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Kibrik P, Ali AB, Chait J, Arustamyan M, Khan H, Mazurovsky S, Alsheekh A, Marks N, Hingorani A, Ascher E. Value and limitations of postoperative duplex scans after endovenous thermal ablation. J Vasc Surg Venous Lymphat Disord 2024; 12:101672. [PMID: 37678668 DOI: 10.1016/j.jvsv.2023.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/25/2023] [Accepted: 06/29/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Endovenous thermal ablation (EVTA) of the lower extremity veins has risen to become the main treatment modality for symptomatic venous reflux disease. One of the main reported side effects of EVTA is recanalization. As of today, there is no clear protocol as to when follow-up duplex ultrasound scans should be performed. However, the standard for postoperative duplex after truncal ablation is within 1 week of the procedure. Our aim is to try to find whether there is a particular time period when postoperative duplex ultrasound scans should be performed to allow us to best diagnose recanalization. METHODS We retrospectively analyzed 9799 procedures in 3237 patients with chronic venous insufficiency owing to great, small, and anterior accessory saphenous vein insufficiency from 2012 to 2018. We excluded 466 perforator veins. All 9799 procedures were performed using EVTA in patients who failed to respond to conservative management initially. Postoperative duplex ultrasound scans were performed within 1 week (3-7 days postoperatively). We defined a successful obliteration as lack of color flow on postoperative scan. We defined symptomatic recanalization as presence of reflux on duplex ultrasound examination in the targeted vessel at follow-up with symptom recurrence. Follow-ups were performed every 3 months in the first year and every 6 months thereafter. RESULTS Patient ages ranged from 15 to 99 years. The median patient age at the time of the procedures was 63 years (interquartile range [IQR], 51-73 years). The median overall follow-up was 25 months (IQR, 4-56 months). The Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) class of all the procedures were: C1, 21; C2, 208; C3, 3585; C4, 4680; C5, 188; and C6, 1117. There were 145 redo procedures performed after symptomatic recanalization was diagnosed in patients. CEAP class of the redo patients were: C1, 0; C2, 2; C3, 49; C4, 70; C5, 5; and C6, 19. CONCLUSIONS Most patients underwent a redo procedure performed within the first year after the initial procedure. Conversely, there was great variability as to when redo procedures were performed. Because there is no defined pattern as to when these symptomatic occurrences arise, it may not be required to perform postoperative duplex ultrasound scans after EVTA routinely, but instead when a patient comes back with symptoms such as swelling.
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Affiliation(s)
| | | | - Jesse Chait
- Vascular Institute of New York, Brooklyn, NY
| | | | - Hason Khan
- Vascular Institute of New York, Brooklyn, NY
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Karnabatidis D, Papageorgiou C, Kitrou P, Spiliopoulos S. One-year duplex ultrasound-assessed closure outcomes of percutaneous endovenous microwave ablation for the treatment of varicose veins of the lower limbs. Vascular 2023; 31:1011-1016. [PMID: 35549952 DOI: 10.1177/17085381221099115] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE This study aims to investigate the safety and efficacy of a new device using microwave technology for the endovenous ablation of the great saphenous vein (GSV) causing symptomatic lower limb varicose veins (LLVV). MATERIALS AND METHODS This prospective, single-arm, single-center, cohort study investigated the safety and effectiveness of endovenous microwave ablation for the treatment of symptomatic LLVV. Enrollment period was set between January and December 2020. Primary safety endpoint was the occurrence of procedure-related complications and primary efficacy endpoint was anatomical success defined as the duplex ultrasound (DUS)-proven GSV occlusion at 1 year follow-up. Secondary endpoints included 1-year clinical success (CEAP classification improvement), repeat procedures rate due to GSV recanalization, and pain assessment at 24 h post treatment. RESULTS In total, 50 patients (42 female; mean age: 62 ± 12 years) with 64 limbs were treated. No procedure-related complications were noted. Technical success was 95.3% (61/64 GSVs), as three cases of GSV recanalization were detected. Clinical success was 100%, as in all cases symptoms improvement by at least one grade according to CEAP classification, was achieved. Mean CEAP grade significantly improved from 3.3 ± 0.72 (median: 3) at baseline to 1.8 ± 0.85 (median: 2) at 1-year (p < 0.0001). There were no repeat procedures due to GSC recanalization. The median 24-h VAS value was 2 (mean: 1.9 ± 1.4). CONCLUSIONS Endovenous microwave ablation was safe and effective for the treatment of varicose veins, achieving high 1-year GSV occlusion rates.
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Affiliation(s)
- Dimitris Karnabatidis
- Department of Interventional Radiology, School of Medicine, Patras University Hospital, Greece
| | - Christos Papageorgiou
- Department of Interventional Radiology, School of Medicine, Patras University Hospital, Greece
| | - Panagiotis Kitrou
- Department of Interventional Radiology, School of Medicine, Patras University Hospital, Greece
| | - Stavros Spiliopoulos
- Department of Radiology, Interventional Radiology Unit, School of Medicine, National and Kapodistrian University of Athens, Greece
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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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Fink C, Hartmann K, Mattausch T, Wenzel HC, Zollmann P, Veltman J, Weiler T, Lengfellner G, Müller L, Stücker M, Pannier F, Dietrich C, Uhlmann L, Hirsch T. Impact of a synchronous prophylactic treatment of the anterior accessory saphenous vein on the recurrent varicose vein rate in patients undergoing thermal ablation of an insufficient great saphenous vein (SYNCHRONOUS-Study): study protocol for a prospective, multicentre, controlled observational study. BMJ Open 2022; 12:e061530. [PMID: 35732403 PMCID: PMC9226876 DOI: 10.1136/bmjopen-2022-061530] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION To date, there are no prospective studies evaluating the prevention of recurrent veins by the simultaneous treatment of a sufficient anterior accessory saphenous vein (AASV) in patients undergoing endovenous laser ablation (EVLA) of an insufficient great saphenous vein (GSV). This study will provide important information about the impact of the AASV on the development of recurrent veins after EVLA of the GSV. Additionally, it will be clarified whether patients benefit from a preventive ablation of a sufficient AASV. METHODS AND ANALYSIS This is a multicentre, prospective, controlled, exploratory clinical study in 1150 patients with a medical indication for EVLA of a refluxing great saphenous vein. Patients will be enrolled into two study groups: in half of the patients EVLA will be performed on the insufficient GSV only. In the other half of the patients EVLA will be performed on the insufficient GSV and additionally on the sufficient AASV. Within seven study visits, patients will be followed-up over a time period of 5 years. Primary study endpoint is the recurrence rate; secondary endpoints include inter alia, complication rate, postoperative pain intensity, quality of life and patient satisfaction. ETHICS AND DISSEMINATION Before initiation of the study, the protocol was presented and approved by the independent ethics committee of the medical faculty of the University of Heidelberg (Ethics approval number S-596/2018). This study was prospectively registered at the German Clinical Trial Register (https://www.germanctr.de/). Research findings will be disseminated in a peer-reviewed journal and at relevant conferences. TRIAL REGISTRATION NUMBER German Clinical Trial Registry (DRKS00015486).
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Affiliation(s)
- Christine Fink
- Department of Dermatology, University Hospital Heidelberg, Heidelberg, Germany
| | | | | | | | | | | | | | | | - Lars Müller
- Department of Vascular Surgery, Dermatologikum Hamburg, Hamburg, Germany
| | - Markus Stücker
- Department of Dermatology, Ruhr-Universität Bochum, Bochum, Germany
| | | | - Carmen Dietrich
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
| | - Lorenz Uhlmann
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Tobias Hirsch
- Praxis für Innere Medizin und Gefäßkrankheiten, Venen Kompetenz-Zentrum, Halle (Saale), Germany
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Zhang YS, Chen PJ, Wan HL, Chen JH, Mei T, Wang WL, Lu YM. Reducing tumescent anesthetic injection pain by topical anesthesia pretreatment among patients undergoing endovenous radiofrequency ablation of varicose veins: Adouble-blind randomized controlled trial. Phlebology 2022; 37:529-534. [PMID: 35505452 DOI: 10.1177/02683555221092193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Tumescent anesthesia frequently causes the intraoperative and postoperative pain during radiofrequency ablation (RFA) of varicose veins. We have to find a way to reduce pain caused by these injections. This randomized controlled trial investigated the effectiveness of topical anesthesia pretreatment (TAP) on relieving needle puncture pain during administration of tumescent anesthesia among patients undergoing RFA of varicose veins. METHODS Eligible patients treated with RFA were recruited and randomized to either application of TAP with lidocaine-prilocaine cream (EMLA) or water-based cream (placebo). The primary outcome was patient described pain scores on the visual analogue scale (VAS) at different time points during the procedure. Secondary outcomes were technical success rate, complications, satisfaction level, expense, and extra analgesia use. RESULTS Sixty-two patients were randomized: 32 to EMLA and 30 to placebo. Both groups had comparable baseline demographics, CEAP classification, and Venous Clinical Severity Score (VCSS). Less tumescent anesthetic needle puncture pain was found in the EMLA group (22 ± 7 vs 42 ± 8, p < .01). Pain scores of other time points were equivalent. There was less pain in EMLA pretreated area compared to non-pretreated area in the same patient during needle puncture (22 ± 7 vs 45 ± 7, p < .01), and similar phenomena did not appear in the placebo group. There was no statistical difference in complications, satisfaction level, expense, and technical success between the two groups. And no extra analgesia was used in all patients. CONCLUSION We recommend the routine use of TAP to reduce the needle puncture pain during tumescent anesthesia in RFA of lower extremity varicose veins.
