Does Puncture Site Affect the Rate of Nerve Injuries Following Endovenous Laser Ablation of the Small Saphenous Veins?

Second-generation treatment of varicose veins: endovenous thermal ablation by laser or radiofrequency ablation

Background: Endovenous thermal ablation (EVTA) is the second-generation treatment of varicose veins in the lower extremities. It has overcome the shortcomings of the first-generation treatment of high ligation and stripping. Further, it is the basis for the development of the third-generation treatment with endovenous glue ablation. It is currently recommended as the first-line treatment for varicose veins accompanied by great saphenous vein incompetence.Current Concepts: EVTA involves obliterating the varicosed veins by applying thermal energy to blood or vein wall. It can be performed by laser or radiofrequency ablation methods, under local anesthesia. The treatment results are excellent and show lesser pain and faster recovery compared to the first-generation treatment. However, complications include endovenous heat-induced thrombosis, deep vein thrombosis, ecchymosis, and phlebitis.Discussion and Conclusion: To enhance the therapeutic effect and reduce the complications of EVTA, sufficient tumescent anesthesia, a controlled number of firing in radiofrequency ablation, and use of the novel highwavelength laser and a radial catheter tip in endovenous laser ablation are recommended. In addition, proficiency in other generations of varicose vein treatments could help in various situations.

Risk factors for saphenous vein recanalization after endovenous radiofrequency ablation

Target vein recanalization is defined as the postoperative detection of blood flow in a venous segment previously ablated. It can be occurred after thermal-tumescent procedures, as radiofrequency (RFA) and endovenous laser (EVLA) ablation techniques. Despite several papers described and analyzed incidence and consequences of recanalization, limited data are published on risk factors for this condition. The aim of this general review is to investigate clinical and instrumental risk factors for great and small saphenous veins recanalization after RFA, indicating their impact in the follow-up period.

Comparison of different approaches to small saphenous vein reflux treatment: a retrospective study in two centers

BACKGROUND

Diagnosis and treatment of small saphenous vein (SSV) insufficiency is of utmost importance for relieving chronic venous insufficiency symptoms.

OBJECTIVES

To investigate the efficacy and safety of five different treatment approaches among patients with SSV insufficiency.

DESIGN AND SETTING

Two-center retrospective clinical study, conducted at cardiovascular surgery clinics in a local training and research hospital and a state hospital.

METHODS

A total of 282 extremities of 268 patients with SSV insufficiency alone who were treated for symptomatic varicose veins between January 2012 and January 2017 were included in the study. All extremities included in the study were divided into five groups as follows: high ligation + stripping; radiofrequency ablation (RFA); cyanoacrylate closure (CAC); and endovenous laser ablation (EVLA) at the wavelengths 980 nm and 1,470 nm.

RESULTS

Although the recurrence rate at six months was similar among the treatment groups, we found significant differences in recurrence rates at one year, with lower rates in the CAC, RFA and 1,470 nm EVLA groups, compared with the other treatments (P = 0.005). No sural neuritis was observed in the CAC group. The pigmentation rate was higher in the two EVLA groups (980 nm and 1,470 nm).

CONCLUSIONS

Our study results showed that although CAC, RFA and EVLA at 1,470 nm seemed to be effective methods for treating SSV insufficiency alone, CAC and RFA had better aesthetic results than EVLA at 1,470 nm. We consider that endovenous non-thermal techniques for treating SSV insufficiency may be preferable because of relatively low risk of nerve injury.

European College of Phlebology guideline for truncal ablation

Background

The purpose of the guideline was to achieve consensus in the care and treatment of patients with chronic venous disease, based on current evidence.

Method

A systematic literature search was performed in PubMed, Embase, Cinahl, and the Cochrane library up until 1 February 2019. Additional relevant literature were added through checking of references. Level of evidence was graded through the GRADE scale and recommendations were concluded.

Results

For the treatment of great and small saphenous vein reflux, endovenous ablation with laser or radiofrequency was recommended in preference to surgery or foam sclerotherapy. If tributaries are to be treated it should be done in the same procedure. Treatment with mecanicochemical ablation and glue can be used but we still need long term follow up results.

Conclusion

For the treatment of truncal varicosities, endovenous ablation with laser or radiofrequency combined with phlebectomies is recommended before surgery or foam.

