WORK Five-year trial results are currently being evaluated to compare the cost-effectiveness of foam, surgery and EVLA, and to determine the recurrence rates following each treatment. This trial has highlighted the need for long-term outcome data from RCTs on QoL, recurrence rates and costs for foam sclerotherapy and other endovenous techniques compared against each other and against surgery. TRIAL REGISTRATION Current Controlled Trials ISRCTN51995477. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 27. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Julie Brittenden
- Division of Applied Medicine, University of Aberdeen, Aberdeen, UK
| | | | - Andrew Elders
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Emma Tassie
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graham Scotland
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Craig R Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Jennifer Burr
- School of Medicine, University of St Andrews, St Andrews, UK
| | - Jill Francis
- School of Health Sciences, City University London, London, UK
| | - Samantha Wileman
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Bruce Campbell
- Department of Vascular Surgery, Royal Devon and Exeter Hospital (Wonford), Exeter, UK
| | - Paul Bachoo
- Division of Applied Medicine, University of Aberdeen, Aberdeen, UK
| | - Ian Chetter
- Department of Vascular Surgery, Hull Royal Infirmary, Hull, UK
| | - Michael Gough
- Vascular Surgery, St James University Hospital, Leeds, UK
| | | | - Tim Lees
- Vascular Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - Julian Scott
- Vascular Surgery, St James University Hospital, Leeds, UK
| | - Sara A Baker
- Vascular Surgical Unit, Royal Bournemouth Hospital, Bournemouth, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Maria Prior
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Denise Bolsover
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Marsden G, Perry M, Bradbury A, Hickey N, Kelley K, Trender H, Wonderling D, Davies A. A Cost-effectiveness Analysis of Surgery, Endothermal Ablation, Ultrasound-guided Foam Sclerotherapy and Compression Stockings for Symptomatic Varicose Veins. Eur J Vasc Endovasc Surg 2015; 50:794-801. [DOI: 10.1016/j.ejvs.2015.07.034] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 07/08/2015] [Indexed: 10/23/2022]
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Gaspar RJ, Castro AN, Simões MDJ, Plapler H. Real time echo-guided endolaser for thermal ablation without perivenous tumescence. J Vasc Bras 2015. [DOI: 10.1590/1677-5449.07214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abstract Background There is no consensus in the medical literature on the ideal procedure for endovenous laser application. Objective To assess the safety and efficacy of real time echo-guided endovenous laser for thermal ablation of great saphenous vein (GSV) incompetence, without perivenous tumescence. Methods Thirty-four limbs of patients with CEAP clinical scores of 2 to 6 and bilateral incompetence of the saphenofemoral junction (SFJ) and GSV, confirmed by Echo-Doppler, underwent endovenous laser therapy and were followed for 1 year. Laser ablation was performed using a 600 µ bare optical fiber introduced endovenously close to the malleolus along the full extent of the GSV in an anterograde direction, using a standardized echo-Doppler-guided AND? 15 watt continuous mode 980 nm diode laser with real-time monitoring of thermal ablation of the whole target vein. Adverse effects and complications were recorded. Results Hyperesthesia, cellulitis, and fibrous cord, all transitory, developed in 2.9% of the 34 limbs treated; 8.8% developed hypoesthesia in the perimalleolar region, which was transitory and had no clinical consequences; there were no cases of deep venous thrombosis. Immediate occlusion was achieved in 100% of the 34 saphenous veins that underwent photocoagulation, although one exhibited recanalization without reflux at 1-month follow-up. After 6 months and 1 year, occlusion was 100% according to echo-Doppler findings. Conclusions Real-time echo-guided 980 nm endovenous laser ablation without perivenous tumescence provided controlled thermal ablation with safe, effective, immediate and medium-term GSV occlusion and can therefore be recommended as a method for the treatment of chronic venous disease.