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Affiliation(s)
- Yuan-Su Zhang
- Department of Vascular Surgery, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
| | - Peng-Jie Chen
- Department of Vascular Surgery, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
| | - Hai-Lin Wan
- Department of Vascular Surgery, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
| | - Jin-Hui Chen
- Department of Vascular Surgery, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
| | - Tong Mei
- Department of Vascular Surgery, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
| | - Wei-Lin Wang
- Department of Vascular Surgery, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
| | - Yong-Ming Lu
- Department of Vascular Surgery, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, Zhejiang, China
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Eggen CAM, Alozai T, Pronk P, Mooij MC, Gaastra MTW, Ünlü Ç, Schreve MA, van Vlijmen CJ. Ten-year follow-up of a randomized controlled trial comparing saphenofemoral ligation and stripping of the great saphenous vein with endovenous laser ablation (980 nm) using local tumescent anesthesia. J Vasc Surg Venous Lymphat Disord 2022; 10:646-653.e1. [PMID: 34450354 DOI: 10.1016/j.jvsv.2021.08.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 08/05/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The long-term results of saphenofemoral ligation and stripping (SFL/S) were compared with 980-nm bare fiber endovenous laser ablation (EVLA) for the treatment of great saphenous vein (GSV) incompetence. METHODS This was a single-center, randomized, controlled trial with a follow-up time of 10 years. Patients with GSV incompetence were randomized to undergo SFL/S or EVLA under tumescent anesthesia. The primary outcome was recurrence of groin-related varicose veins seen on duplex ultrasound imaging and clinical examination. The secondary outcomes were (changes or improvement in) CEAP clinical class, venous symptoms, cosmetic results, quality of life, reinterventions, and complications. RESULTS Between June 2007 and December 2008, 122 patients (130 limbs) were included; of these, 68 limbs were treated with SFL/S and 62 limbs with EVLA. The 10-year estimated freedom from groin recurrence as seen on duplex ultrasound imaging was higher in the SFL/S group (73% vs 44% in the EVLA group; P = .002), and the same trend was seen for clinically evident recurrence (77% vs 58%, respectively; P = .034). Nine reinterventions (17%) were deemed necessary in the SFL/S group vs 18 (36%) in the EVLA group (P = .059). All reinterventions in the SFL/S group consisted of foam sclerotherapy. Reinterventions in the EVLA group included foam sclerotherapy (n = 5), crossectomy (n = 2), and endovenous procedures (n = 11). There was no significant differences in quality of life and relief of venous symptoms. Cosmetic appearance improved, with a better cosmetic rating in the SFL/S group compared with the EVLA group (P = .026). One patient in the SFL/S group had a persisting neurosensory deficit remaining at 10 years. CONCLUSIONS This study showed no clear long-term advantage of EVLA with a 980-nm wavelength and bare-tip fiber over high ligation and stripping of the GSV under local tumescent anesthesia.
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Affiliation(s)
- Céline A M Eggen
- Department of Phlebology, Skin and Vein Clinic Oosterwal, Alkmaar, The Netherlands.
| | - Tamana Alozai
- Department of Surgery, Northwest Clinics, Alkmaar, The Netherlands
| | - Pascal Pronk
- Department of Phlebology, Skin and Vein Clinic Oosterwal, Alkmaar, The Netherlands
| | - Michael C Mooij
- Department of Phlebology, Skin and Vein Clinic Oosterwal, Alkmaar, The Netherlands
| | - Menno T W Gaastra
- Department of Phlebology, Skin and Vein Clinic Oosterwal, Alkmaar, The Netherlands
| | - Çağdaş Ünlü
- Department of Surgery, Northwest Clinics, Alkmaar, The Netherlands
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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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Chaitidis N, Kokkinidis DG, Papadopoulou Z, Kyriazopoulou M, Schizas D, Bakoyiannis C. Treatment of chronic venous disorder: A comprehensive review. Dermatol Ther 2021; 35:e15238. [PMID: 34859549 DOI: 10.1111/dth.15238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 11/15/2021] [Accepted: 11/28/2021] [Indexed: 12/16/2022]
Abstract
Chronic venous disorder (CVD) is highly prevalent vascular disorder affecting up to 45% of the general population, with clinical manifestations ranging from teleangiectasias to venous leg ulcers (VLUs). We examined the currently available data in order to provide an updated, comprehensive review on treatment options of CVD. We searched MEDLINE, Cochrane, Scopus, EMBASE, ClinicalTrials, and OpenGrey databases for relevant articles in English published until November 2020. Compression treatment is the mainstay of conservative treatment. Pharmacological treatment can provide significant symptomatic relief and hence it should be considered as part of conservative treatment. Transcutaneous Lacer treatment (TCL) is a safe and effective alternative option to sclerotherapy for treatment of C1 stage. High ligation and stripping (HL/S), ultrasound-guided foam sclerotherapy (UGFS), endovenous thermal ablation (EVTA) systems and non thermal non tumescent ablation (NTNT) systems are safe and efficacious first-line options for treatment of saphenous insufficiency. Interventional treatment of co-existing incompetent perforator veins (IPVs) is not supported by contemporary evidence. Regarding deep venous insufficiency (DVI), treatment of symptomatic femoroiliocaval occlusive venous disease refractory to conservative treatment with percutaneous transluminal venoplasty stenting has produced encouraging results.
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Affiliation(s)
| | - Damianos G Kokkinidis
- Section of Cardiovascular Medicine, Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Zoi Papadopoulou
- 3rd Department of Pediatrics, Ippokrateio General Hospital Of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria Kyriazopoulou
- Department of Dermatology and Venereology, 401 General Military Hospital of Athens, Athens, Greece
| | - Dimitrios Schizas
- 1st Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Christos Bakoyiannis
- 1st Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Rajendran S, Nair HR, Irshad K M, Unais T M, Thaikattil NJ. Ultrasound-assisted varicose vein surgery and endovenous laser ablation using 1470-nm laser for treatment of great saphenous vein incompetence has similar outcomes at 1 year: A single-center prospective randomized study. J Vasc Surg Venous Lymphat Disord 2021; 10:370-375. [PMID: 34438089 DOI: 10.1016/j.jvsv.2021.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 08/13/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Technical errors are the most common preventable cause of recurrence after high ligation and stripping procedures for the treatment of great saphenous vein incompetence. Ultrasound-assisted varicose vein surgery (UAVS) uses intraoperative ultrasound during high ligation and stripping to minimize such failures, although no data have been reported regarding its use during open surgery. The present study compared the short-term outcomes of UAVS and endovenous laser ablation (EVLA) with a 1470-nm laser. METHODS The present prospective randomized study was conducted from January 2019 to December 2019. We compared 40 patients who had undergone UAVS under regional anesthesia with an equal number of patients who had undergone EVLA under tumescent anesthesia. Both groups received 1 week of standardized postoperative analgesia. The improvements in the pain score, venous clinical severity score, and recurrence at 6 months and 1 year were studied. RESULTS No significant differences were found in either clinical or radiologic great saphenous vein recurrence after UAVS compared with EVLA at 1 year. The mean pain score at 8 hours after the procedure was higher in the UAVS group (3.7 ± 1.2 vs 2.9 ± 1.0; P = .03). At 1 week, the score was higher in the EVLA group (1.8 ± 0.7 vs 1.4 ± 0.5; P = .01). At 6 months, the venous clinical severity score had improved from 9.2 ± 3.7 to 2.4 ± 1.4 in the UAVS group and from 9.3 ± 3.2 to 2.1 ± 0.8 in the EVLA group (P = .64). At 1 year, the corresponding scores were 1.3 ± 0.7 and 1.4 ± 0.6 (P = .21). CONCLUSIONS UAVS has high technical success, making it a suitable alternative to EVLA using a 1470-nm laser.
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Affiliation(s)
- Sunil Rajendran
- Department of General Surgery and Vascular Surgery, MES Medical College, Perinthalmanna, Malaparamba, India.
