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Chin AL, Talutis SD, Lawrence PF, Woo K, Rigberg DA, Rollo JC, Jimenez JC. Factors associated with ablation-related thrombus extension following microfoam versus radiofrequency saphenous vein closure. J Vasc Surg Venous Lymphat Disord 2024; 12:101815. [PMID: 38215907 DOI: 10.1016/j.jvsv.2024.101815] [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: 10/02/2023] [Revised: 11/03/2023] [Accepted: 11/14/2023] [Indexed: 01/14/2024]
Abstract
OBJECTIVE Polidocanol endovenous microfoam ablation (MFA) is approved by the US Food and Drug Administration for great saphenous vein (GSV) closure, yet there are few published data on the subsequent risk of ablation-related thrombus extension (ARTE). Recent societal practice guidelines recommend against routine postprocedure duplex ultrasound (DU) examination after thermal ablation of the GSV in asymptomatic patients. At present, limited data do not allow this recommendation to extend to MFA. Our aim is to identify characteristics and outcomes associated with ARTE following MFA vs radiofrequency ablation (RFA). METHODS A retrospective review of a prospectively maintained database was conducted of patients who underwent MFA and RFA closure of incompetent above-knee GSVs. Patients treated for isolated tributary vein treatment or did not have a postprocedure DU examination within 48 to 72 hours were not included. Patients were classified into two groups: ARTE and no ARTE. Demographic data, Clinical, Etiologic, Anatomic and Pathophysiologic class, Venous Clinical Severity Score, operative details, postprocedure (48-72 hours) DU findings, and adverse events were analyzed. Variables that were significant on univariate analysis were evaluated using multivariate logistic regression with the primary outcome being development of ARTE. RESULTS Between June 2018 and February 2023, 800 limbs were treated with either MFA (n = 224) or RFA (n = 576). Ninety-six GSVs treated with MFA met the study criteria. One hundred fifty successive GSVs treated with RFA during the same period were included as a comparison group. There was no statistically significant difference in baseline demographics between the two groups. Six patients (2.4%) demonstrated ARTE on postoperative DU examination at 48 to 72 hours (MFA, n = 5 [5.2%]; RFA, n = 1 [0.7%]; P = .02). Saphenous vein ablation with MFA (P = .045) and a vein diameter of >10 mm (P = .017) were associated with ARTE on both univariable and multivariable analysis. All patients who developed ARTE were treated with oral anticoagulants (mean, 15.6 days). Body mass index, Clinical, Etiologic, Anatomic and Pathophysiologic class, Venous Clinical Severity Score, microfoam volume, operative time, and prior deep venous thrombosis were not predictive of ARTE. CONCLUSIONS ARTE after above-knee GSV closure occurred more frequently after MFA. Our results suggest that a saphenous vein diameter of >10 mm may be associated with ARTE. Despite this finding, all patients with ARTE were treated with short-term anticoagulation with no related complications. Until larger studies with high-risk subgroups have been studied after MFA, DU examination should be performed routinely after this procedure and patients with ARTE anticoagulated until the thrombus retracts caudal to the saphenofemoral junction or is no longer present on DU examination. Current societal guidelines recommending against routine post-thermal ablation DU examination should not be applied to similar patients after saphenous nonthermal MFA ablation.
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Affiliation(s)
- Amanda L Chin
- Division of Vascular and Endovascular Surgery, Gonda Venous Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Stephanie D Talutis
- Division of Vascular and Endovascular Surgery, Gonda Venous Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Peter F Lawrence
- Division of Vascular and Endovascular Surgery, Gonda Venous Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Karen Woo
- Division of Vascular and Endovascular Surgery, Gonda Venous Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - David A Rigberg
- Division of Vascular and Endovascular Surgery, Gonda Venous Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Johnathon C Rollo
- Division of Vascular and Endovascular Surgery, Gonda Venous Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Juan Carlos Jimenez
- Division of Vascular and Endovascular Surgery, Gonda Venous Center, David Geffen School of Medicine at UCLA, Los Angeles, CA.
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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 2023 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 II: Endorsed by the Society of Interventional Radiology and the Society for Vascular Medicine. J Vasc Surg Venous Lymphat Disord 2024; 12:101670. [PMID: 37652254 DOI: 10.1016/j.jvsv.2023.08.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 08/20/2023] [Indexed: 09/02/2023]
Abstract
The Society for Vascular Surgery, the American Venous Forum, and the American Vein and Lymphatic Society recently published Part I of the 2022 clinical practice guidelines on varicose veins. Recommendations were based on the latest scientific evidence researched following an independent systematic review and meta-analysis of five critical issues affecting the management of patients with lower extremity varicose veins, using the patients, interventions, comparators, and outcome system to answer critical questions. Part I discussed the role of duplex ultrasound scanning in the evaluation of varicose veins and treatment of superficial truncal reflux. Part II focuses on evidence supporting the prevention and management of varicose vein patients with compression, on treatment with drugs and nutritional supplements, on evaluation and treatment of varicose tributaries, on superficial venous aneurysms, and on the management of complications of varicose veins and their treatment. All guidelines were based on systematic reviews, and they were graded according to the level of evidence and the strength of recommendations, using the GRADE method. All ungraded Consensus Statements were supported by an extensive literature review and the unanimous agreement of an expert, multidisciplinary panel. Ungraded Good Practice Statements are recommendations that are supported only by indirect evidence. The topic, however, is usually noncontroversial and agreed upon by most stakeholders. The Implementation Remarks contain technical information that supports the implementation of specific recommendations. This comprehensive document includes a list of all recommendations (Parts I-II), ungraded consensus statements, implementation remarks, and best practice statements to aid practitioners with appropriate, up-to-date management of patients with lower extremity varicose 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, CA