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Affiliation(s)
- Ricardo José Gaspar
- Universidade Federal de São Paulo, Brazil; Sociedade Brasileira de Angiologia e Cirurgia Vascular, Brazil; Instituto Vascular Ricardo Gaspar, Brazil
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Obi AT, Reames BN, Rook TJ, Mouch SO, Zarinsefat A, Stabler C, Rectenwald JE, Coleman DM, Wakefield TW. Outcomes associated with ablation compared to combined ablation and transilluminated powered phlebectomy in the treatment of venous varicosities. Phlebology 2015; 31:618-24. [PMID: 26376824 DOI: 10.1177/0268355515604257] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with painful varicose veins and venous insufficiency can be treated by eliminating axial reflux only or by eliminating axial reflux plus phlebectomy with transilluminated powered phlebectomy. This study was undertaken with the aim of determining and improving signs and symptoms of venous disease (measured by venous clinical severity score) and complications (by routine surveillance ultrasound and long-term post-operative follow up) for each treatment strategy. METHODS We performed a retrospective evaluation of prospectively collected data from 979 limbs undergoing procedures for significant varicose veins and venous insufficiency from March 2008 until June 2014 performed at a single tertiary referral hospital. Patient demographics, Clinical Etiology Anatomy and Pathophysiology classification, venous clinical severity scores pre- and post-procedure, treatment chosen, and peri-operative complications were collected; descriptive statistics were calculated and unadjusted surgical outcomes for patients stratified by the procedure performed. Multivariable logistic regression was used to evaluate the relationship between procedure type and thrombotic complications after adjusting for patient characteristics, severity of disease, pre-operative anticoagulation, and post-operative compression. RESULT Venous clinical severity scores improved more with radiofrequency ablation + transilluminated powered phlebectomy as compared to radiofrequency ablation alone (3.8 ± 3.4 vs. 3.2 ± 3.1, p = 0.018). Regarding deep venous thrombosis, there was no significant difference between radiofrequency ablation + transilluminated powered phlebectomy vs. radiofrequency ablation alone. There was no statistical difference in asymptomatic endovenous heat-induced thrombosis or infection, although there were slightly more hematomas and cases of asymptomatic superficial thrombophlebitis with combined therapy. On multivariable analysis, only procedure type predicted thrombotic complications. CONCLUSION Ablation of axial reflux plus transilluminated powered phlebectomy produces improved outcomes as measured by venous clinical severity score, with slight increases in minor post-operative complications and should be strongly considered as initial therapy when patients present with significant symptomatic varicose veins and superficial venous insufficiency. Implementation of a standardized thromboprophylaxis protocol with individual risk assessment results in few significant thrombotic complications amongst high-risk patients, thus potentially obviating the need for routine post-operative duplex.
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Abstract
OBJECTIVE A randomized clinical trial assessing the difference in quality of life and clinical outcomes between delayed and simultaneous phlebectomies in the context of endovenous truncal vein ablation. BACKGROUND Endovenous ablation has replaced open surgery as the treatment of choice for truncal varicose veins. Timing of varicosity treatment is controversial with delayed and simultaneous pathways having studies advocating their benefits. A previous small randomized study has shown improved outcomes for simultaneous treatment. METHODS Patients undergoing local anesthetic endovenous thermal ablation were randomized to either simultaneous phlebectomy or delayed varicosity treatment. Patients were reviewed at 6 weeks, 6 months, and 1 year with clinical and quality of life scores completed, and were assessed at 6 weeks for need for further varicosity intervention, which was completed with either ultrasound-guided foam sclerotherapy or local anesthetic phlebectomy. Duplex ultrasound assessment of the treated trunk was completed at 6 months. RESULTS 101 patients were successfully recruited and treated out of 221 suitable patients from a screened population of 393. Patients in the simultaneous group (n = 51) showed a significantly improved Venous Clinical Severity Score at all time points, 36% of the delayed group required further treatment compared with 2% of the simultaneous group (P < 0.001). There were no deep vein thromboses, with 1 superfificial venous thrombosis in each group. CONCLUSIONS Combined endovenous ablation and phlebectomy delivers improved clinical outcomes and a reduced need for further procedures, as well as early quality of life improvements.