Mid-calf level as a puncture site is not safe enough for thermal ablation of the small saphenous vein

Background:

Endovenous thermal ablation of the small saphenous vein carries a risk for sural nerve injury. Ablation above mid-calf level is recommended to avoid it. However, this strategy could not eradicate this complication. We present our results of consecutive 30 small saphenous vein thermal ablations which are performed after ultrasonographic identification of the sural nerve.

Methods:

We studied 26 consecutive subjects with a total of 30 limbs. Ablation was performed proximal to the risk point by a 1470-nm diode laser. Patients were asked to attend follow-up outpatient controls at 7 days, 30 days, and 180 days postoperatively. Rate of identification of the sural nerve by ultrasonography, safety of the mid-calf level as a puncture site and postoperative sural nerve damage were assessed.

Results:

The sural nerve identification was achieved by ultrasonography in all patients except for one. Mid-calf level as a puncture site was not safe in three (10%) extremities. None of the patients showed any evidence suggesting postoperative sural nerve damage.

Conclusion:

Choosing the puncture site according to the risk point may be more reasonable than general mid-calf level which is being used.

Hydrodisplacement of sural nerve for safety and efficacy of endovenous thermal ablation for small saphenous vein incompetence

Background

Endovenous radio frequency ablation for small saphenous vein incompetence by and large appears to be superior and safer than conventional open surgery. Small saphenous vein ablation from approximately mid-calf to the point proximally where the small saphenous vein dives into the popliteal fossa is considered to be safe, as the sural nerve is in most cases separated from this segment of the small saphenous vein by the deep fascia. The outcome of the distal incompetent small saphenous vein remains unclear. Efficacy of the endovenous radio frequency ablation can be enhanced by increasing the length of the ablatable small saphenous vein segment.

Methodology

To optimise endovenous radio frequency ablation outcome, the distal small saphenous vein may be made amenable to ablation if safety of the sural nerve can be assured. The sural nerve was successfully located using duplex ultrasound in 100% of our cohort in this study. The standard entry point for venous access was just above the lateral malleolus. After introduction of the introducer sheath, the radio frequency catheter was advanced proximally; the sural nerve was displaced from the small saphenous vein by approximately 1 cm with the administration of tumescent anaesthesia ( hydrodisplacement). A total of 118 patients underwent extended endovenous radio frequency ablation of 124 incompetent small saphenous vein trunks using the method described.

Results

Successful extended ablation of the small saphenous vein was achieved in 100% of cases and it was confirmed by duplex scanning at one and six weeks. Two neurological events were recorded during the study:  1. One patient with temporary foot drop lasting for less than 6 h with complete recovery.  2. A second patient with a sural nerve sensory deficit reported by the patient at day 2–3, which remains current at six weeks.

Conclusions

Extended endovenous radio frequency ablation of the small saphenous vein to optimise length of the ablatable vein segment is feasible with careful identification and hydrodisplacement of the sural nerve. This method is shown to be associated with fewer neurological complications than other methods reported in the literature.

Retrograde Endovenous Laser Ablation through Saphenopopliteal Junctional Area for Incompetent Small Saphenous Vein: Comparison with Antegrade Approach

Objective

To evaluate the safety and efficacy of retrograde endovenous laser ablation (EVLA) and to compare it with the conventional antegrade EVLA for incompetent small saphenous vein (SSV).

Materials and Methods

Small saphenous vein was cannulated via two approaches under ultrasound-guidance. One method involved puncturing the SSV cranially at mid-calf (the antegrade group). If the antegrade puncture into the SSV failed twice, the other approach for puncture was selected that involved puncturing the SSV toward the ankle (the retrograde group). Patients were evaluated in terms of technical & clinical success, closure rates of the SSV, and complications including pain, bruising, or paresthesia at all follow-up visits.

Results

The 1470 nm endovenous laser was used in all limbs. Technical success was seen in all limbs in both groups (100%). Closure rate in both groups showed about 95%, without significant difference (p = 0.685). Similar linear endovenous energy density was supplied during the EVLA in both groups (p = 0.876). Three frequent complications including bruising, pain, and paresthesia did not show statistical significance between groups (p = 0.465, 0.823, 1.000, respectively). Major complications were absent in both groups.