| | - Suman M Wasan
- Department of Medicine, University of North Carolina, Chapel Hill, Rex Vascular Specialists, UNC Health, Raleigh, NC
| | - Mark H Meissner
- Division of Vascular Surgery, University of Washington, Seattle, WA
| | - Jose Almeida
- Division of Vascular and Endovascular Surgery, University of Miami Miller School of Medicine, Miami, FL
| | | | - Ruth L Bush
- John Sealy School of Medicine, University of Texas Medical Branch, Galveston, TX
| | | | - John Fish
- Department of Medicine, Jobst Vascular Institute, University of Toledo, Toledo, OH
| | - Eri Fukaya
- Division of Vascular Surgery, Stanford University, Stanford, CA
| | - Monika L Gloviczki
- Department of Internal Medicine and Gonda Vascular Center, Rochester, MN
| | | | - 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 Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
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Kawabata S, Nakasa T, Ikuta Y, Sumii J, Nekomoto A, Sakurai S, Moriwaki D, Adachi N. Safe Insertion Angle of the Suture Button to Avoid Saphenous Structure in Syndesmosis Injury. Foot Ankle Spec 2023:19386400231213761. [PMID: 38018519 DOI: 10.1177/19386400231213761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
In placing the medial suture button for syndesmosis injury, the risk of great saphenous vein and saphenous nerve injury has been reported. This study aimed to determine the safe insertion angle of the guide pin to avoid saphenous structure injury during suture button fixation. The incidence of saphenous structure injury was investigated using 8 legs of cadavers. The greater saphenous vein was depicted on the skin using near-infrared light (VeinViewer® Flex) and the distance between the greater saphenous vein and the posterior edge of the tibia at levels of 10, 20, and 30 mm from the joint line of the tibiotalar joint was measured in the 60 legs of healthy participants. On computed tomography (CT) images, the angles between the greater saphenous vein and transmalleolar axis at levels of 10, 20, and 30 mm from the joint line of the tibiotalar joint were measured. The cadaveric study revealed that the percentages of contact with the saphenous nerve were 8.3% to 16.7%. Using near-infrared light, the vein and tibia distance was 32.9 ± 6.8 mm of 10 mm, 26.6 ± 6.4 mm of 20 mm, and 20.4 ± 6.4 mm of 30 mm. The angle between the vein and transmalleolar axis was 1.0° to 9.4°, and more proximal, the angle was smaller. The veins depicted by near-infrared light can be a landmark to identify great saphenous vein, and injury of the saphenous structure can be prevented using VeinViewer Flex or considering the insertion angle defined in this study when placing the suture button for syndesmosis injuries.Level of Evidence: Level IV.
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Affiliation(s)
- Shingo Kawabata
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Tomoyuki Nakasa
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
- Department of Artificial Joints and Biomaterials, Graduate School of Biomedical and Health Sciences, Hiroshima University Hospital, Hiroshima, Japan
| | - Yasunari Ikuta
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Junichi Sumii
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Akinori Nekomoto
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Satoru Sakurai
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Dan Moriwaki
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Nobuo Adachi
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Braet DJ, Loi K, Stabler C, Vemuri C, Coleman DM, Obi AT, Wakefield TW. Thromboembolic outcomes are decreased with the use of a standardized venous thromboembolism risk assessment and prophylaxis protocol for patients undergoing superficial venous procedures. J Vasc Surg Venous Lymphat Disord 2023; 11:928-937.e1. [PMID: 37127256 DOI: 10.1016/j.jvsv.2023.04.008] [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: 03/13/2023] [Revised: 04/11/2023] [Accepted: 04/21/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE Patients with venous insufficiency can be treated with ablation or phlebectomy, or both. Patients undergoing superficial venous procedures have an elevated risk of deep vein thrombosis (DVT) and pulmonary embolism (PE). At our institution, we initiated a standardized protocol in which patients with a Caprini score (2005 version) of ≥8 are treated with 1 week of prophylactic anticoagulation after the procedure. Duplex ultrasound was performed at 1 week and then within 90 days after the procedure. This aim of the present study was to determine the thrombotic and clinical outcomes after superficial vein procedures using a standardized protocol for DVT/PE risk assessment and prophylaxis. METHODS We performed a retrospective analysis of prospectively collected data of superficial vein procedures from 2015 to 2021 at a single center. The patient demographics, CEAP (Clinical-Etiology-Anatomy-Pathophysiology) clinical class, venous clinical severity score, patient-reported outcomes, treatment type, Caprini scores, pre- and postoperative anticoagulation use, and outcomes were collected. Descriptive statistics were used for the patient demographics, procedure details, and unadjusted surgical outcomes. Multivariable logistic regression was used to evaluate the relationship between procedure type and DVT and PE after adjusting for patient characteristics, disease severity, periprocedural anticoagulation, and Caprini score. RESULTS A total of 1738 limbs were treated with ablation (n = 820), phlebectomy (n = 181), or ablation and phlebectomy (n = 737). More patients were women (67.1%) and White (90.9%). The overall incidence of DVT/PE was 1.4%. Patients undergoing ablation with phlebectomy had higher rates of DVT/PE (2.7%) than those undergoing ablation (0.2%) or phlebectomy alone (1.7%; P < .01). However, only 30% of DVTs were above the knee. On multivariate analysis, only the procedure type predicted for DVT/PE. However, patients undergoing ablation and phlebectomy achieved better patient-reported outcomes (Caprini score, 5.9) compared with those undergoing ablation (Caprini score, 7.2) or phlebectomy (Caprini score, 7.9) alone (P < .01). The best improvement in the venous clinical severity score was seen with phlebectomy alone. CONCLUSIONS The expected difference in the DVT/PE rates between high- and low-risk groups did not materialize in our patients, perhaps secondary to the additional chemoprophylaxis prescribed for the high-risk cohort (Caprini score, ≥8). These results call for a randomized trial to assess the efficacy of a standardized protocol in the reduction of DVT/PE after superficial vein procedures.