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Wittens C, Davies AH, Bækgaard N, Broholm R, Cavezzi A, Chastanet S, de Wolf M, Eggen C, Giannoukas A, Gohel M, Kakkos S, Lawson J, Noppeney T, Onida S, Pittaluga P, Thomis S, Toonder I, Vuylsteke M, Kolh P, de Borst GJ, Chakfé N, Debus S, Hinchliffe R, Koncar I, Lindholt J, de Ceniga MV, Vermassen F, Verzini F, De Maeseneer MG, Blomgren L, Hartung O, Kalodiki E, Korten E, Lugli M, Naylor R, Nicolini P, Rosales A. Editor's Choice - Management of Chronic Venous Disease: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2015; 49:678-737. [PMID: 25920631 DOI: 10.1016/j.ejvs.2015.02.007] [Citation(s) in RCA: 501] [Impact Index Per Article: 55.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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El-Sheikha J. A multilevel regression of patient-reported outcome measures after varicose vein treatment in England. Phlebology 2015; 31:421-9. [PMID: 25883246 DOI: 10.1177/0268355515580233] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The relationship between patient and hospital characteristics and their influence on quality of life (QoL) variance following varicose vein treatment is little understood. Whilst Patient-reported outcome measures (PROMs) can record postoperative outcomes, the actual comparison of PROMs between hospitals can be misleading when the clustered nature of varicose vein care is overlooked. Multilevel models can accommodate hierarchical data and therefore can provide a more accurate reflection of the relationship between patients and hospitals when investigating postoperative outcomes. METHODS A multilevel model of PROMs was developed to analyse the relationship of patient characteristics (gender, age), postoperative outcomes (complications, postoperative satisfaction, treatment success) and hospital type (operative volume and if private or NHS institution) with the change in Aberdeen Varicose Vein Score (AVVQ) six months after varicose vein treatment. RESULTS Between April 2010 and July 2014, some 24,460 PROMs from 162 hospitals were analysed. Whilst the majority of variance in AVVQ improvement was due to patient factors, a small but statistically significant amount of variance was detected due to differences between hospitals. Multilevel regression revealed that females saw a greater improvement in AVVQ, as did those who reported greater levels of treatment success and satisfaction. Patient age, complications, intervention, readmission, hospital size and hospital type were not significantly associated with AVVQ improvement. CONCLUSION Although QoL is intrinsically tied to an individual, hospitals can provide a small but potentially important benefit in AVVQ improvement following vein treatment. A patient-centred approach is therefore recommended to optimise patient outcomes.
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Affiliation(s)
- Joseph El-Sheikha
- Academic Vascular Surgery Unit, Hull Royal Infirmary, Hull, Humberside, UK
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El-Sheikha J, Nandhra S, Carradice D, Acey C, Smith GE, Campbell B, Chetter IC. Compression regimes after endovenous ablation for superficial venous insufficiency – A survey of members of the Vascular Society of Great Britain and Ireland. Phlebology 2015; 31:16-22. [DOI: 10.1177/0268355514567732] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction The optimal compression regime following ultrasound guided foam sclerotherapy (UGFS), radiofrequency ablation (RFA) and endovenous laser ablation (EVLA) for varicose veins is not known. The aim of this study was to document current practice. Methods Postal questionnaire sent to 348 consultant members of the Vascular Society of Great Britain and Ireland. Results Valid replies were received from 41% ( n = 141) surgeons representing at least 68 (61%) vascular units. UGFS was used by 74% surgeons, RFA by 70% and EVLA by 32%, but fewer patients received UGFS (median 30) annually, than endothermal treatment (median 50) – P = 0.019. All surgeons prescribed compression: following UGFS for median seven days (range two days to three months) and after endothermal ablation for 10 days (range two days to six weeks) – P = 0.298. Seven different combinations of bandages, pads and compression stockings were reported following UGFS and four after endothermal ablation. Some surgeons advised changing from bandages to stockings from five days (range 1–14) after UGFS. Following endothermal ablation, 71% used bandages only, followed by compression stockings after two days (range 1–14). The majority of surgeons (87%) also treated varicose tributaries: 65% used phlebectomy, the majority (65%) synchronously with endothermal ablation. Concordance of compression regimes between surgeons within vascular units was uncommon. Only seven units using UGFS and six units using endothermal ablation had consistent compression regimes. Conclusion Compression regimes after treatments for varicose veins vary significantly: more evidence is needed to guide practice.