| | | | - Mohammed Irshad K
- Department of General Surgery and Vascular Surgery, MES Medical College, Perinthalmanna, Malaparamba, India
| | - Muhammed Unais T
- Department of General Surgery, IQRAA Hospital, Malaparamba, India
| | - Navya J Thaikattil
- Department of Health, District Medical Office (Health), Malappuram, India
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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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11
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Abstract
BACKGROUND Great saphenous vein (GSV) incompetence, causing varicose veins and venous insufficiency, makes up the majority of lower-limb superficial venous diseases. Treatment options for GSV incompetence include surgery (also known as high ligation and stripping), laser and radiofrequency ablation, and ultrasound-guided foam sclerotherapy. Newer treatments include cyanoacrylate glue, mechanochemical ablation, and endovenous steam ablation. These techniques avoid the need for a general anaesthetic, and may result in fewer complications and improved quality of life (QoL). These treatments should be compared to inform decisions on treatment for varicosities in the GSV. This is an update of a Cochrane Review first published in 2011. OBJECTIVES To assess the effects of endovenous laser ablation (EVLA), radiofrequency ablation (RFA), endovenous steam ablation (EVSA), ultrasound-guided foam sclerotherapy (UGFS), cyanoacrylate glue, mechanochemical ablation (MOCA) and high ligation and stripping (HL/S) for the treatment of varicosities of the great saphenous vein (GSV). SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, and AMED databases, and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 2 November 2020. We undertook reference checking to identify additional studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) treating participants for varicosities of the GSV using EVLA, RFA, EVSA, UGFS, cyanoacrylate glue, MOCA or HL/S. Key outcomes of interest are technical success, recurrence, complications and QoL. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, applied Cochrane's risk of bias tool, and extracted data. We calculated odds ratios (ORs) with 95% confidence intervals (CIs) and assessed the certainty of evidence using GRADE. MAIN RESULTS We identified 11 new RCTs for this update. Therefore, we included 24 RCTs with 5135 participants. Duration of follow-up ranged from five weeks to eight years. Five comparisons included single trials. For comparisons with more than one trial, we could only pool data for 'technical success' and 'recurrence' due to heterogeneity in outcome definitions and time points reported. All trials had some risk of bias concerns. Here we report the clinically most relevant comparisons. EVLA versus RFA Technical success was comparable up to five years (OR 0.98, 95% CI 0.41 to 2.38; 5 studies, 780 participants; moderate-certainty evidence); over five years, there was no evidence of a difference (OR 0.85, 95% CI 0.30 to 2.41; 1 study, 291 participants; low-certainty evidence). One study reported recurrence, showing no clear difference at three years (OR 1.53, 95% CI 0.78 to 2.99; 291 participants; low-certainty evidence), but a benefit for RFA may be seen at five years (OR 2.77, 95% CI 1.52 to 5.06; 291 participants; low-certainty evidence). EVLA versus UGFS Technical success may be better in EVLA participants up to five years (OR 6.13, 95% CI 0.98 to 38.27; 3 studies, 588 participants; low-certainty evidence), and over five years (OR 6.47, 95% CI 2.60 to 16.10; 3 studies, 534 participants; low-certainty evidence). There was no clear difference in recurrence up to three years and at five years (OR 0.68, 95% CI 0.20 to 2.36; 2 studies, 443 participants; and OR 1.08, 95% CI 0.40 to 2.87; 2 studies, 418 participants; very low-certainty evidence, respectively). EVLA versus HL/S Technical success may be better in EVLA participants up to five years (OR 2.31, 95% CI 1.27 to 4.23; 6 studies, 1051 participants; low-certainty evidence). No clear difference in technical success was seen at five years and beyond (OR 0.93, 95% CI 0.57 to 1.50; 5 studies, 874 participants; low-certainty evidence). Recurrence was comparable within three years and at 5 years (OR 0.78, 95% CI 0.47 to 1.29; 7 studies, 1459 participants; and OR 1.09, 95% CI 0.68 to 1.76; 7 studies, 1267 participants; moderate-certainty evidence, respectively). RFA versus MOCA There was no clear difference in technical success (OR 1.76, 95% CI 0.06 to 54.15; 3 studies, 435 participants; low-certainty evidence), or recurrence (OR 1.00, 95% CI 0.21 to 4.81; 3 studies, 389 participants; low-certainty evidence). Long-term data are not available. RFA versus HL/S No clear difference in technical success was detected up to five years (OR 5.71, 95% CI 0.64 to 50.81; 2 studies, 318 participants; low-certainty evidence); over five years, there was no evidence of a difference (OR 0.88, 95% CI 0.29 to 2.69; 1 study, 289 participants; low-certainty evidence). No clear difference in recurrence was detected up to three years (OR 0.93, 95% CI 0.58 to 1.51; 4 studies, 546 participants; moderate-certainty evidence); but a possible long-term benefit for RFA was seen (OR 0.41, 95% CI 0.22 to 0.75; 1 study, 289 participants; low-certainty evidence). UGFS versus HL/S Meta-analysis showed a possible benefit for HL/S compared with UGFS in technical success up to five years (OR 0.32, 95% CI 0.11 to 0.94; 4 studies, 954 participants; low-certainty evidence), and over five years (OR 0.09, 95% CI 0.03 to 0.30; 3 studies, 525 participants; moderate-certainty evidence). No clear difference was detected in recurrence up to three years (OR 1.81, 95% CI 0.87 to 3.77; 3 studies, 822 participants; low-certainty evidence), and after five years (OR 1.24, 95% CI 0.57 to 2.71; 3 studies, 639 participants; low-certainty evidence). Complications were generally low for all interventions, but due to different definitions and time points, we were unable to draw conclusions (very-low certainty evidence). Similarly, most studies evaluated QoL but used different questionnaires at variable time points. Rates of QoL improvement were comparable between interventions at follow-up (moderate-certainty evidence). AUTHORS' CONCLUSIONS Our conclusions are limited due to the relatively small number of studies for each comparison and differences in outcome definitions and time points reported. Technical success was comparable between most modalities. EVLA may offer improved technical success compared to UGFS or HL/S. HL/S may have improved technical success compared to UGFS. No evidence of a difference was detected in recurrence, except for a possible long-term benefit for RFA compared to EVLA or HL/S. Studies which provide more evidence on the breadth of treatments are needed. Future trials should seek to standardise clinical terminology of outcome measures and the time points at which they are measured.
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Affiliation(s)
- Jade Whing
- Northern Vascular Centre, Freeman Hospital, Newcastle, UK
| | - Sandip Nandhra
- Northern Vascular Centre, Freeman Hospital, Newcastle, UK
| | - Craig Nesbitt
- Northern Vascular Centre, Freeman Hospital, Newcastle, UK
| | - Gerard Stansby
- Northern Vascular Centre, Freeman Hospital, Newcastle, UK
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Siribumrungwong B, Wilasrusmee C, Orrapin S, Srikuea K, Benyakorn T, McKay G, Attia J, Rerkasem K, Thakkinstian A. Interventions for great saphenous vein reflux: network meta-analysis of randomized clinical trials. Br J Surg 2021; 108:244-255. [PMID: 33793723 PMCID: PMC10364879 DOI: 10.1093/bjs/znaa101] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 10/12/2020] [Accepted: 11/01/2020] [Indexed: 11/14/2022]
Abstract
BACKGROUND A variety of endovascular and open surgical interventions exist to treat great saphenous vein reflux. However, comparisons of treatment outcomes have been inconsistent. METHODS A systematic review and network meta-analysis of RCTs was performed to compare rates of incomplete stripping or non-occlusion of the great saphenous vein with or without reflux (anatomical failure) at early, mid- and long-term follow-up; and secondary outcomes (reintervention and clinical recurrence) among intervention groups. The surface under the cumulative ranking curve (SUCRA) method was used to estimate the probability of the intervention with the lowest anatomical failure rates. RESULTS Some 72 RCTs were included. Comparisons of endothermal techniques with open surgery were mostly not significantly different, except for endovenous laser ablation (EVLA), which had higher long-term anatomical failure rates (pooled risk ratio (RR) 1.87, 95 per cent c.i. 1.14 to 3.07). Mechanochemical ablation had higher anatomical failure rates than radiofrequency ablation (RFA) (pooled RR 2.77, 1.38 to 5.53), and cyanoacrylate closure (CAC) had a RR 0.56 (0.34 to 0.93) times lower than either RFA or EVLA at the early term. Ultrasound-guided foam sclerotherapy had a higher risk of anatomical failure and reintervention than open surgery, with the lowest SUCRA value, and CAC was ranked first, third and first for best intervention for anatomical failure at early, mid and long term respectively. However, clinical recurrence rates were not significantly different between all comparisons. CONCLUSION Mechanochemical ablation and ultrasound-guided foam sclerotherapy performed poorly, with higher anatomical failure rates in the long term. The other treatment modalities had similar rates of anatomical failure in the short and mid term.
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Affiliation(s)
- B Siribumrungwong
- Division of Vascular and Endovascular Surgery, Department of Surgery, Thammasat University Hospital, Pathum Thani, Thailand.,Centre of Excellence in Applied Epidemiology, Thammasat University Hospital, Thammasat University, Pathum Thani, Thailand
| | - C Wilasrusmee
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - S Orrapin
- Division of Vascular and Endovascular Surgery, Department of Surgery, Thammasat University Hospital, Pathum Thani, Thailand
| | - K Srikuea
- Division of Vascular and Endovascular Surgery, Department of Surgery, Thammasat University Hospital, Pathum Thani, Thailand
| | - T Benyakorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Thammasat University Hospital, Pathum Thani, Thailand
| | - G McKay
- Centre for Public Health, School of Medicine, Dentistry, and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - J Attia
- Centre for Clinical Epidemiology and Biostatistics, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, and Hunter Medical Research Institute, NSW, Australia
| | - K Rerkasem
- Division of Vascular and Endovascular Surgery, Department of Surgery, Faculty of Medicine; Non-Communicable Disease Centre of Excellence, Research Institute of Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - A Thakkinstian
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Outcomes of Saphenous Vein Intervention in the Management of Superficial Venous Incompetence: A Systematic Review and Network Meta-Analysis. Ann Surg 2021; 275:e324-e333. [PMID: 33843795 DOI: 10.1097/sla.0000000000004914] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine the most effective modality of intervention to treat saphenous vein insufficiency. SUMMARY BACKGROUND DATA Endovenous therapies have instigated a paradigm shift in the management of superficial venous incompetence (SVI). When compared with open surgery, endovenous interventions (foam sclerotherapy (FS), radiofrequency ablation (RFA), endovenous laser ablation (EVLA), mechanochemical ablation (MOCA), and cyanoacrylate glue (CAE) closure) potentially offer reduced morbidity with similar procedural efficacy. METHODS A systematic review and series of network meta-analyses of randomized controlled trials (RCTs) were performed assessing risks of procedural failure (within 6-weeks) and recurrence (6-weeks to 5-years), defined by ultrasound, between the different SVI modalities. Treatment comparisons addressing risks of common adverse events, Venous Clinical Severity Score (VCSS) and pain were also performed. RESULTS A systematic search identified 51 articles, describing 36 RCTs, incorporating 7,576 limbs. Outcome data on ten modalities of intervention were analyzed up to five-year follow-up. CAE resulted in the lowest risk of procedural failure within six-weeks. Foam sclerotherapy had the highest risk of recurrence while high ligation with stripping (HLS) and CHIVA were ranked best to reduce long-term recurrence. No intervention increased risks of venous thromboembolism and there was minimal difference in morbidity between treatments. All interventions improved VCSS (Range -1.02 to -4.95), however RFA demonstrated the greatest improvement, followed by EVLA and HLS between two to five-years. EVLA was associated with the highest risk of pain, while MOCA offered the least. CONCLUSION While CAE offered the lowest risk of initial procedural failure, HLS resulted in lower rates of long-term recurrence without considerably increasing morbidity when compared with other endovenous options.
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Tiwari K, Kamerkar D, Shinde B. Endovenous laser therapy in varicose veins-recanalization rate and quality of life. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2021. [DOI: 10.4103/ijves.ijves_169_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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[Pros and cons of classic crossectomy with stripping compared to endoluminal treatment : Competition or team play?]. Hautarzt 2020; 71:6-11. [PMID: 31807791 DOI: 10.1007/s00105-019-04515-z] [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: 10/25/2022]
Abstract
The chronic venous insufficiency (CVI) of the leg veins is one of the most common diseases in our society. Thus, it is important to know the clinical picture of CVI and the pros and cons of the different treatment options. Of the various treatments available for varicose veins (conservative therapy, operative procedures, endoluminal techniques, foam sclerotherapy), an evidence-based, treatment option should be individually chosen for each patient. In this article, the pros and cons of surgery are compared with endoluminal therapy in order to draw practical conclusions for the treatment decision.