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Affiliation(s)
- Drew J Braet
- Section of Vascular Surgery, Department of Surgery, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Kyle Loi
- Department of Surgery, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Cathy Stabler
- Section of Vascular Surgery, Department of Surgery, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Chandu Vemuri
- Section of Vascular Surgery, Department of Surgery, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Dawn M Coleman
- Section of Vascular Surgery, Department of Surgery, University of Michigan Medical Center, Ann Arbor, MI, USA; Division of Vascular Surgery, Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Andrea T Obi
- Section of Vascular Surgery, Department of Surgery, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Thomas W Wakefield
- Section of Vascular Surgery, Department of Surgery, University of Michigan Medical Center, Ann Arbor, MI, USA.
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Turner BRH, Machin M, Jasionowska S, Salim S, Onida S, Shalhoub J, Davies AH. Systematic Review and Meta-analysis of the Additional Benefit of Pharmacological Thromboprophylaxis for Endovenous Varicose Vein Interventions. Ann Surg 2023; 278:166-171. [PMID: 36205129 PMCID: PMC10321513 DOI: 10.1097/sla.0000000000005709] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The primary objective of this systematic review and meta-analysis was to elucidate the rate of venous thromboembolism (VTE) after endovenous interventions for varicose veins in the presence of pharmacological and mechanical thromboprophylaxis versus mechanical thromboprophylaxis alone. BACKGROUND The VTE rate after endovenous procedures for varicose veins is higher than other day-case procedures and could be reduced with pharmacological thromboprophylaxis. METHODS The review followed Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines with a registered protocol (PROSPERO: CRD42021274963). Studies of endovenous intervention for superficial venous incompetence reporting the predefined outcomes with at least 30 patients were eligible. Data were pooled with a fixed effects model. RESULTS There were 221 trials included in the review (47 randomized trial arms, 105 prospective cohort studies, and 69 retrospective studies). In randomized trial arms, the rate of deep venous thrombosis with additional pharmacological thromboprophylaxis was 0.52% (95% CI, 0.23%-1.19%) (9 studies, 1095 patients, 2 events) versus 2.26% (95% CI, 1.81%-2.82%) (38 studies, 6951 patients, 69 events) with mechanical thromboprophylaxis alone. The rate of pulmonary embolism in randomized trial arms with additional pharmacological thromboprophylaxis was 0.45% (95% CI, 0.09-2.35) (5 studies, 460 participants, 1 event) versus 0.23% (95% CI, 0.1%-0.52%) (28 studies, 4834 participants, 3 events) for mechanical measures alone. The rate of EHIT grade III to IV was 0.35% (95% CI, 0.09-1.40) versus 0.88% (95% CI, 0.28%-2.70%). There was 1 VTE-related mortality and 1 instance of major bleeding, with low rates of minor bleeding. CONCLUSIONS There is a significant reduction in the rate of DVT with additional pharmacological thromboprophylaxis and routine prescription of anticoagulation after endovenous varicose vein intervention should be considered. VTE risk for individual study participants is heterogeneous and risk stratification in future randomized interventional studies is critical to establish the clinical effectiveness and safety of additional pharmacological thromboprophylaxis.
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Woodhouse E, DiMusto P. Outcomes of a Single-center Experience In Eliminating Routine Postoperative Duplex Ultrasound Following Endovenous Ablation. J Vasc Surg Venous Lymphat Disord 2023; 11:642-647. [PMID: 36935080 DOI: 10.1016/j.jvsv.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 12/16/2022] [Accepted: 01/07/2023] [Indexed: 03/19/2023]
Abstract
OBJECTIVES The current guidelines recommend routine postoperative screening duplex ultrasound (DUS) after endovenous ablation (EVA). This is a grade 2C recommendation and several contemporary reports have called for revision of this recommendation as there is insufficient evidence to support universal screening DUS after EVA. There are currently no studies that evaluate outcomes among EVA patients who did not have screening DUS. The aim of our study is to present outcomes from our single-center experience among patients who did not have DUS routinely performed after EVA. METHODS We performed a single-center, prospective cohort study that included consecutive patients undergoing EVA of the great saphenous vein at our institution between September 30, 2021 and March 15, 2022. At 30 days post procedure, electronic medical records were queried to identify patients who may have presented for evaluation of VTE symptoms. RESULTS Over the study period, a total of 80 lower extremity EVA procedures (71 EVLT, 9 RFA) were performed among 76 patients. Postoperative DUS was performed on 24 patients of which none were identified as having EHIT. Of the 54 patients who did not have DUS, a 30-day post procedure chart review revealed that none of these patients were seen for symptoms of venous thromboembolism (VTE). We estimate total cost savings of $14,289 by eliminating routine DUS without impact to clinical outcomes following EVA. CONCLUSION Postoperative DUS assessment after EVA comes with associated healthcare cost and has low yield given the incidence of clinically significant EHIT (3 and 4) is rare. In our experience, eliminating routine DUS had no impact on clinical outcomes, improved vascular lab access, and had a positive financial impact in our organization. Limiting DUS screening to EVA patients who exhibit symptoms of VTE can be a cost-effective approach that limits unnecessary imaging, time, and resources with no potential change in clinical outcomes based on our data. Further research is required and a randomized controlled trial would be ideal to answer this question.