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Affiliation(s)
- J El-Sheikha
- Academic Vascular Surgery Unit, Hull York Medical School/Hull University, Hull, UK
| | - S Nandhra
- Academic Vascular Surgery Unit, Hull York Medical School/Hull University, Hull, UK
| | - D Carradice
- Academic Vascular Surgery Unit, Hull York Medical School/Hull University, Hull, UK
| | - C Acey
- Academic Vascular Surgery Unit, Hull York Medical School/Hull University, Hull, UK
| | - GE Smith
- Academic Vascular Surgery Unit, Hull York Medical School/Hull University, Hull, UK
| | - B Campbell
- Royal Devon and Exeter Hospital and University of Exeter Medical School, Exeter, UK
| | - IC Chetter
- Academic Vascular Surgery Unit, Hull York Medical School/Hull University, Hull, UK
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Joh JH, Kim WS, Jung IM, Park KH, Lee T, Kang JM. Consensus for the Treatment of Varicose Vein with Radiofrequency Ablation. Vasc Specialist Int 2014. [PMID: 26217628 PMCID: PMC4480318 DOI: 10.5758/vsi.2014.30.4.105] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
The objective of this paper is to introduce the schematic protocol of radiofrequency (RF) ablation for the treatment of varicose veins. Indication: anatomic or pathophysiologic indication includes venous diameter within 2–20 mm, reflux time ≥0.5 seconds and distance from the skin ≥5 mm or subfascial location. Access: it is recommended to access at or above the knee joint for great saphenous vein and above the mid-calf for small saphenous vein. Catheter placement: the catheter tip should be placed 2.0 cm inferior to the saphenofemoral or saphenopopliteal junction. Endovenous heat-induced thrombosis ≥class III should be treated with low-molecular weight heparin. Tumescent solution: the composition of solution can be variable (e.g., 2% lidocaine 20 mL+500 mL normal saline+bicarbonate 2.5 mL with/without epinephrine). Infiltration can be done from each direction. Ablation: two cycles’ ablation for the first proximal segment of saphenous vein and the segment with the incompetent perforators is recommended. The other segments should be ablated one time. During RF energy delivery, it is recommended to apply external compression. Concomitant procedure: It is recommended to do simultaneously ambulatory phlebectomy. For sclerotherapy, it is recommended to defer at least 2 weeks. Post-procedural management: post-procedural ambulation is encouraged to reduce the thrombotic complications. Compression stocking should be applied for at least 7 days. Minor daily activity is not limited, but strenuous activities should be avoided for 2 weeks. It is suggested to take showers after 24 hours and tub baths, swimming, or soaking in water after 2 weeks.