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Alwahbi A, Alamri A, Alotaibi W. Risk Factors of Saphenous Vein Insufficiency in Female Patients in Riyadh, Saudi Arabia. Cureus 2020; 12:e6643. [PMID: 31966948 PMCID: PMC6961556 DOI: 10.7759/cureus.6643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 01/13/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Venous reflux most frequently occurs in the great saphenous vein (GSV), which is the most commonly diseased vein and is associated with venous insufficiency and varicose veins. OBJECTIVE We aimed, in this study, to determine risk factors for saphenous vein insufficiency in female patients in Riyadh, Saudi Arabia. METHODS This was a retrospective cohort study. Data were collected from the medical records of adult female patients who developed saphenous vein insufficiency at King Abdulaziz Medical City, between 2015 and 2017. RESULTS A total of 97 subjects participated in the study, 53 patients had saphenous vein reflux while 44 patients did not have reflux. Leg swelling was the only symptom that showed a significant difference between the two groups (p<0.001); patients with reflux had significantly higher rates of endovenous laser therapy (p=0.021). While the same patient group showed significantly lower rates of sclerotherapy compared to patients without reflux (p=0.006). The proportion of hypertension patients without reflux (22.7%) was significantly larger than that of hypertension patients with reflux (1.9%) (p= 0.001). CONCLUSION More research is encouraged to provide better understanding and management of saphenous vein insufficiency in the Saudi population, especially in females who are at high risk.
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Affiliation(s)
- Abdullah Alwahbi
- Vascular Surgery, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, SAU
| | - Amal Alamri
- Vascular Surgery, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Wafa Alotaibi
- Vascular Surgery, King Saud Bin Abdulaziz University for Health Sciences (ksau-Hs), Riyadh, Saudi Arabia, Riyadh, SAU
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Nandhra S, Wallace T, El-Sheikha J, Carradice D, Chetter I. A randomised controlled trial of perivenous tumescent anaesthesia in addition to general anaesthesia for surgical ligation and stripping of the great saphenous vein. Phlebology 2019; 35:305-315. [PMID: 31660788 DOI: 10.1177/0268355519885221] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Open surgical ligation and stripping of the great saphenous vein is a highly cost-effective treatment when compared with conservative management and foam sclerotherapy but has limitations including post-operative morbidity and pain. This study aims to identify if the addition of tumescent anaesthesia could improve patient outcomes following treatment. METHODS Patients with primary superficial venous incompetence undergoing open surgical ligation and stripping of the great saphenous vein were randomised to either General Anaesthesia (GA) alone (GA) procedure or the addition of tumescent (G + T). The primary outcome was bodily pain (within SF-36) at one week. Additional outcomes included post-procedural pain score (100 mm visual analogue scale), complications and quality of life. RESULTS A total of 90 patients were randomised for inclusion. There was no significant difference in primary outcome; bodily pain at one week. Secondary outcome of 4-h post-procedural scores were significantly lower in the G + T group (32 (20-54) mm vs. (GA alone) 56 (24-70) mm (P = 0.016)). Complications were minor and equivalent. Both groups saw a significant increase (worsening) in Aberdeen Varicose Vein Questionnaire scores at week 1 with the G + T group faring worse at six weeks (10.0 (Interquartile Range [IQR] 5.6-17.9) vs. 4.3 (IQR 2.7-7.9) P = 0.004). CONCLUSION The G + T group did not demonstrate a significant difference in the one-week bodily pain domain. The addition of tumescent anaesthesia does improve immediate post-operative pain but appears to negatively impact on six-week quality of life. EudraCT Number: 2011-005574-39.
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Affiliation(s)
- Sandip Nandhra
- Academic Vascular Surgery, Hull Royal Infirmary, Hull, UK
| | - Tom Wallace
- Academic Vascular Surgery, Hull Royal Infirmary, Hull, UK
| | | | | | - Ian Chetter
- Academic Vascular Surgery, Hull Royal Infirmary, Hull, UK
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Leopardi M, Salerno A, Dante A, Cofini V, Necozione S, Ventura M. Endovenous Laser Ablation with 1,470-nm Diode with Tumescence Anesthesia and Saphenofemoral Ligation: Propensity Score Match Comparison. Ann Vasc Surg 2019; 58:302-308. [DOI: 10.1016/j.avsg.2018.11.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 11/22/2018] [Accepted: 11/22/2018] [Indexed: 11/29/2022]
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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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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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Meta-analysis of nontumescent-based versus tumescent-based endovenous therapies for patients with great saphenous insufficiency and varicose veins. J Vasc Surg Venous Lymphat Disord 2018; 6:779-787.e6. [DOI: 10.1016/j.jvsv.2018.05.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 05/30/2018] [Indexed: 11/19/2022]
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Aurshina A, Alsheekh A, Kibrik P, Hingorani A, Marks N, Ascher E. Recanalization After Endovenous Thermal Ablation. Ann Vasc Surg 2018; 52:158-162. [DOI: 10.1016/j.avsg.2018.03.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 03/04/2018] [Accepted: 03/15/2018] [Indexed: 11/27/2022]
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Inderhaug E, Schelp CH, Glambek I, Kristiansen IS. Cost-effectiveness analysis of five procedures for great saphenous vein reflux in a Norwegian healthcare setting or societal setting. SAGE Open Med 2018; 6:2050312118801709. [PMID: 30263121 PMCID: PMC6153534 DOI: 10.1177/2050312118801709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 08/27/2018] [Indexed: 01/22/2023] Open
Abstract
Objective The aim of this work was to estimate cost-effectiveness of five common procedures for varicose vein surgery (high ligation and stripping, radiofrequency ablation, endovenous laser ablation, steam vein sclerosis and cyanoacrylate glue) in a Norwegian setting from both a societal and a healthcare payer perspective. Design Cost-effectiveness analysis using decision tree modelling. Methods A structured literature search was conducted to estimate the clinical effectiveness and the rate of complications in the five methods. Data on costs and health-related quality of life associated with varicose vein disease were also collected. With the aid of an expert panel, a structured decision tree was developed. A 1-year perspective was modelled, and a variety of common complications were included. Monte Carlo simulation was used for probabilistic sensitivity analyses. Results The laser ablation strategy was the most cost-effective option from a societal perspective, with an incremental cost-effectiveness ratio of €8448 compared to a no-treatment alternative, and had a 42% probability of being cost-effective using the Norwegian willingness-to-pay threshold of €59,880. From a healthcare payer perspective, however, the steam vein sclerosis strategy was the most cost-effective with an incremental cost-effectiveness ratio of €4072 compared to a no-treatment alternative, and this strategy had a 50% probability of being cost-effective. Conclusion Results from this study did depend upon the perspective chosen for analyses. Although recent endovenous surgical procedures (including laser ablation and steam vein sclerosis) provide clinically effective treatment for advanced, symptomatic varicose vein disease, availability of high-level data is currently limiting the cost-effectiveness analyses.
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Affiliation(s)
- Eivind Inderhaug
- Surgical Department, Haraldsplass Deaconess University Hospital, Bergen, Norway
| | | | - Inge Glambek
- Surgical Department, Haraldsplass Deaconess University Hospital, Bergen, Norway
| | - Ivar S Kristiansen
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
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de Mik SM, Stubenrouch FE, Legemate DA, Balm R, Ubbink DT. Treatment of varicose veins, international consensus on which major complications to discuss with the patient: A Delphi study. Phlebology 2018; 34:201-207. [PMID: 30012048 PMCID: PMC6431782 DOI: 10.1177/0268355518785482] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Objective To reach consensus on which complications of varicose vein treatments
physicians consider major or minor, in order to standardize the informed
consent procedure and improve shared decision-making. Methods Using the e-Delphi method, expert physicians from 10 countries were asked to
rate complications as “major” or “minor” on a 5-point Likert scale.
Reference articles from a Cochrane review on varicose veins were used to
compose the list of complications. Results Participating experts reached consensus on 12 major complications: allergic
reaction, cellulitis requiring intravenous antibiotics/intensive care, wound
infection requiring debridement, hemorrhage requiring blood
transfusion/surgical intervention, pulmonary embolism, skin necrosis
requiring surgery, arteriovenous fistula requiring repair, deep venous
thrombosis, lymphocele, thermal injury, transient ischemic attack/stroke,
and permanent discoloration. Conclusion An international consensus was reached about what physicians consider to be
major complications of varicose vein treatments. This consensus may assist
in standardizing the information physicians discuss with patients prior to
varicose vein treatment.
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Affiliation(s)
- Sylvana Ml de Mik
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | | | - Dink A Legemate
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - Ron Balm
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - Dirk T Ubbink
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
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Gloviczki P, Dalsing MC, Henke P, Lal BK, O'Donnell TF, Shortell CK, Huang Y, Markovic J, Wakefield TW. Report of the Society for Vascular Surgery and the American Venous Forum on the July 20, 2016 meeting of the Medicare Evidence Development and Coverage Advisory Committee panel on lower extremity chronic venous disease. J Vasc Surg Venous Lymphat Disord 2018; 5:378-398. [PMID: 28411706 DOI: 10.1016/j.jvsv.2017.02.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 02/04/2017] [Indexed: 12/21/2022]
Abstract
On July 20, 2016, a Medicare Evidence Development and Coverage Advisory Committee panel assessed the benefits and risks of currently used lower extremity chronic venous disease (CVD) treatments and their effects on health outcome of the American adult population. The main purpose of the meeting was to advise the Centers for Medicare & Medicaid Services on coverage determination for interventions used for treatment of CVD. A systematic review of the Agency for Healthcare Research and Quality was presented, followed by lectures of invited experts and a public hearing of representatives of professional societies and the industry. After discussing critical issues, the panel voted for key questions. This report summarizes the presented evidence to support recommendations of the Society for Vascular Surgery/American Venous Forum coalition and the presentations on selected discussion topics. These included important venous disease evidence gaps that have not been sufficiently addressed, venous disease treatment disparities and how they may affect the health outcomes of Medicare beneficiaries, and mechanisms that might be supported by the Centers for Medicare & Medicaid Services to improve the evidence base to optimize the care of patients with lower extremity CVD.