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Affiliation(s)
- Erik Woodhouse
- Division of Vascular Surgery, Department of Surgery, University of Wisconsin-Madison, Madison, WI.
| | - Paul DiMusto
- Division of Vascular Surgery, Department of Surgery, University of Wisconsin-Madison, Madison, WI
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Suarez LB, Alnahhal KI, Salehi PA, King EG, O'Donnell TF, Iafrati MD. A systematic review of routine post operative screening duplex ultrasound after thermal and non-thermal endovenous ablation. J Vasc Surg Venous Lymphat Disord 2023; 11:193-200.e6. [PMID: 35940446 DOI: 10.1016/j.jvsv.2022.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/20/2022] [Accepted: 06/09/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The Society of Vascular Surgery and the American Venous Forum recommend duplex ultrasound (DUS) following endovenous ablation. However, this screening may not be cost-effective or clinically indicated. The most common abnormal finding, endovenous heat-induced thrombosis (EHIT level 1-2), represents extension of thrombus from the saphenous <50% across the femoral or popliteal vein, which is thought to have a benign course regardless of intervention. The likelihood of venous thromboembolism (VTE) after thermal and non-thermal ablations was explored to determine the utility of routine postoperative DUS. METHODS This is an updated and expanded systematic review including data from randomized trials and large observational studies (≥150 patients) of thermal and non-thermal ablations, examining the incidence of VTE. Using PubMed and EMBASE, 4584 publications were screened from 2000 through 2020. After applying inclusion and exclusion criteria, 72 studies were included. Random effects DerSimonian-Laird method was conducted to obtain the pooled incidence. We calculated the number of tests needed to detect one VTE, and the cost was derived from Center for Medicare Services tables. RESULTS A total of 31,663 patients were included. The pooled incidence of EHIT II-IV, deep venous thrombosis (DVT), and pulmonary embolism (PE) was 1.32% (95% confidence interval [CI], 0.75%-2.02%); DVT (excluding EHIT), 0.20% (95% CI, 0.0%-0.2%); EHIT (I-IV), 2.51% (95% CI, 1.54%-3.68%); and EHIT (II-IV), 1.00% (95% CI, 0.51%-1.61%). There was no mortality. There was a lower DVT rate in thermal vs non-thermal ablations (0.23% vs 0.43%; P = .02); however, for all VTE (EHIT I-IV + DVT + PE), thermal techniques had more thrombosis (2.5% vs 0.5%; P <.001). When clinical significance is defined as DVT + EHIT (II-IV), 175 studies are needed to identify one VTE, costing $21,813 per "significant VTE." Patients receiving pharmacological prophylaxis had less EHIT I-IV compared with those who did not (3.04% vs 1.63%; P < .001); those who received DUS during the first post-op week had three times higher EHIT incidence compared with those whose first DUS was >7 days postoperative (6.6% vs 2.4%; P < .001). CONCLUSIONS For thermal and non-thermal endovenous ablations, the incidence of VTE diagnosed with routine DUS is small and without clear clinical significance but caries a high cost. The Society of Vascular Surgery and the American Venous Forum recommendation to perform DUS within 72 hours is not justified by these data. We recommend a more targeted post-ablation scanning protocol including symptomatic patients and those at high risk.
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Affiliation(s)
- Luis B Suarez
- Department of Vascular Surgery, Tufts Medical Center, Boston, MA
| | | | - Payam A Salehi
- Department of Vascular Surgery, Tufts Medical Center, Boston, MA
| | - Elizabeth G King
- Department of Vascular Surgery, Boston University Medical Center, Boston, MA
| | | | - Mark D Iafrati
- Department of Vascular Surgery, Vanderbilt University Medical Center, Nashville, TN.
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Sadek M, Kabnick LS. Endothermal Heat Induced Thrombosis. PHLEBOLOGIE 2021. [DOI: 10.1055/a-1518-0551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AbstractEndothermal heat induced thrombosis (EHIT) is a post-procedural entity following endothermal superficial venous ablation that refers to the propagation of thrombus into the adjacent deep vein lumen. It is identified most commonly during the post-procedural surveillance venous duplex ultrasound. EHIT is recognized as a unique post-procedural entity, distinct in clinical behavior from a deep vein thrombosis. The definition, classification systems, pathophysiology, risk factors, treatment, and prevention are all discussed. The understanding of EHIT has advanced considerably, but additional data are required to understand its impact on quality of life and the cost-effectiveness of surveillance.
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10
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Borsuk DA, Sadek M, Kabnick LS. Current status of endothermal heat induced thrombosis. INT ANGIOL 2021; 40:277-282. [PMID: 34008932 DOI: 10.23736/s0392-9590.21.04667-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND There remain many questions regarding the pathophysiology and risk factors for endothermal heat induced thrombosis formation. Moreover, there are a paucity of data on the timing of its occurrence, and there has been no consensus regarding for its treatment. The purpose of this review is to summarize the current knowledge on the pathophysiology, risk factors and treatment strategies for endothermal heat induced thrombosis. METHODS The PubMed database was searched from 2001 to present for endothermal heat induced thrombosis, EHIT, deep vein thrombosis, chronic venous insufficiency, varicose veins, endovenous laser and radiofrequency ablation (treatment). All relevant articles identified by the authors mentioning endothermal heat induced thrombosis were included in this review. RESULTS A multitude of risk factors, several pathophysiological hypotheses and different treatment strategies are described in the literature. CONCLUSIONS Endothermal heat induced thrombosis is marginally understood. There remains a theoretical risk for significant venous thromboembolic complications. With the new uniform classification of EHIT (American Venous Forum), healthcare providers should continue to investigate the nature of this event.