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Affiliation(s)
- Jin Hyun Joh
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Seoul
| | - Woo-Shik Kim
- Department of Cardiothoracic Surgery, National Medical Center, Seoul
| | - In Mok Jung
- Department of Surgery, SVU-SMG Boramae Medical Center, Seoul
| | - Ki-Hyuk Park
- Department of Surgery, Daegu Catholic University Medical Center, Daegu
| | - Taeseung Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam
| | - Jin Mo Kang
- Department of Vascular Surgery, Gachon University Gil Medical Center, Incheon, Korea
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Health-related quality-of-life scales specific for chronic venous disorders of the lower limbs. J Vasc Surg Venous Lymphat Disord 2014; 3:219-27.e1-3. [PMID: 26993844 DOI: 10.1016/j.jvsv.2014.08.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 08/23/2014] [Indexed: 11/20/2022]
Abstract
OBJECTIVE We conducted a systematic review of the literature about quality-of-life (QOL) scales in chronic venous disorders (CVDs) comprising leg ulcers to identify the respective advantages and deficits of existing tools. METHODS A research protocol was built following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and the PICO (population, intervention, comparator, and outcome) criteria. The following databases were screened: MEDLINE, SCOPUS, EMBASE, CINHAL, and Cochrane. Psychometric and linguistic validation studies in English were included, as were clinical trials that have used QOL scales in CVDs. The data search was up to date as of October 31, 2013. RESULTS Inclusion criteria were met in 103 of the 511 recorded references, in which 10 scales were identified: two for the full spectrum of CVDs, three for patients with CVDs without leg ulceration, four for leg ulcers, and one exclusively for patients with varicose veins. Among them, the ChronIc Venous Insufficiency Questionnaire (CIVIQ), Aberdeen Varicose Vein Questionnaire (AVVQ), and VEnous INsufficiency Epidemiological and Economic Study on Quality of Life (VEINES-QOL) scales were the most highly used according to the literature, and CIVIQ and VEINES-QOL were the most extensively validated scales and had the longest iterative validation process. A total of 31 psychometric and linguistic validations of the 10 QOL scales and 66 clinical trials that have used these scales were identified. The validation studies were based on acceptability, content validity, construct validity, reliability, and responsiveness. The clinical trials were composed of 25 randomized controlled trials and 41 observational studies. Only the randomized controlled trials are considered in the present article. CONCLUSIONS This systematic review confirmed that CVDs have an important effect on QOL. The majority of the studies addressed the application rather than the validation of the 10 identified scales. Two scales, CIVIQ and VEINES-QOL, emerged as being thoroughly validated instruments, although factorial stability was not demonstrated for the VEINES-QOL. Our findings confirm a paucity of validation studies.
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Vun SV, Rashid ST, Blest NC, Spark JI. Lower pain and faster treatment with mechanico-chemical endovenous ablation using ClariVein®. Phlebology 2014; 30:688-92. [DOI: 10.1177/0268355514553693] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives To assess the efficacy of the ClariVein® system of mechanico-chemical ablation of superficial vein incompetence. Method ClariVein® treatment uses a micropuncture technique and a 4-Fr sheath to allow a catheter to be placed 1.5 cm from the saphenofemoral junction. Unlike laser (endovenous laser treatment (EVLT)) or radiofrequency ablation (RFA), no tumescence is required. The technique depends on a wire rotating at 3500 r/min causing endothelial damage whilst liquid sclerosant (1.5% sodium tetradecyl sulphate) is infused. The wire is pulled back whilst continuously infusing sclerosant along the target vessel’s length. Initially, 8 mL of dilute sclerosant was used, but this was subsequently increased to 12 mL. No routine post-op analgesia was prescribed and specifically no non-steroidal anti-inflammatory drugs. Procedure times and pain scores (visual analogue scale) were recorded and compared to EVLT and RFA. All patients were invited for duplex post-procedure. Results Fifty-one great saphenous veins and six short saphenous veins were treated and followed up with duplex in the 10 months from July 2011. No major complications or deep vein thrombosis were reported. Duplex showed patency of three treated veins with two more veins having only a short length of occlusion, giving a technical success rate of 91%. Comparison with 50 RFA and 40 EVLT showed procedure times were significantly less for ClariVein® (23.0 ± 8.3 min) than for either RFA (37.9 ± 8.3 min) or EVLT (44.1 ± 11.4 min). Median pain scores were significantly lower for ClariVein® than RFA and EVLT (1 vs. 5 vs. 6, p < 0.01). Conclusion Mechanochemical ablation with the ClariVein® system is safe and effective. After some initial failures, the use of 12 mL of dilute sclerosant results in a very high technical success rate >90% which accords with the limited published literature. Procedure times and pain scores are significantly better than for RFA and EVLT. We await the long-term clinical outcomes.