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Affiliation(s)
- Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.
| | - Michael C Dalsing
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Peter Henke
- Section of Vascular Surgery, University of Michigan, Ann Arbor, Mich
| | - Brajesh K Lal
- Department of Vascular Surgery, University of Maryland, Baltimore, Md
| | | | - Cynthia K Shortell
- Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Ying Huang
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Jovan Markovic
- Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
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Vemulapalli S, Parikh K, Coeytaux R, Hasselblad V, McBroom A, Johnston A, Raitz G, Crowley MJ, Lallinger KR, Jones WS, Sanders GD. Systematic review and meta-analysis of endovascular and surgical revascularization for patients with chronic lower extremity venous insufficiency and varicose veins. Am Heart J 2018; 196:131-143. [PMID: 29421005 DOI: 10.1016/j.ahj.2017.09.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 09/26/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Chronic lower extremity venous disease (LECVD) is twice as prevalent as coronary heart disease, and invasive therapies to treat LECVD accounted for an estimated $290 million in Medicare expenditures in 2015. Despite increasing use of these invasive therapies, their comparative effectiveness is unknown. METHODS We conducted a systematic review and meta-analysis of treatments for patients (symptomatic and asymptomatic) with lower extremity varicosities and/or lower extremity chronic venous insufficiency/incompetence/reflux. We searched PubMed, Embase, and the Cochrane Database of Systematic Reviews for relevant English-language studies published from January 2000 to July 2016. We included comparative randomized controlled trials (RCTs) with >20 patients and observational studies with >500 patients. Short-, intermediate-, and long-term outcomes of placebo, mechanical compression therapy, and invasive therapies (surgical and endovascular) were included. Quality ratings and evidence grading was performed. Random-effects models were used to compute summary estimates of effects. RESULTS We identified a total of 57 studies representing 105,878 enrolled patients, including 53 RCTs comprised of 10,034 patients. Among the RCTs, 16 were good quality, 28 were fair quality, and 9 were poor quality. Allocation concealment, double blinding, and reporting bias were inadequately addressed in 25 of 53 (47%), 46 of 53 (87%), and 15 of 53 (28.3%), respectively. Heterogeneity in therapies, populations, and/or outcomes prohibited meta-analysis of comparisons between different endovascular therapies and between endovascular intervention and placebo/compression. Meta-analysis evaluating venous stripping plus ligation (high ligation/stripping) compared with radiofrequency ablation revealed no difference in short-term bleeding (odds ratio [OR]=0.30, 95% CI -0.16 to 5.38, P=.43) or reflux recurrence at 1-2 years (OR=0.76, 95% CI 0.37-1.55, P=.44). Meta-analysis evaluating high ligation/stripping versus endovascular laser ablation revealed no difference in long-term symptom score (OR 0.02, 95% CI -0.19 to 0.23, P=.84) or quality of life at 2 years (OR 0.06, 95% CI -0.12 to 0.25, P=.50). CONCLUSIONS The paucity of high-quality comparative effectiveness and safety data in LECVD is concerning given the overall rise in endovascular procedures. More high-quality studies are needed to determine comparative effectiveness and guide policy and practice.
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Abstract
ZusammenfassungEinführung: Zur Behandlung der Stammvarikose mit dem VenaSeal™ Closure-System ist eine Narkoseform oder Tumeszenzanästhesie nicht erforderlich. Ebenfalls kann auf das Tragen von Kompressionsstrümpfen verzichtet werden. Über die Anwendung, erste Erfahrungen und 2 Jahresergebnisse wird berichtet.Material und Methode: In der Zeit von März 2012 bis Mai 2014 wurden 218 Patienten an 274 Stammvenen mit dem VenaSeal™ Closure-System therapiert. Doppler und Duplexuntersuchungen erfolgten nach 7 Tagen, 6 Wochen, 1 Jahr und 2 Jahren. Erhoben wurde die Verschluss- und Komplikationsrate, der visuelle analoge Schmerz-Score und der Venous Clinical Severity Score(VCSS).Ergebnisse: Nachuntersucht wurden 227 Stammvenen der Vena saphena magna (VSM) und 24 Stammvenen der Vena saphena parva (VSP). Die Verschlussrate der VSM betrug 99,5 % (n= 227) nach 7 Tagen, 96,5 % nach 6 Wochen (n= 172), 93,4 % nach 1 Jahr (n= 61) und 100 % nach 2 Jahren (n= 20). Die Verschlussrate der VSP betrug jeweils 100 % nach 7 Tagen (n= 24), 6 Wochen (n= 12) und nach 1 Jahr (n=4). Majorkomplikationen traten nicht auf. Als Minorkomplikationen traten nach Behandlung der Vena saphena magna inflammatorische Reaktionen bei 44 Beinen und Phlebitiden bei 32 Beinen auf. Der Pain Score entwickelte sich unter der Behandlung von 1,4 auf 1,5 (3. Tag), 2,1 (5. Tag), 1,6 (10. Tag), 0,2 (4 Wochen) auf 0,1 (6 Wochen). Der VCSS betrug präoperativ 4,4 und sank auf 2,9 (7. Tag), 2,1 (6 Wochen) auf 1,8 (1 und 2 Jahr)Diskussion: Die VenaSeal™ Closure-Behand-lung der Stammvarikose ist sicher und effektiv. Die Ergebnisse sind vergleichbar denen der thermischen Ablationsverfahren. Ohne die Anwendung der Tumeszenz-Anästhesie haben die Patientin deutlich weniger Beschwerden im Vergleich zu den thermischen Ablationsverfahren, sowohl während der Behandlung, als auch postoperativ.
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Die LaVaCro-Studie: Langzeitergebnisse der Varizenoperation mit Crossektomie und Stripping der V. saphena magna. PHLEBOLOGIE 2018. [DOI: 10.12687/phleb2139-5-2013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
ZusammenfassungHintergrund: Multizentrische Langzeitstudien mit hohen Fallzahlen nach Crossektomie und Stripping der Vena saphena magna (VSM) liegen nicht vor. Den in mehreren Studien und Registern erhobenen Daten zu den Rezidivraten der endovenösen Therapieverfahren stehen außerordentlich heterogene Daten der operativen Therapie gegenüber.Methode: In einer von der Arbeitsgemeinschaft für Venenoperationen (VOP-AG) der Deutschen Gesellschaft für Phlebologie (DGP) initiierten prospektiven Multizenterstudie wurden in 12 Zentren 841 Patienten (1 070 Extremitäten) mit einer Stammvarikose der VSM aufgenommen und entsprechend einem streng standardisierten Protokoll operiert. Primärer Endpunkt ist das hämodynamisch relevante saphenofemorale Rezidiv, definiert als eine Vene in der Crossenregion (Durchmesser >5 mm, Reflux >0,5 sec) mit einer Verbindung zur V. femoralis communis Sekundäre Endpunkte sind die Rate duplexsonografisch nachweisbarer pathologischer Crossenrefluxe (Durchmesser <5 mm, Reflux >0,5 sec.), perioperative Komplikationen und neu aufgetretene Varizen nach dem REVAS Klassifikation. Die klinischen und duplexsonografischen Kontrollen erfolgten 7 bis 14 Tage, 3 bis 4 Monate und ein Jahr postoperativ. Hiernach sind jährliche Kontrollen vorgesehen.Ergebnis: Die Rate klinischer Rezidive lag 3–4 Monate postoperativ bei 1,1 % und ein Jahr postoperativ bei 6,4 %. Die Rate duplexsonografischer Rezidive im Crossenbereich betrug nach 3–4 Monaten 0,53 % und nach einem Jahr 2,24 %. Davon waren lediglich zwei (0,29 %) ein Jahr postoperativ hämodynamisch relevant (Durchmesser >5 mm).Schlussfolgerung: Die unter standardisierten Bedingungen vorgenommene Crossektomie und Stripping-Operation weist im Verlauf bis zu einem Jahr eine geringe Rezidivrate auf.
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Lawson JA, Gauw SA, van Vlijmen CJ, Pronk P, Gaastra MT, Tangelder MJ, Mooij MC. Prospective comparative cohort study evaluating incompetent great saphenous vein closure using radiofrequency-powered segmental ablation or 1470-nm endovenous laser ablation with radial-tip fibers (Varico 2 study). J Vasc Surg Venous Lymphat Disord 2018; 6:31-40. [DOI: 10.1016/j.jvsv.2017.06.016] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 06/20/2017] [Indexed: 12/28/2022]
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Bellam Premnath KP, Joy B, Raghavendra VA, Toms A, Sleeba T. Cyanoacrylate adhesive embolization and sclerotherapy for primary varicose veins. Phlebology 2017; 33:547-557. [PMID: 28956692 DOI: 10.1177/0268355517733339] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Various treatment methods are available for the treatment of varicose veins, and there has been a recent surge in the usage of cyanoacrylate glue for treating varicose veins. Purpose To investigate the technical possibility, efficiency and safety of cyanoacrylate adhesive embolization and sclerotherapy using commonly available n-butyl cyanoacrylate glue for the treatment of primary varicose veins due to great saphenous vein reflux with or without incompetent perforators. Materials and Methods One hundred forty-five limbs of 124 patients with varicose veins due to great saphenous vein reflux were subjected to cyanoacrylate adhesive embolization and sclerotherapy - adhesive embolization of great saphenous vein in the thigh and perforators using cyanoacrylate followed by sclerotherapy of any residual varicose veins in the leg. Procedural success, venous closure rates and clinical improvement were assessed. Follow-up for 1, 3, 6, 9 and 12 months was obtained. Results Technical success rate was 100%. Saphenous vein closure rate was 96.5% at one year. There was no femoral venous extension of cyanoacrylate in any of the patients. Posterior tibial vein extension of cyanoacrylate was seen in three patients (2.6%) without untoward clinical effect.Significant improvement was found in venous clinical severity score (VCSS) from a baseline mean of 7.98 ± 4.42 to 4.74 ± 3, 1.36 ± 1.65 and 0.79 ± 1.19 at 1, 6 and 12 months' follow-up. Ulcer healing rate was 100%. Conclusion Cyanoacrylate adhesive embolization and sclerotherapy for the treatment of primary varicose veins is efficacious and can be performed as an outpatient procedure, but has a guarded safety profile due to its propensity to cause deep venous occlusion if not handled carefully.