Conclusion

The EVLA for the incompetent SSV using a retrograde approach is safe and effective and should be considered the alternative method if the antegrade access fails due to vasospasm or small SSV diameter.

Treatment Modalities for Small Saphenous Vein Insufficiency: Systematic Review and Meta-analysis

PURPOSE

To investigate and compare the anatomical success rates and complications of the treatment modalities for small saphenous vein (SSV) incompetence.

METHODS

A systematic literature search was performed in PubMed, EMBASE, and the Cochrane Library on the following therapies for incompetence of SSVs: surgery, endovenous laser ablation (EVLA), radiofrequency ablation (RFA), ultrasound-guided foam sclerotherapy (UGFS), steam ablation, and mechanochemical endovenous ablation (MOCA). The search found 49 articles (5 randomized controlled trials, 44 cohort studies) reporting on the different treatment modalities: surgery (n=9), EVLA (n=28), RFA (n=9), UGFS (n=6), and MOCA (n=1). A random-effects model was used to estimate the primary outcome of anatomical success, which was defined as closure of the treated vein on follow-up duplex ultrasound imaging. The estimate is reported with the 95% confidence interval (CI). Secondary outcomes were technical success and major complications [paresthesia and deep vein thrombosis (DVT)], given as the weighted means.

RESULTS

The pooled anatomical success rate was 58.0% (95% CI 40.9% to 75.0%) for surgery in 798 SSVs, 98.5% (95% CI 97.7% to 99.2%) for EVLA in 2950 SSVs, 97.1% (95% CI 94.3% to 99.9%) for RFA in 386 SSVs, and 63.6% (95% CI 47.1% to 80.1%) for UGFS in 494 SSVs. One study reported results of MOCA, with an anatomical success rate of 94%. Neurologic complications were most frequently reported after surgery (mean 19.6%) and thermal ablation (EVLA: mean 4.8%; RFA: mean 9.7%). Deep venous thrombosis was a rare complication (0% to 1.2%).

CONCLUSION

Endovenous thermal ablation (EVLA/RFA) should be preferred to surgery and foam sclerotherapy in the treatment of SSV incompetence. Although data on nonthermal techniques in SSV are still sparse, the potential benefits, especially the reduced risk of nerve injury, might be of considerable clinical importance.

Dutch Venous Ulcer guideline update

The revised guideline of 2013 is an update of the 2005 guideline "venous leg ulcer". In this special project four separate guidelines (venous leg ulcer, varicose veins, compression therapy and deep venous disorders) were revised and developed simultaneously. A meeting was held including representatives of any organisation involved in venous disease management including patient organizations and health insurance companies. Eighteen clinical questions where defined, and a new strategy was used to accelerate the process. This resulted in two new and two revised guidelines within one year. The guideline committee advises use of the C of the CEAP classification as well as the Venous Clinical Severity Score (VCSS) and a Quality of life (QoL) score in the assessment of clinical signs. These can provide insight into the burden of disease and the effects of treatment as experienced by the patient. A duplex ultrasound should be performed in every patient to establish the underlying aetiology and to evaluate the need for treatment (which is discussed in a separate guideline). The use of the TIME model for describing venous ulcers is recommended. There is no evidence for antiseptic or antibiotic wound care products except for a Cochrane review in which some evidence is presented for cadexomer iodine. Signs of infection are the main reason for the use of oral antibiotics. When the ulcer fails to heal the use of oral aspirin and pentoxifylline can be considered as an adjunct. For the individual patient, the following aspects should be considered: the appearance of the ulcer (amount of exudate) according to the TIME model, the influence of wound care products on moisturising the wound, frequency of changing compression bandages, pain and allergies. The cost of the dressings should also be considered. Education and training of patients t improves compliance with compression therapy but does not influence wound healing rates.

Guidelines of the First International Consensus Conference on Endovenous Thermal Ablation for Varicose Vein Disease--ETAV Consensus Meeting 2012

AIM

Endovenous thermal ablation (ETA) procedures are catheter-directed, ultrasound (US)-guided thermal methods for treatment in varicose veins disease. Radiofrequency, laser or steam energy thermally denatures vein wall collagen, leading first to vein wall inflammation, then fibrosis and finally to occlusion. The aim of this guideline is to give evidence-based recommendations for ETA procedures.