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Affiliation(s)
- SV Vun
- Department of Vascular Surgery, Flinders Medical Centre, South Australia, Australia
- Department of Vascular Surgery, Flinders University, South Australia, Australia
| | - ST Rashid
- Department of Vascular Surgery, Flinders Medical Centre, South Australia, Australia
| | - NC Blest
- Department of Vascular Surgery, Flinders Medical Centre, South Australia, Australia
| | - JI Spark
- Department of Vascular Surgery, Flinders Medical Centre, South Australia, Australia
- Department of Vascular Surgery, Flinders University, South Australia, Australia
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Brittenden J, Cotton SC, Elders A, Ramsay CR, Norrie J, Burr J, Campbell B, Bachoo P, Chetter I, Gough M, Earnshaw J, Lees T, Scott J, Baker SA, Francis J, Tassie E, Scotland G, Wileman S, Campbell MK. A randomized trial comparing treatments for varicose veins. N Engl J Med 2014; 371:1218-27. [PMID: 25251616 DOI: 10.1056/nejmoa1400781] [Citation(s) in RCA: 143] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Ultrasound-guided foam sclerotherapy and endovenous laser ablation are widely used alternatives to surgery for the treatment of varicose veins, but their comparative effectiveness and safety remain uncertain. METHODS In a randomized trial involving 798 participants with primary varicose veins at 11 centers in the United Kingdom, we compared the outcomes of foam, laser, and surgical treatments. Primary outcomes at 6 months were disease-specific quality of life and generic quality of life, as measured on several scales. Secondary outcomes included complications and measures of clinical success. RESULTS After adjustment for baseline scores and other covariates, the mean disease-specific quality of life was slightly worse after treatment with foam than after surgery (P=0.006) but was similar in the laser and surgery groups. There were no significant differences between the surgery group and the foam or the laser group in measures of generic quality of life. The frequency of procedural complications was similar in the foam group (6%) and the surgery group (7%) but was lower in the laser group (1%) than in the surgery group (P<0.001); the frequency of serious adverse events (approximately 3%) was similar among the groups. Measures of clinical success were similar among the groups, but successful ablation of the main trunks of the saphenous vein was less common in the foam group than in the surgery group (P<0.001). CONCLUSIONS Quality-of-life measures were generally similar among the study groups, with the exception of a slightly worse disease-specific quality of life in the foam group than in the surgery group. All treatments had similar clinical efficacy, but complications were less frequent after laser treatment and ablation rates were lower after foam treatment. (Funded by the Health Technology Assessment Programme of the National Institute for Health Research; Current Controlled Trials number, ISRCTN51995477.).