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Affiliation(s)
| | - Binu Joy
- Department of Radiology, Rajagiri Hospital, Aluva, Kerala, India
| | | | - Ajith Toms
- Department of Radiology, Rajagiri Hospital, Aluva, Kerala, India
| | - Teena Sleeba
- Department of Radiology, Rajagiri Hospital, Aluva, Kerala, India
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Abstract
Open and endovenous surgery of varicose veins provides an excellent way to treat varicose veins. However, there are great differences in the how the techniques are performed. No matter which procedure is carried out, there are standards that should be observed. The state of the art of open venous surgery with radical crossectomy is well-known, but unfortunately is still not always performed correctly nowadays. The state of the art of endovenous surgery has unfortunately not yet been sufficiently documented, but should be based on open-surgical techniques. How the standard of both methods today is (or should be) is described in detail in this work. A recurrence definition which applies to both techniques, is set up.
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Takahashi K, Ito H, Katsube T, Hashimoto M, Mita K, Asakawa H, Hayashi T, Fujino K. Association between antithrombotic therapy and risk of postoperative complications among patients undergoing endovenous laser ablation. J Vasc Surg Venous Lymphat Disord 2017; 5:339-345. [PMID: 28411700 DOI: 10.1016/j.jvsv.2016.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 11/19/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND The aim of the study was to evaluate the clinical results and postoperative complications, especially recanalization or bleeding complications, in patients with saphenous varicose veins undergoing endovenous laser ablation (EVLA) while receiving antithrombotic therapy (ATT). METHODS This retrospective cohort study included 1136 Japanese patients undergoing EVLA with a 980-nm diode laser between January 2012 and November 2015 at our institution. The patients were divided into two groups: ATT users (ATT group) and nonusers (control group). The ATT group was further divided into two subgroups according to whether the patients received antiplatelet or anticoagulant therapy. Clinical outcomes and postoperative complications among these patients were assessed. RESULTS Approximately 20% of the patients undergoing surgery for saphenous varicose veins at our institution received ATT. Of these, 141 (12.4%) received antiplatelet therapy and 95 (8.4%) received anticoagulant therapy. Successful occlusion of the full length of the treated vein was achieved in 99.9% of the patients; there were no severe perioperative complications. Endovenous heat-induced thrombosis occurred in 2.4% of patients, whereas postoperative complications developed in 1.2% of patients. One patient experienced recanalization (0.08%). There were no significant between-group differences in the incidence of recanalization and postoperative complications on univariate analysis. CONCLUSIONS The clinical outcomes and postoperative complications of EVLA in the ATT group were equivalent to those in the control group, indicating that EVLA can be safely performed in patients receiving ATT.
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Affiliation(s)
| | - Hideto Ito
- Department of Surgery, New-Tokyo Hospital, Chiba, Japan
| | | | | | - Kazuhito Mita
- Department of Surgery, New-Tokyo Hospital, Chiba, Japan
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Prospective Randomized Study of Ultrasound-Guided Foam Sclerotherapy Combined with Great Saphenous Vein High Ligation in the Treatment of Severe Lower Extremity Varicosis. Ann Vasc Surg 2017; 39:256-263. [DOI: 10.1016/j.avsg.2016.06.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Revised: 05/11/2016] [Accepted: 06/17/2016] [Indexed: 11/23/2022]
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Tabuchi A, Masaki H, Yunoki Y, Watanabe Y, Furukawa H, Yamasawa T, Takiuchi H, Honda T, Kuwada N, Kojima K, Tanemoto K. Positioning for Endovenous Laser Ablation: Comparative Study with Thigh Stripping. Ann Vasc Dis 2016; 9:154-159. [PMID: 27738455 DOI: 10.3400/avd.oa.16-00073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 07/23/2016] [Indexed: 11/13/2022] Open
Abstract
We performed a comparative study of surgical outcomes and venous functions between endovenous laser ablation with a 980-nm diode laser (EV group) and thigh stripping (ST group). There were no severe complications and initial success rates were 100% in both groups. In the EV group, preoperative symptoms improved in 94.3% of cases, the venous occlusion rate was 98%, and endovenous heat induced thrombosis had occurred in 11.9% (Class 3: 0.7%) at 12 months after the operation. Although comparative study of postoperative venous function by air plethysmography showed significant improvement in both groups, there was less recovery of postoperative venous function in the EV than in the ST group. (This article is a translation of J Jpn Coll Angiol 2015; 55: 13-20.).
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Affiliation(s)
- Atsushi Tabuchi
- Department of Cardiovascular Surgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Hisao Masaki
- Department of Cardiovascular Surgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Yasuhiro Yunoki
- Department of Cardiovascular Surgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Yoshiko Watanabe
- Department of Cardiovascular Surgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Hiroshi Furukawa
- Department of Cardiovascular Surgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Takahiko Yamasawa
- Department of Cardiovascular Surgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Hiroki Takiuchi
- Department of Cardiovascular Surgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Takeshi Honda
- Department of Cardiovascular Surgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Noriaki Kuwada
- Department of Cardiovascular Surgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - Kenji Kojima
- Department of Physiological Laboratory, Kawasaki Medical School Hospital, Kurashiki, Okayama, Japan
| | - Kazuo Tanemoto
- Department of Cardiovascular Surgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
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Wallace T, Leung C, Nandhra S, Samuel N, Carradice D, Chetter I. Defining the optimum tumescent anaesthesia solution in endovenous laser ablation. Phlebology 2016; 32:322-333. [PMID: 27306991 DOI: 10.1177/0268355516653905] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives To produce a tumescent anaesthesia solution with physiological pH for endovenous thermal ablation and evaluate its influence on peri- and postoperative pain, clinical and quality of life outcomes, and technical success. Methods Tumescent anaesthetic solution (0.1% lidocaine with 1:2,000,000 epinephrine) was titrated to physiological pH by buffering with 2 ml incremental aliquots of 8.4% sodium bicarbonate. Patients undergoing great saphenous vein endovenous laser ablation and ambulatory phlebectomy were studied before and after introduction of buffered tumescent anaesthetic. Primary outcome was perioperative pain measured on a 10 cm visual analogue scale. Secondary outcomes were daily pain scores during the first postoperative week, complications, time to return to normal activity, patient satisfaction, generic and disease-specific quality of life, and technical success. Patients were assessed at baseline, and at 1, 6 and 12 weeks following the procedure. Results A physiological pH was achieved with the addition of 10 ml of 8.4% sodium bicarbonate to 1 l of standard tumescent anaesthetic solution. Sixty-two patients undergoing great saphenous vein endovenous laser ablation with phlebectomy were recruited before and after the introduction of buffered tumescent anaesthetic solution. Baseline and operative characteristics were well matched. The buffered solution was associated with significantly lower (median (interquartile range)) periprocedural pain scores (1 (0.25-2.25) versus 4 (3-6), p < 0.001) and postoperative pain score at the end of the treatment day (1.8 (0.3-2.8) versus 3.0 (1.2-5.2), p = 0.033). There were no significant differences in postoperative pain scores between the groups at any other time. There were no significant differences in other clinical outcomes between the groups. Both groups demonstrated significant improvements in generic and disease-specific quality of life, with no intergroup differences. Both groups demonstrated 100% ultrasonographic technical success at all time points. Conclusions Buffering of tumescent anaesthetic solution during endovenous thermal ablation is a simple, safe, inexpensive and effective means of reducing perioperative and early postoperative pain.
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Affiliation(s)
- Tom Wallace
- Academic Vascular Surgical Unit, Hull York Medical School / Hull Royal Infirmary, Hull, UK
| | - Clement Leung
- Academic Vascular Surgical Unit, Hull York Medical School / Hull Royal Infirmary, Hull, UK
| | - Sandip Nandhra
- Academic Vascular Surgical Unit, Hull York Medical School / Hull Royal Infirmary, Hull, UK
| | - Nehemiah Samuel
- Academic Vascular Surgical Unit, Hull York Medical School / Hull Royal Infirmary, Hull, UK
| | - Daniel Carradice
- Academic Vascular Surgical Unit, Hull York Medical School / Hull Royal Infirmary, Hull, UK
| | - Ian Chetter
- Academic Vascular Surgical Unit, Hull York Medical School / Hull Royal Infirmary, Hull, UK
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Go SJ, Cho BS, Mun YS, Kang YJ, Ahn HY. Study on the Long-Term Results of Endovenous Laser Ablation for Treating Varicose Veins. Int J Angiol 2016; 25:117-20. [PMID: 27231428 DOI: 10.1055/s-0035-1555749] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Background Endovenous laser ablation (EVLA) is widely performed since the early 2000s, but there are few long-term results. Objectives The aim of this study was to evaluate the long-term results of EVLA employed for treating varicose veins of the lower limbs by duplex ultrasonographic study. Methods A total of 24 limbs of 17 patients who underwent EVLA between 2004 and 2007 were examined with duplex ultrasonographic scans. The mean follow-up period was 66.1 months. Results There were five recurrences of saphenofemoral junction reflux. The occlusion rate was 79.2% at a mean follow-up of 66.1 months. There were 14 recanalizations and 5 recurrences of the great saphenous vein. Five partial and nine total recanalizations were observed. Conclusions EVLA is an effective and minimally invasive treatment for varicose veins. Our long-term result was acceptable, but the result was not outstanding.