METHODS

These guidelines were drafted during a consensus meeting of a group of experts in the field of ETA in June 2012 (Hvar, Croatia) under the auspices of the International Union of Phlebology (IUP). These guidelines review the present state of knowledge as reflected in peer-reviewed published medical literature. The recommendations of these guidelines are graded according to the American College of Chest Physicians Task Force recommendations on Grading Strength of Recommendations and Quality of Evidence in Clinical Guidelines.

RESULTS

Recommendations on the use of ETA procedures were made based on the quality of evidence for efficacy, safety, tolerability, cosmetic outcome, patient satisfaction/preference and, where appropriate, on the experts' opinion. Health economics were not considered, since differences in national health systems and pricing make it difficult to form general conclusions that are relevant at an international level.

A double-blind, randomized, intra-individual controlled feasibility trial comparing the use of 1,470 and 940 nm diode laser for the treatment of hyperplastic inferior nasal turbinates

INTRODUCTION

Various laser systems have been used for volume reduction of hyperplastic nasal turbinates. For endonasal application, fiber controlled diode lasers are preferred over conventional laser systems for reasons of cost and practicability. This study compares coagulative tissue effects using λ = 1,470 nm and λ = 940 nm lasers in treatment of hyperplastic inferior nasal turbinates in an intraindividual manner.

METHODS

Twenty patients underwent laser coagulation for hyperplastic inferior nasal turbinates in this prospective, randomized, double-blind, clinical feasibility trial. In each case, one nasal cavity was treated using 1,470 nm laser (4-5 W power), the other one with 940 nm laser (12 W power), endoscopically controlled in noncontact mode. Clinical presentation and patients symptoms were documented preoperatively and on day 1, 3, 7, 14, and 21 postoperatively using rhinomanometry, standardized questionnaires including SNOT 20 GAV (German adapted version), and separate endoscopic examination, respectively.

RESULTS

No infections, hemorrhages, or other complications occurred intra- or postoperatively. The mean operation time was significantly shorter using the 1,470 nm diode laser as compared to the 940 nm laser. There was a significant reduction of nasal obstruction on day 21 postoperatively compared to the preoperative condition on both sides regardless of the laser system used. Evaluation of the SNOT-Scores as assessed before and 3 weeks after surgery showed significant subjective improvements.

CONCLUSIONS

1,470 nm diode laser system offers an efficient method for tissue reduction in hyperplasia of inferior nasal turbinate. Compared with our standard practice (940 nm diode laser), 1,470 nm diode laser application provides an equivalent tissue reduction in shorter operation time using less total energy and a comparable relief of nasal obstruction postoperatively.

Complications of Radiofrequency Ablation of Varicose Veins

Radiofrequency ablation (RFA) has become a valued weapon in the phlebologist's armoury. It offers ease of use and reproducibility with good outcomes. However, as with all interventions, complications arise. In this review we examine the complications inherent with RFA and their relative risk, with their avoidance measures if available. Overall, we find that RFA offers a very safe procedure with rare severe complications.

Results of Radiofrequency Ablation of the Small Saphenous Vein in the Supine Position

Objectives: To report the results of a novel approach using supine positioning for radiofrequency ablation (RFA) of the small saphenous vein (SSV) with combined ablation of the great saphenous vein (GSV). Methods: Over a 24-month period, we identified patients with symptomatic SSV incompetence. Access to the SSV was accomplished by ultrasound-guided venipuncture with the patient in the supine position. Results: Small saphenous vein ablation was performed on 27 limbs in 26 patients. Median follow-up was 94 days (interquartile range [IQR] 26, 171). Mean clinical–etiologic–anatomic–pathophysiologic (CEAP) score was 3.5 ± 1.3. Small saphenous vein ablation was performed in conjunction with GSV ablation in 17 patients and with phlebectomy in 14 patients. Postoperative ultrasound was performed after 26 of 27 procedures. The SSV was sealed in all 26 cases. Two patients (8%) had a deep venous thrombosis (DVT). Conclusions: The SSV can be effectively sealed by RFA from the supine position and combined SSV/GSV ablation can be carried out in a single setting.