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Affiliation(s)
- Julie Brittenden
- From the Division of Applied Medicine (J. Brittenden), the Health Services Research Unit (S.C.C., A.E., C.R.R., J.N., G.S., S.W., M.K.C.), and the Health Economics Research Unit (E.T., G.S.), University of Aberdeen, and the Department of Vascular Surgery, NHS Grampian, Aberdeen Royal Infirmary (P.B.), Aberdeen; the School of Medicine, Medical and Biological Sciences, University of St. Andrews, St. Andrews (J. Burr); the Department of Vascular Surgery, Royal Devon and Exeter Hospital, Exeter (B.C.); the Department of Vascular Surgery, Hull Royal Infirmary, Hull (I.C.); the School of Surgery, University of Leeds (M.G.), and Vascular Surgery, St. James University Hospital (J.S.), Leeds; Vascular Surgery, Gloucestershire Royal Hospital, Gloucester (J.E.); Vascular Surgery, Freeman Hospital, Newcastle upon Tyne (T.L.); the Vascular Surgical Unit, Royal Bournemouth Hospital, Bournemouth (S.A.B.); and the School of Health Sciences, City University London, London (J.F.) - all in the United Kingdom
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Lane TRA, Onida S, Gohel MS, Franklin IJ, Davies AH. A systematic review and meta-analysis on the role of varicosity treatment in the context of truncal vein ablation. Phlebology 2014; 30:516-24. [DOI: 10.1177/0268355514548473] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background With the advent of endovenous truncal ablation under local anaesthetic for the treatment of varicose veins, the fate of varicosed tributaries has become controversial, with centres offering different timings of treatment, if offered at all. This study aims to review the literature assessing delayed and simultaneous varicosity treatment during truncal ablation. Methods Randomised trials and cohort studies concerning varicosity treatment timing were identified through a systematic literature search. Requirements for further treatment, quality of life and rate of venous thrombotic events were assessed for meta-analysis. Results Four studies were identified assessing need for further varicosity procedure, with no significant difference seen between simultaneous or delayed treatment ( p = 0.339). Two studies assessed quality of life, with simultaneous treatment providing significantly improved outcomes at six weeks ( p = 0.029) but not at 12 weeks ( p = 0.283). Studies examining venous thrombotic events showed no difference in venous thromboembolism rate between simultaneous or delayed treatment approaches ( p = 0.078). Conclusion The evidence base regarding timing of varicosity treatment is sparse; however, it does show that simultaneous treatment of varicosities leads to early gains in quality of life, with a non-significant trend for fewer further procedures but more venous thrombotic events.
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Affiliation(s)
- TRA Lane
- Academic Section of Vascular Surgery, Imperial College London, London, UK
| | - S Onida
- Academic Section of Vascular Surgery, Imperial College London, London, UK
| | - MS Gohel
- Academic Section of Vascular Surgery, Imperial College London, London, UK
- Department of Vascular Surgery, Cambridge Universities NHS Foundation Trust, Cambridge, UK
| | - IJ Franklin
- Academic Section of Vascular Surgery, Imperial College London, London, UK
- London Vascular Clinic, London, UK
| | - AH Davies
- Academic Section of Vascular Surgery, Imperial College London, London, UK
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Nesbitt C, Bedenis R, Bhattacharya V, Stansby G. Endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus open surgery for great saphenous vein varices. Cochrane Database Syst Rev 2014:CD005624. [PMID: 25075589 DOI: 10.1002/14651858.cd005624.pub3] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Minimally invasive techniques to treat great saphenous varicose veins include ultrasound-guided foam sclerotherapy (UGFS), radiofrequency ablation (RFA) and endovenous laser therapy (EVLT). Compared with flush saphenofemoral ligation with stripping, also referred to as open surgery or high ligation and stripping (HL/S), proposed benefits include fewer complications, quicker return to work, improved quality of life (QoL) scores, reduced need for general anaesthesia and equivalent recurrence rates. This is an update of a review first published in 2011. OBJECTIVES To determine whether endovenous ablation (radiofrequency and laser) and foam sclerotherapy have any advantages or disadvantages in comparison with open surgical saphenofemoral ligation and