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Affiliation(s)
- Seung Je Go
- Department of Surgery, Eulji University Hospital, Daejeon, South Korea
| | - Byung Sun Cho
- Department of Surgery, Eulji University Hospital, Daejeon, South Korea
| | - Yun Su Mun
- Department of Surgery, Eulji University Hospital, Daejeon, South Korea
| | - Yoon Jung Kang
- Department of Surgery, Eulji University Hospital, Daejeon, South Korea
| | - Hye Young Ahn
- Eulji University College of Nursing, Daejeon, South Korea
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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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Van der Velden SK, Lawaetz M, De Maeseneer MGR, Hollestein L, Nijsten T, van den Bos RR. Predictors of Recanalization of the Great Saphenous Vein in Randomized Controlled Trials 1 Year After Endovenous Thermal Ablation. Eur J Vasc Endovasc Surg 2016; 52:234-41. [PMID: 26994834 DOI: 10.1016/j.ejvs.2016.01.021] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Accepted: 01/24/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVE/BACKGROUND The objective was to identify predictors to develop and validate a prognostic model of recanalization of the great saphenous vein (GSV) in patients treated with endovenous thermal ablation (EVTA). METHODS The search strategy of Siribumrungwong was updated between August 2011 and August 2014 using MEDLINE, Embase, and the Cochrane register to identify randomized controlled trials (RCTs), in which patients presenting with GSV reflux were treated with radiofrequency or endovenous laser ablation. Leg level data (n = 1226) of 15/23 selected RCTs were pooled. The primary outcome was recanalization of the GSV; the secondary outcome was change in health related quality of life (HRQoL) measured by the Chronic Venous Insufficiency quality of life Questionnaire or Aberdeen Varicose Vein Questionnaire 1 year post-procedure. Candidate predictors were age, sex, body mass index, clinical class, GSV diameter, saphenofemoral junction reflux, type of device, energy, and length of treated vein. RESULTS At 1 year, 130 GSVs were recanalized (11%). Clinical class (odds ratio [OR] 2.1, 95% confidence interval [CI] 1.4-3.3) and diameter (OR 1.8, 95% CI 1.2-2.7) of the GSV were the strongest predictors of recanalization. Other predictors included in the final model were sex, type of device, and length of treated vein. The performance of the recanalization model was moderate, with an area under the curve above 0.717. GSV diameter, type of device, and amount of energy delivered were the only predictors of the change of HRQoL. None of the candidate predictors were included in the final HRQoL model (R(2) = .027). CONCLUSION There are several important prognostic factors for GSV recanalization and change of HRQoL after EVTA. However, the performance of each model was unsatisfactory to allow use in clinical practice yet.
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Affiliation(s)
| | - M Lawaetz
- Danish Vein Centers, Åreknudeklinikken, and Surgical Center Roskilde, Naestved, Denmark
| | | | - L Hollestein
- Department of Dermatology, Erasmus MC, Rotterdam, The Netherlands
| | - T Nijsten
- Department of Dermatology, Erasmus MC, Rotterdam, The Netherlands
| | - R R van den Bos
- Department of Dermatology, Erasmus MC, Rotterdam, The Netherlands
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Cotton SC, MacLennan G, Brittenden J, Prior M, Francis J. Behavioural recovery after treatment for varicose veins. Br J Surg 2016; 103:374-81. [PMID: 26805720 PMCID: PMC4819709 DOI: 10.1002/bjs.10081] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Revised: 10/22/2015] [Accepted: 11/17/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND The aim of this study was to assess behavioural recovery from the patient's perspective as a prespecified secondary outcome in a multicentre parallel-group randomized clinical trial comparing ultrasound-guided foam sclerotherapy (UGFS), endovenous laser ablation (EVLA) and surgery for the treatment of primary varicose veins. METHODS Participants were recruited from 11 UK sites as part of the CLASS trial, a randomized trial of UGFS, EVLA or surgery for varicose veins. Patients were followed up 6 weeks after treatment and asked to complete the Behavioural Recovery After treatment for Varicose Veins (BRAVVO) questionnaire. This is a 15-item instrument that covers eight activity behaviours (tasks or actions an individual is capable of doing in an idealized situation) and seven participation behaviours (what the individual does in an everyday, real-world situation) that were identified to be important from the patient's perspective. RESULTS A total of 798 participants were recruited. Both UGFS and EVLA resulted in a significantly quicker recovery compared with surgery for 13 of the 15 behaviours assessed. UGFS was superior to EVLA in terms of return to full-time work (hazard ratio 1·43, 95 per cent c.i. 1·11 to 1·85), looking after children (1·45, 1·04 to 2·02) and walks of short (1·48, 1·19 to 1·84) and longer (1·32, 1·05 to 1·66) duration. CONCLUSION Both UGFS and EVLA resulted in more rapid recovery than surgery, and UGFS was superior to EVLA for one-quarter of the behaviours assessed. The BRAVVO questionnaire has the potential to provide important meaningful information to patients about their early recovery and what they may expect to be able to achieve after treatment.
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Affiliation(s)
- S C Cotton
- Health Services Research Unit, University of Aberdeen, Foresterhill, Aberdeen, UK
| | - G MacLennan
- Health Services Research Unit, University of Aberdeen, Foresterhill, Aberdeen, UK
| | - J Brittenden
- Division of Applied Medicine, University of Aberdeen, Foresterhill, Aberdeen, UK
| | - M Prior
- Health Services Research Unit, University of Aberdeen, Foresterhill, Aberdeen, UK
| | - J Francis
- School of Health Sciences, City University London, London, 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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Gauw SA, Lawson JA, van Vlijmen-van Keulen CJ, Pronk P, Gaastra MTW, Mooij MC. Five-year follow-up of a randomized, controlled trial comparing saphenofemoral ligation and stripping of the great saphenous vein with endovenous laser ablation (980 nm) using local tumescent anesthesia. J Vasc Surg 2015; 63:420-8. [PMID: 26602795 DOI: 10.1016/j.jvs.2015.08.084] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 08/17/2015] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The objective of this study was to compare the long-term results (groin-related recurrence, great saphenous vein [GSV] occlusion rate, Clinical class, Etiology, Anatomy, and Pathophysiology [CEAP] staging, and quality of life [QoL]) after the treatment of a GSV incompetence by saphenofemoral ligation and stripping (SFL/S) with endovenous laser ablation bare fiber, 980 nm (EVLA). METHODS Patients with GSV insufficiency and varicose veins were randomized to either undergo SFL/S or EVLA, both of which were performed under tumescent anesthesia. The long-term results, which included the anatomic occlusion rate, varicose vein recurrence at the saphenofemoral junction (SFJ), relief of venous symptoms and QoL, were compared up to 5 years after treatment. RESULTS A total of 130 legs of 121 patients were treated with either SFL/S (n = 68) or EVLA (n = 62). In the first 12 months, three recanalizations of the GSV were observed after EVLA. Up to 5 years later, more recurrent varicose veins caused by neoreflux in incompetent tributaries of the SFJ were observed in after EVLA (31%; 19/61) compared with SFL/S (7%; 4/60; P < .01). Neovascularization in the groin with clinically visible recurrence identified at 3 and 5 years post-treatment follow-up was only observed in the SFL/S group (n = 6). After 5 years, clinically visible recurrences originating from the SFJ region after EVLA were observed 33% (20/61) compared with 17% of patients (10/60) after SFL/S (P < .04). In both treatment groups, venous symptoms improved significantly. Patients in both groups reported a continuing significant cosmetic improvement measured on a visual analog scale of 1 to 10 (mean, 7.49; P < .01). There was no difference in the CEAP staging and a standardized, non-disease-specific instrument for describing and valuing health states (EuroQol-5D), between the groups up to 5 years after follow-up. CONCLUSIONS At the 5-year follow-up, a significantly higher varicose vein recurrence rate originated at the SFJ region after EVLA compared with SFL/S. There were no differences in the relief of venous symptoms, CEAP staging, or general QoL between the groups.
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Rass K, Frings N, Glowacki P, Gräber S, Tilgen W, Vogt T. Same Site Recurrence is More Frequent After Endovenous Laser Ablation Compared with High Ligation and Stripping of the Great Saphenous Vein: 5 year Results of a Randomized Clinical Trial (RELACS Study). Eur J Vasc Endovasc Surg 2015; 50:648-56. [PMID: 26319476 DOI: 10.1016/j.ejvs.2015.07.020] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 07/08/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To compare the long-term clinical efficacy of endovenous laser ablation (EVLA) with high ligation and stripping (HLS) as standard treatment for great saphenous vein (GSV) incompetence. DESIGN Investigator initiated two centre randomized controlled trial with 5 year follow up. MATERIALS AND METHODS Interventions were performed on ambulatory and hospitalized patients at two vein centres, a university dermatology department (EVLA) and a specialized vein clinic (HLS). Four hundred patients suffering from GSV incompetence were assigned to EVLA or HLS of the GSV. One hundred and eighty five and 161 patients (=limbs), respectively, were treated per protocol. Main outcome measures were clinically recurrent varicose veins after surgery (REVAS classification, primary study objective), Duplex detected saphenofemoral recurrence, clinical venous severity scoring (Homburg Varicose Vein Severity Score), quality of life (Chronic Venous Insufficiency Questionnaire 2), side effects, and patient satisfaction 5 years after treatment. RESULTS Two hundred and eighty one legs (81% of the study population) were evaluated with a median follow up of 60.4 (EVLA) and 60.7 months (HLS). Overall, REVAS was similarly observed in both groups: 45% (EVLA) and 54% (HLS), p = .152. Patients of the EVLA group showed significantly more clinical recurrences in the operated region (REVAS: same site): 18% vs. 5%, p = .002. In contrast, more different site recurrences were observed in the HLS group: 50% vs. 31%, p = .002. Duplex detected saphenofemoral refluxes occurred more frequently after EVLA: 28% vs. 5%, p < .001. Both treatments improved disease severity and quality of life without any difference. CONCLUSIONS EVLA and HLS are comparably effective concerning overall REVAS, improvement of disease severity, and quality of life. In terms of same site clinical recurrence and saphenofemoral refluxes, HLS is superior to EVLA 5 years after treatment. CLINICAL TRIAL REGISTRATION ISRCTN18322872.