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Affiliation(s)
| | - Mikel Sadek
- Division of Vascular Surgery, Department of Surgery, NYU Langone Health, New York, NY, USA
| | - Lowell S Kabnick
- Kabnick Vein Center, Morristown Medical Center, Morristown, NJ, USA
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Sumpio BJ, Png CYM, Harrington A, Root D, McLaughlin R, Manchester S, Latz CA, Feldman ZM, Eagleton M, Dua A. Utility of unilateral versus bilateral venous reflux studies for venous insufficiency. J Vasc Surg Venous Lymphat Disord 2021; 9:1297-1301. [PMID: 33529718 DOI: 10.1016/j.jvsv.2021.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 01/14/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Duplex ultrasonography is the reference standard for diagnosing chronic venous insufficiency. Bilateral venous reflux ultrasound studies are among the most time-consuming and physically demanding tests for vascular ultrasound technologists to perform. Furthermore, if a venous procedure is required, many insurance policies require that a diagnostic venous ultrasound scan for reflux must be performed within 1 year of the procedure. If the intervention is scheduled for >1 year after the ultrasound scan, the insurance company might require a repeat venous ultrasound scan before granting insurance authorization. Hence, ordering bilateral venous duplex ultrasound scans to evaluate for reflux when an intervention might only be performed on one limb within the year could be a waste of time and resources. The aim of the present study was to determine the utility of ordering bilateral vs unilateral studies to evaluate for reflux in patients with suspected chronic venous insufficiency and to determine whether a resource-saving potential exists for vascular laboratories through optimization of the process of ordering venous duplex ultrasound studies. METHODS A retrospective review of all patients who had undergone bilateral lower extremity ultrasound scanning to evaluate for reflux from January 1, 2016 to December 31, 2016 at the Massachusetts General Hospital vascular laboratory was performed. The demographics, indications for ultrasound scanning, comorbidities, time required to perform the ultrasound study, and interval to intervention were documented. The data were analyzed using SPSS statistical software (IBM Corp, Armonk, NY). RESULTS During the study period, 13,854 ultrasound studies had been performed in our vascular laboratory, of which 606 (4.4%) had been bilateral ultrasound scans for venous insufficiency. The time allotted for a bilateral study was 2 hours. Of the 606 studies evaluated, 152 (25.1%) showed no evidence of reflux, 284 (46.9%) showed bilateral lower extremity reflux, and 170 (28.1%) showed only venous insufficiency in one leg. Venous ablation, phlebectomy, and/or sclerotherapy were performed for 28.7% of the patients. However only 6.2% of patients had undergone venous procedures on both legs within 1 year after the ultrasound studies. Ablation was the most common procedure performed (54.6%), followed by phlebectomy (27.%) and sclerotherapy (17.9%). Overall, 94.7% of patients had not undergone a venous procedure on both legs within 1 year after the ultrasound studies and, hence, would have required a repeat duplex ultrasound scan to ensure insurance coverage for future procedures. CONCLUSIONS Most bilateral ultrasound scans for venous insufficiency will not result in an intervention. Thus, most patients (95%) could have undergone a unilateral scan before the initial intervention instead of bilateral duplex ultrasound scanning.
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Affiliation(s)
- Brandon J Sumpio
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass.
| | - C Y Maximilian Png
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Anita Harrington
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Drena Root
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Robert McLaughlin
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Scott Manchester
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Christopher A Latz
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Zachary M Feldman
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Matthew Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
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12
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Xu Z, Hall TL, Vlaisavljevich E, Lee FT. Histotripsy: the first noninvasive, non-ionizing, non-thermal ablation technique based on ultrasound. Int J Hyperthermia 2021; 38:561-575. [PMID: 33827375 PMCID: PMC9404673 DOI: 10.1080/02656736.2021.1905189] [Citation(s) in RCA: 93] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/23/2021] [Accepted: 03/12/2021] [Indexed: 01/09/2023] Open
Abstract
Histotripsy is the first noninvasive, non-ionizing, and non-thermal ablation technology guided by real-time imaging. Using focused ultrasound delivered from outside the body, histotripsy mechanically destroys tissue through cavitation, rendering the target into acellular debris. The material in the histotripsy ablation zone is absorbed by the body within 1-2 months, leaving a minimal remnant scar. Histotripsy has also been shown to stimulate an immune response and induce abscopal effects in animal models, which may have positive implications for future cancer treatment. Histotripsy has been investigated for a wide range of applications in preclinical studies, including the treatment of cancer, neurological diseases, and cardiovascular diseases. Three human clinical trials have been undertaken using histotripsy for the treatment of benign prostatic hyperplasia, liver cancer, and calcified valve stenosis. This review provides a comprehensive overview of histotripsy covering the origin, mechanism, bioeffects, parameters, instruments, and the latest results on preclinical and human studies.
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Affiliation(s)
- Zhen Xu
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Timothy L. Hall
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Eli Vlaisavljevich
- Department of Biomedical Engineering and Mechanics, Virginia Polytechnic Institute and State University, Blacksburg, VA, USA
| | - Fred T. Lee
- Departments of Radiology, Biomedical Engineering, and Urology, University of Wisconsin, Madison, WI, USA
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13
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Keo HH, Knoechel J, Spinedi L, Engelberger RP, Staub D, Regli C, Diehm N, Uthoff H. Thromboprophylaxis practice after outpatient endovenous thermal ablation. J Vasc Surg Venous Lymphat Disord 2020; 9:916-924. [PMID: 33263288 DOI: 10.1016/j.jvsv.2020.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 10/07/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The use of endovenous thermal ablation (ETA) for the treatment of truncal varicose veins has been increasing worldwide; however, uncertainty remains regarding the need for thromboprophylaxis and follow-up of patients undergoing this minimally invasive procedure. A nationwide survey of among physicians performing ETA was conducted to assess the thromboprophylaxis practice and follow-up protocols after ETA in Switzerland. METHODS A questionnaire was sent to all ETA-certified physicians (n = 193) in Switzerland. The survey covered procedure type, thromboprophylaxis (including pharmacologic and compression therapy), duplex ultrasound follow-up examinations, and the management of endovenous heat-induced thrombosis (EHIT). RESULTS Overall, 121 responses were received, for a response rate of 62.7%. Of the 121 respondents, 71 were vascular medicine specialists (58.7%) and 46 were general or vascular surgeons (38.0%), representing the two largest groups of specialists, followed by 2 dermatologists (1.7%) and 2 interventional radiologists (1.7%). Pharmacologic thromboprophylaxis after ETA was always used by 86 physicians (71.1%), nearly always by 8 (6.6%), frequently used by 5 (4.1%), rarely used by 21 (17.4%), and never by 1 physician (0.8%). A direct oral anticoagulant drug was the preferred type of thromboprophylaxis used by 92 physicians (77.3%). The first dose of thromboprophylaxis was mostly administered immediately after intervention by 53 physicians (53.7%). The duration of postablation thromboprophylaxis ranged from 1 to 21 days, with 7 to 10 days used by 57 physicians. Compression therapy was used by all physicians, with large variation in duration ranging from 1 to 42 days after a single ETA session and after ETA with concomitant phlebectomy. Postablation duplex ultrasonography was performed routinely by 120 respondents (99.2%), and 84 respondents (69.4%) performed two to three duplex ultrasound scans. Management of EHIT depended on the EHIT class and differed widely among the physicians. CONCLUSIONS Our nationwide survey on thromboprophylaxis practices after ETA of truncal varicose veins in Switzerland showed that most physicians use pharmacologic thromboprophylaxis, with a direct oral anticoagulant drug the preferred agent. However, the timing of the first dose and the duration of thromboprophylaxis varied widely among the respondents, reflecting the uncertainty in this domain owing to the absence of high-quality evidence-based guidelines.