stripping of great saphenous vein varices. SEARCH METHODS For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched January 2014) and CENTRAL (2013, Issue 12). Clinical trials databases were also searched for details of ongoing or unpublished studies. SELECTION CRITERIA All randomised controlled trials (RCTs) of UGFS, EVLT, RFA and HL/S were considered for inclusion. Primary outcomes were recurrent varicosities, recanalisation, neovascularisation, technical procedure failure, patient QoL scores and associated complications. DATA COLLECTION AND ANALYSIS CN and RB independently reviewed, assessed and selected trials which met the inclusion criteria. CN and RB extracted data and used the Cochrane Collaboration's tool for assessing risk of bias. CN and RB contacted trial authors to clarify details as needed. MAIN RESULTS For this update, eight additional studies were included making a total of 13 included studies with a combined total of 3081 randomised patients. Three studies compared UGFS with surgery, eight compared EVLT with surgery and five compared RFA with surgery (two studies had two or more comparisons with surgery). Study quality, evaluated through the six domains of risk of bias, was generally moderate for all included studies, however no study blinded participants, researchers and clinicians or outcome assessors. Also, nearly all included studies had other sources of bias. The overall quality of the evidence was moderate due to the variations in the reporting of results, which limited meaningful meta-analyses for the majority of proposed outcome measures. For the comparison UGFS versus surgery, the findings may have indicated no difference in the rate of recurrences in the surgical group when measured by clinicians, and no difference between the groups for symptomatic recurrence (odds ratio (OR) 1.74, 95% confidence interval (CI) 0.97 to 3.12; P = 0.06 and OR 1.28, 95% CI 0.66 to 2.49, respectively). Recanalisation and neovascularisation were only evaluated in a single study. Recanalisation at < 4 months had an OR of 0.66 (95% CI 0.20 to 2.12), recanalisation > 4 months an OR of 5.05 (95% CI 1.67 to 15.28) and for neovascularisation an OR of 0.05 (95% CI 0.00 to 0.94). There was no difference in the rate of technical failure between the two groups (OR 0.44, 95% CI 0.12 to 1.57). For EVLT versus surgery, there were no differences between the treatment groups for either clinician noted or symptomatic recurrence (OR 0.72, 95% CI 0.43 to 1.22; P = 0.22 and OR 0.87, 95% CI 0.47 to 1.62; P = 0.67, respectively). Both early and late recanalisation were no different between the two treatment groups (OR 1.05, 95% CI 0.09 to 12.77; P = 0.97 and OR 4.14, 95% CI 0.76 to 22.65; P = 0.10). Neovascularisation and technical failure were both statistically reduced in the laser treatment group (OR 0.05, 95% CI 0.01 to 0.22; P < 0.0001 and OR 0.29, 95% CI 0.14 to 0.60; P = 0.0009, respectively). Long-term (five-year) outcomes were evaluated in one study so no association could be derived,but it appeared that EVLT and surgery maintained similar findings. Comparing RFA versus surgery, there were no differences in clinician noted recurrence (OR 0.82, 95% CI 0.49 to 1.39; P = 0.47); symptomatic noted recurrence was only evaluated in a single study. There were also no differences between the treatment groups for recanalisation (early or late) (OR 0.68, 95% CI 0.01 to 81.18; P = 0.87 and OR 1.09, 95% CI 0.39 to 3.04; P = 0.87, respectively), neovascularisation (OR 0.31, 95% CI 0.06 to 1.65; P = 0.17) or technical failure (OR 0.82, 95% CI 0.07 to 10.10; P = 0.88).QoL scores, operative complications and pain were not amenable to meta-analysis, however quality of life generally increased similarly in all treatment groups and complications were generally low, especially major complications. Pain reporting varied greatly between the studies but in general pain was similar between the treatment groups. AUTHORS' CONCLUSIONS Currently available clinical trial evidence suggests that UGFS, EVLT and RFA are at least as effective as surgery in the treatment of great saphenous varicose veins. Due to large incompatibilities between trials and different time point measurements for outcomes, the evidence is lacking in robustness. Further randomised trials are needed, which should aim to report and analyse results in a congruent manner to facilitate future meta-analysis.
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Affiliation(s)
- Craig Nesbitt
- Sunderland Royal Hospital, Kayll Road, Sunderland, UK
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