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Affiliation(s)
- K Rass
- Department of Dermatology, Venerology and Allergology, Saarland University Hospital, Homburg, Germany; Eifelklinik St. Brigida, Vein and Skin Centre, Simmerath, Germany.
| | - N Frings
- Capio Mosel-Eifel-Klinik, Clinic for Vein Disorders, Bad Bertrich, Germany
| | - P Glowacki
- Capio Mosel-Eifel-Klinik, Clinic for Vein Disorders, Bad Bertrich, Germany
| | - S Gräber
- Institute of Medical Biometry, Epidemiology and Medical Informatics, Saarland University Hospital, Homburg, Germany
| | - W Tilgen
- Department of Dermatology, Venerology and Allergology, Saarland University Hospital, Homburg, Germany
| | - T Vogt
- Department of Dermatology, Venerology and Allergology, Saarland University Hospital, Homburg, Germany
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Kosenkov AN, Vakhrat'yan PE, Avakyan AV. [Efficiency of minimally invasive methods in treatment of varicose veins]. Khirurgiia (Mosk) 2015:51-57. [PMID: 26271424 DOI: 10.17116/hirurgia2015651-57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
It was analyzed the results of studies comparing an efficiency of minimally invasive methods in treatment of varicose veins of lower extremities. Based on presented data similar efficiency of minimally invasive methods and conventional surgical treatment was proved. The graph reflecting remote results was made.
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Affiliation(s)
- A N Kosenkov
- Chair of Cardiovascular Surgery and Interventional Cardiology, I.M. Sechenov First Moscow State Medical University
| | - P E Vakhrat'yan
- Department of Vascular Surgery, acad. B.V. Petrovskiy Russian Scientific Center for Surgery of RAS, Moscow, Russia
| | - A V Avakyan
- Chair of Cardiovascular Surgery and Interventional Cardiology, I.M. Sechenov First Moscow State Medical University
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Lam YL, Toonder IM, Wittens CHA. Clarivein® mechano-chemical ablation an interim analysis of a randomized controlled trial dose-finding study. Phlebology 2015; 31:170-6. [DOI: 10.1177/0268355515599692] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives The ClariVein® system is an endovenous technique that uses mechano-chemical ablation to treat incompetent truncal veins. This study was conducted to identify the ideal Polidocanol dosage and form for mechano-chemical ablation in order to occlude the great saphenous vein. When adhering to safe dosage levels, sclerosants with higher concentrations potentially limit the extent of treatment. It has been demonstrated that this problem may be overcome by using Polidocanol as a microfoam. This paper was established on findings of a preliminary analysis. Material and methods The initial study was a single-blinded multicenter randomized controlled trial where patients are allocated to three treatment arms. Group 1 consisted of mechano-chemical ablation +2% Polidocanol liquid, group 2: mechano-chemical ablation +3% Polidocanol liquid and group 3: mechano-chemical ablation +1% Polidocanol foam Results Eighty-seven, 34 males and 53 females (60.9%), mean age 55 years s.d. 16.0 (range 24–84), were enrolled in the study. Treatment length was 30 cm (range 10–30) for 95.2% of the patients. Mean operating time was 16 minutes (range 5–70). The mean saphenofemoral junction diameter (7.7 mm) was similar in all three groups. At 6 weeks post-treatment duplex ultrasound showed that 25 out of 25 = 100%, 27 out of 28 = 96.4% and 13 out of 23 = 56.5% were occluded in the mechano-chemical ablation + 2% Polidocanol liquid, mechano-chemical ablation + 3% Polidocanol liquid and mechano-chemical ablation + 1% Polidocanol microfoam respectively ( p < 0.001). However, stricter scrutiny showed that the anatomical success rate defined as occlusion of at least 85% of the treated length to be 88.0%, 85.7% and 30.4% respectively ( p < 0.001). Conclusion Mechano-chemical ablation using ClariVein® combined with 1% Polidocanol microfoam is significantly less effective and should not be considered as a treatment option of incompetent truncal veins. Further investigation to determine the ideal Polidocanol liquid dosage with mechano-chemical ablation is advocated and is being conducted accordingly.
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Affiliation(s)
- YL Lam
- Department of Vascular Surgery, Maastricht University Medical Centre, The Netherlands
- Department of Dermatology, Maastricht University Medical Centre, The Netherlands
| | - Irwin M Toonder
- Department of Vascular Surgery, Maastricht University Medical Centre, The Netherlands
| | - Cees HA Wittens
- Department of Vascular Surgery, Maastricht University Medical Centre, The Netherlands
- Department of Vascular Surgery, Universitätsklinikum Aachen, Germany
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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: 493] [Impact Index Per Article: 54.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Krasznai AG, Sigterman TA, Willems CE, Dekkers P, Snoeijs MGJ, Wittens CHA, Sikkink CJ, Bouwman LH. Prospective study of a single treatment strategy for local tumescent anesthesia in Muller phlebectomy. Ann Vasc Surg 2015; 29:586-93. [PMID: 25595104 DOI: 10.1016/j.avsg.2014.10.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 10/23/2014] [Accepted: 10/23/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Ambulatory Muller phlebectomy for varicose veins can be performed under local anesthesia. However, subcutaneous injection of local tumescent anesthetics may cause discomfort because of acidity of the solution. Addition of sodium bicarbonate lowers the acidity of anesthetic solutions, which might cause less pain. The objective of this study was to study whether alkalinization of the local anesthetic solution with sodium bicarbonate 1.4% decreases perioperative pain during Muller phlebectomies. METHODS It is a double-blind single-center randomized controlled trial. In all, 101 patients scheduled for ambulatory Muller phlebectomy were randomized to receive either local anesthesia with alkalinized solution (lidocaine 1% and epinephrine in sodium bicarbonate 1.4%) or standard solution (lidocaine 1% and epinephrine in saline 0.9%). Primary outcome was pain during injection of local anesthetics with the use of the Visual Analogue Scale (VAS). Secondary outcomes were peroperative and postoperative pain, use of analgesics, patient satisfaction, return to function, and complications. RESULTS Patients receiving subcutaneous injection of local anesthetics diluted in sodium bicarbonate 1.4% experienced significantly less pain during injection compared with patients treated with standard anesthetic solution (VAS, 1.75 ± 1.8 vs. 3.55 ± 2.2, P < 0.00). Peroperative and postoperative pain, complication rates, use of analgesics, patient satisfaction, return to function, and complications did not differ between the 2 groups (P > 0.10). CONCLUSIONS Alkalinization of local anesthetic solution with sodium bicarbonate 1.4% significantly improves patient comfort during injection of local tumescent anesthesia.
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Affiliation(s)
- Attila G Krasznai
- Department of Surgery, Atrium Medical Centre, Heerlen, The Netherlands
| | - Tim A Sigterman
- Department of Surgery, Atrium Medical Centre, Heerlen, The Netherlands.
| | | | - Peter Dekkers
- Department of Pharmacy, Atrium Medical Centre, Heerlen, The Netherlands
| | | | - Cees H A Wittens
- Department of Surgery, MUMC, Maastricht, The Netherlands; Department of Surgery, Uniklinik Aachen, Aachen, Germany
| | - Cees-Jan Sikkink
- Department of Surgery, Atrium Medical Centre, Heerlen, The Netherlands
| | - Lee H Bouwman
- Department of Surgery, Atrium Medical Centre, Heerlen, The Netherlands
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Schmedt CG, Dikic S, Esipova A, Demhasaj S, Küspert T, Sroka R. Endovenöse Lasertherapie der Varikose – Evidenz und Perspektiven. GEFÄSSCHIRURGIE 2014. [DOI: 10.1007/s00772-014-1355-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Rustempasic N, Cvorak A, Agincic A. Outcome of endovenous laser ablation of varicose veins. Acta Inform Med 2014; 22:329-32. [PMID: 25568583 PMCID: PMC4272832 DOI: 10.5455/aim.2014.22.329-332] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 10/25/2014] [Indexed: 11/25/2022] Open
Abstract
Introduction: In Bosnia and Herzegovina according to available data, treatment of incompetent superficial lower extremity varicose veins by endovenous laser ablation (EVLA) has been introduced two years ago and so far no paper has been published regarding results of EVLA treatment of patients from our country. We wanted to present our results with EVLA treatment. Aim of study: to evaluate and compare primary posttreatment outcomes of endovenous laser ablation (EVLA) with classical surgical method of varicose vein treatment. Patients and methods: The study was clinical and prospective. It was carried out at Clinic for vascular surgery in Sarajevo where fifty-eight (58) patients received surgical treatment for varicose veins and in Aesthetic Surgery Center “Nasa mala klinika” in Sarajevo were sixty-one (61) patients with varicose veins were treated by endovenous laser ablation. Total 119 patients (limbs) with pathologic reflux only in great saphenous vein were evaluated between 1st of January 2013 and 31st of April 2014. Following primary outcome endpoints were evaluated smean day of return to normal everyday activities, patient subjective quantification of pain during first seven days after intervention, incidence of deep venous thrombosis (DVT), incidence of wound bleeding requiring surgical intervention, incidence of peri-saphenous vein hematoma and infection rate. Results: Mean of return to normal activities (expressed in days after intervention); EVLA vs. stripping (surgery) =1.21vs12.24, T test 13,619; p=0, 000, p<0,05. T test was used for comparing Mean value of visual pain analog scale for the first 7 days between groups, for all seven days pain was significantly higher in surgical group of patients as compared to EVLA group; p<0,05. Incidence of hematoma greater than 1% of total body surface area was significantly higher in patients receiving surgical treatment; Pearson Chi Square=23,830, p<0,05; odds ratio:10,453. Incidences of infection, deep venous thrombosis and posttreatment bleeding were not statistically different between analyzed groups; EVLA vs Surgery (Pearson Chi Square =3,237; p>0,05; Pearson Chi Square=2,139, p>0,05, Pearson Chi Square=2,139, p>0,05, respectively.) Conclusion: EVLA offers better patient recovery in terms of significantly lower post treatment pain, faster return to everyday activities and lower incidence of bruising (hematomas).
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Affiliation(s)
- Nedzad Rustempasic
- Clinic for Vascular Surgery, Clinical Center of University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Alemko Cvorak
- Clinic for Plastic and Reconstructive Surgery, Clinical Center of University of Sarajevo, Sarajevo, Bosnia and Herzegovna
| | - Alija Agincic
- Clinic for Plastic and Reconstructive Surgery, Clinical Center of University of Sarajevo, Sarajevo, Bosnia and Herzegovna
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