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Affiliation(s)
- Hak Hong Keo
- Vascular Institute Central Switzerland, Aarau, Switzerland; Department of Angiology, University Hospital and University of Basel, Basel, Switzerland.
| | - Jonas Knoechel
- Vascular Institute Central Switzerland, Aarau, Switzerland
| | | | - Rolf P Engelberger
- Division of Angiology, Cantonal Hospital Fribourg, Fribourg, Switzerland
| | - Daniel Staub
- Department of Angiology, University Hospital and University of Basel, Basel, Switzerland
| | | | - Nicolas Diehm
- Vascular Institute Central Switzerland, Aarau, Switzerland
| | - Heiko Uthoff
- Department of Angiology, University Hospital and University of Basel, Basel, Switzerland; Gefässpraxis am See - Lakeside Vascular Center, Lucerne, Switzerland
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14
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Classification and treatment of endothermal heat-induced thrombosis: Recommendations from the American Venous Forum and the Society for Vascular Surgery. J Vasc Surg Venous Lymphat Disord 2020; 9:6-22. [PMID: 33012690 DOI: 10.1016/j.jvsv.2020.06.008] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 06/09/2020] [Indexed: 12/12/2022]
Abstract
The American Venous Forum (AVF) and the Society for Vascular Surgery set forth these guidelines for the management of endothermal heat-induced thrombosis (EHIT). The guidelines serve to compile the body of literature on EHIT and to put forth evidence-based recommendations. The guidelines are divided into the following categories: classification of EHIT, risk factors and prevention, and treatment of EHIT. One major feature is to standardize the reporting under one classification system. The Kabnick and Lawrence classification systems are now combined into the AVF EHIT classification system. The novel classification system affords standardization in reporting but also allows continued combined evaluation with the current body of literature. Recommendations codify the use of duplex ultrasound for the diagnosis of EHIT. Risk factor assessments and methods of prevention including mechanical prophylaxis, chemical prophylaxis, and ablation distance are discussed. Treatment guidelines are tailored to the AVF EHIT class (ie, I, II, III, IV). Reference is made to the use of surveillance, antiplatelet therapy, and anticoagulants as deemed indicated, and the recommendations incorporate the use of the novel direct oral anticoagulants. Last, EHIT management as it relates to the great and small saphenous veins is discussed.
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15
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Kabnick LS, Sadek M, Bjarnason H, Coleman DM, Dillavou ED, Hingorani AP, Lal BK, Lawrence PF, Malgor R, Puggioni A. Classification and treatment of endothermal heat-induced thrombosis: Recommendations from the American Venous Forum and the Society for Vascular Surgery This Practice Guidelines document has been co-published in Phlebology [DOI: 10.1177/0268355520953759] and Journal of Vascular Surgery: Venous and Lymphatic Disorders [DOI: 10.1016/j.jvsv.2020.06.008]. The publications are identical except for minor stylistic and spelling differences in keeping with each journal's style. The contribution has been published under a Attribution-Non Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0), (https://creativecommons.org/licenses/by-nc-nd/4.0/). Phlebology 2020; 36:8-25. [PMID: 32998622 PMCID: PMC7820569 DOI: 10.1177/0268355520953759] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The American Venous Forum (AVF) and the Society for Vascular Surgery set forth these guidelines for the management of endothermal heat-induced thrombosis (EHIT). The guidelines serve to compile the body of literature on EHIT and to put forth evidence-based recommendations. The guidelines are divided into the following categories: classification of EHIT, risk factors and prevention, and treatment of EHIT. One major feature is to standardize the reporting under one classification system. The Kabnick and Lawrence classification systems are now combined into the AVF EHIT classification system. The novel classification system affords standardization in reporting but also allows continued combined evaluation with the current body of literature. Recommendations codify the use of duplex ultrasound for the diagnosis of EHIT. Risk factor assessments and methods of prevention including mechanical prophylaxis, chemical prophylaxis, and ablation distance are discussed. Treatment guidelines are tailored to the AVF EHIT class (ie, I, II, III, IV). Reference is made to the use of surveillance, antiplatelet therapy, and anticoagulants as deemed indicated, and the recommendations incorporate the use of the novel direct oral anticoagulants. Last, EHIT management as it relates to the great and small saphenous veins is discussed.
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Affiliation(s)
- Lowell S Kabnick
- Atlantic Health System, Morristown Medical Center, Kabnick Vein Center, Morristown, NJ, USA
| | - Mikel Sadek
- Division of Vascular Surgery, NYU Langone Health, New York, NY, USA
| | - Haraldur Bjarnason
- Division of Vascular and Interventional Radiology, Mayo Clinic, Rochester, MN, USA
| | - Dawn M Coleman
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Ellen D Dillavou
- Division of Vascular Surgery, Duke University Medical Center, Durham, NC, USA
| | - Anil P Hingorani
- Division of Vascular Surgery, NYU Langone Hospital-Brooklyn, Brooklyn, NY, USA
| | - Brajesh K Lal
- Center for Vascular Research and Department of Vascular Surgery, University of Maryland, and the Vascular Service, Baltimore VA Medical Center, Baltimore, MD, USA
| | - Peter F Lawrence
- Department of Surgery, Division of Vascular Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Rafael Malgor
- Division of Vascular Surgery and Endovascular Therapy, The University of Colorado, Anschutz Medical Center, Aurora, CO, USA
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16
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Dattani N, Shalhoub J, Nandhra S, Lane T, Abu-Own A, Elbasty A, Jones A, Duncan A, Garnham A, Thapar A, Murray A, Baig A, Saratzis A, Sharif A, Huasen B, Dawkins C, Nesbitt C, Carradice D, Morrow D, Bosanquet D, Kavanagh E, Shaikh F, Gosi G, Ambler G, Fulton G, Singh G, Travers H, Moore H, Olivier J, Hitchman L, O’Donohoe M, Popplewell M, Medani M, Jenkins M, Goh MA, Lyons O, McBride O, Moxey P, Stather P, Burns P, Forsythe R, Sam R, Brar R, Brightwell R, Benson R, Onida S, Paravastu S, Lambracos S, Vallabhaneni SR, Walsh S, Aktar T, Moloney T, Mzimba Z, Nyamekye I. Reducing the risk of venous thromboembolism following superficial endovenous treatment: A UK and Republic of Ireland consensus study. Phlebology 2020; 35:706-714. [DOI: 10.1177/0268355520936420] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Objectives Venous thromboembolism is a potentially fatal complication of superficial endovenous treatment. Proper risk assessment and thromboprophylaxis could mitigate this hazard; however, there are currently no evidence-based or consensus guidelines. This study surveyed UK and Republic of Ireland vascular consultants to determine areas of consensus. Methods A 32-item survey was sent to vascular consultants via the Vascular and Endovascular Research Network (phase 1). These results generated 10 consensus statements which were redistributed (phase 2). ‘Good’ and ‘very good’ consensus were defined as endorsement/rejection of statements by >67% and >85% of respondents, respectively. Results Forty-two consultants completed phase 1. This generated seven statements regarding risk factors mandating peri-procedural pharmacoprophylaxis and three statements regarding specific pharmacoprophylaxis regimes. Forty-seven consultants completed phase 2. Regarding venous thromboembolism risk factors mandating pharmacoprophylaxis, ‘good’ and ‘very good’ consensus was achieved for 5/7 and 2/7 statements, respectively. Regarding specific regimens, ‘very good’ consensus was achieved for 3/3 statements. Conclusions The main findings from this study were that there was ‘good’ or ‘very good’ consensus that patients with any of the seven surveyed risk factors should be given pharmacoprophylaxis with low-molecular-weight heparin. High-risk patients should receive one to two weeks of pharmacoprophylaxis rather than a single dose.
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Affiliation(s)
- Nikesh Dattani
- Worcestershire Acute Hospitals NHS Trust, The Vascular Surgery Unit, Worcester, Worcestershire, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Joseph Shalhoub
- Imperial College Healthcare NHS Trust, London, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Sandip Nandhra
- Northern Vascular Centre, Freeman Hospital, Newcastle University, Newcastle Upon Tyne, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Tristan Lane
- Department of Surgery and Cancer, Imperial College London, Academic Section of Vascular Surgery, London, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Abdulsalam Abu-Own
- Colchester Hospital University NHS Foundation Trust, Colchester, Essex, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Ahmed Elbasty
- Frimley Park Hospital NHS Foundation Trust, Frimley, Surrey, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Aled Jones
- Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Andrew Duncan
- University Hospitals of Leicester NHS Trust, Leicester, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Andrew Garnham
- Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Ankur Thapar
- Imperial College London, Academic Section of Vascular Surgery, London, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Anna Murray
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Anzar Baig
- Norfolk and Norwich University Hospital NHS Trust, Norwich, Norfolk, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Athanasios Saratzis
- University Hospitals of Leicester NHS Trust, Leicester, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Atif Sharif
- Dudley Group NHS Foundation Trust, Dudley, West Midlands, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Bella Huasen
- Lancashire Teaching Hospitals NHS Foundation Trust, Preston, Lancashire, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Claire Dawkins
- Sunderland Royal Hospital, Sunderland, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Craig Nesbitt
- Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Daniel Carradice
- Hull Royal Infirmary, Hull, Kingston upon Hull, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Darren Morrow
- Norfolk and Norwich University Hospital NHS Trust, Norwich, Norfolk, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - David Bosanquet
- Southmead Hospital, Bristol, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Eamon Kavanagh
- University of Limerick Hospitals Group, Vascular Surgery, Limerick, Ireland
- University of Limerick Graduate Entry Medical School, Limerick, Ireland
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Faisal Shaikh
- Heartlands Hospital, Birmingham, West Midlands, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Gergely Gosi
- University Hospital Waterford, Vascular Surgery, Waterford, Ireland
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Graeme Ambler
- Royal Gwent Hospital, Newport, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Gregory Fulton
- Cork University Hospital Group, Cork, Ireland
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Gurdas Singh
- Guy’s Hospital, London, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Hannah Travers
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Hayley Moore
- Frimley Park Hospital NHS Foundation Trust, Frimley, Surrey, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - James Olivier
- Musgrove Park Hospital, Taunton, Somerset, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Louise Hitchman
- Hull Royal Infirmary, Hull, Kingston upon Hull, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Martin O’Donohoe
- Mater Misericordiae University Hospital, Dublin, Ireland
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Matthew Popplewell
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Mekki Medani
- Beaumont Hospital, Dublin, Ireland
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Michael Jenkins
- Imperial College Healthcare NHS Trust, London, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Mingzheng A Goh
- Basildon University Hospital, Basildon, Essex, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Oliver Lyons
- Basildon University Hospital, Basildon, Essex, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Olivia McBride
- Edinburgh Royal Infirmary, Edinburgh, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Paul Moxey
- St George’s Hospital, Vascular Surgery, London, Tooting, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Philip Stather
- Addenbrooke’s Hospital, Cambridge, Cambridgeshire, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Phillipa Burns
- Edinburgh Royal Infirmary, Edinburgh, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Rachel Forsythe
- Royal Infirmary of Edinburgh, Edinburgh, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Rachel Sam
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Ranjeet Brar
- Royal Free London NHS Foundation Trust, London, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Robert Brightwell
- Norfolk and Norwich University Hospital NHS Trust, Norwich, Norfolk, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Ruth Benson
- University of Birmingham Institute of Cancer and Genomic Sciences, Birmingham, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Sarah Onida
- Imperial College London, Academic Section of Vascular Surgery, London, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Sharath Paravastu
- Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, Gloucestershire, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Simon Lambracos
- Western Sussex Hospitals NHS Trust, Worthing, West Sussex, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Srinivasa R Vallabhaneni
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Stewart Walsh
- Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Tasleem Aktar
- Dudley Group NHS Foundation Trust, Dudley, West Midlands, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Tony Moloney
- University of Limerick Hospitals Group, Dooradoyle, Limerick, Ireland
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Zola Mzimba
- Altnagelvin Hospitals Health and Social Services Trust, Londonderry, UK
- *The Vascular and Endovascular Research Network (VERN) collaborators
| | - Isaac Nyamekye
- Worcestershire Acute Hospitals NHS Trust, The Vascular Surgery Unit, Worcester, Worcestershire, UK
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Gracia S, Miserey G, Risse J, Abbadie F, Auvert JF, Chauzat B, Combes P, Creton D, Creton O, Da Mata L, Diard A, Giordana P, Josnin M, Keïta-Perse O, Lasheras A, Ouvry P, Pichot O, Skopinski S, Mahé G. Update of the SFMV (French society of vascular medicine) guidelines on the conditions and safety measures necessary for thermal ablation of the saphenous veins and proposals for unresolved issues. JOURNAL DE MÉDECINE VASCULAIRE 2020; 45:130-146. [PMID: 32402427 DOI: 10.1016/j.jdmv.2020.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Venous insufficiency is a very common disease affecting about 25% of the French population (if we combine all stages of its progression). It is a complex disease and its aetiology has not yet been fully elucidated. Some of its causes are well known, such as valvular dysfunction, vein wall defect, and the suctioning effect common to all varicose veins. These factors are generally associated and together lead to dysfunction of one or more of the saphenous veins. Saphenous vein dysfunction is revealed by ultrasound scan, a reflux lasting more than 0.5 seconds indicating venous incompetence. The potential consequences of saphenous vein dysfunction over time include: symptoms (heaviness, swellings, restlessness, cramps, itching of the lower limbs), acute complications (superficial venous thrombosis, varicose bleeding), chronic complications (changes in skin texture and colour, stasis dermatitis, eczema, vein atresia, leg ulcer), and appearance of unaesthetic varicose veins. It is not possible to repair an incompetent saphenous vein. The only therapeutic options at present are ultrasound-guided foam sclerotherapy, physical removal of the vein (saphenous stripping), or its thermal ablation (by laser or radiofrequency treatment), the latter strategy having now become the gold standard as recommended by international guidelines. Recommendations concerning thermal ablation of saphenous veins were published in 2014 by the Société française de médecine vasculaire. Our society has now decided to update these recommendations, taking this opportunity to discuss unresolved issues and issues not addressed in the original guidelines. Thermal ablation of an incompetent saphenous vein consists in destroying this by means of a heating element introduced via ultrasound-guided venous puncture. The heating element comprises either a laser fibre or a radiofrequency catheter. The practitioner must provide the patient with full information about the procedure and obtain his/her consent prior to its implementation. The checklist concerning the interventional procedure issued by the HAS should be validated for each patient (see the appended document).
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Affiliation(s)
- S Gracia
- Clinique de l'Atlantique, 17138 Puilboreau-La Rochelle, France.
| | - G Miserey
- Cabinet de Médecine Vasculaire, 78120 Rambouillet, France
| | - J Risse
- Hôpital Robert-Pax, 57200 Sarreguemines, France
| | - F Abbadie
- Hopital de Vichy, 03200 Vichy, France
| | - J F Auvert
- Cabinet de Médecine Vasculaire, 28100 Dreux, France
| | - B Chauzat
- Cabinet de Médecine Vasculaire, 24100 Bergerac, France
| | - P Combes
- Cabinet de Médecine Vasculaire, 64200 Biarritz, France
| | - D Creton
- Clinique Ambroise Paré, 54100 Nancy, France
| | - O Creton
- Hôpital Privé des Côtes d'Armor, 22190 Plérin, France
| | - L Da Mata
- Service d'Anesthésie et Réanimation Chirurgicale, Centre Hospitalier Universitaire de Nantes, 44000 Nantes, France
| | - A Diard
- Clinique Sainte Anne, 33210 Langon, France
| | - P Giordana
- Service de Chirurgie Vasculaire, Centre Hospitalier Universitaire de Nice, 06000 Nice, France
| | - M Josnin
- Clinique Saint-Charles, 85000 La Roche sur Yon, France
| | - O Keïta-Perse
- Centre Hospitalier Princesse Grace, Service Epidémiologie et Hygiène Hospitalière, 98000 Monaco, Monaco
| | - A Lasheras
- Service d'Hygiène Hospitalière, Centre Hospitalier Universitaire de Bordeaux, 33000 Bordeaux, France
| | - P Ouvry
- Cabinet de Médecine Vasculaire, 76550 Saint-Aubin-sur-Scie, France
| | - O Pichot
- Centre de Médecine Vasculaire, 38000 Grenoble, France
| | - S Skopinski
- Service de Médecine Vasculaire Hôpital Saint-André, Centre Hospitalier Universitaire de Bordeaux, 33000 Bordeaux, France
| | - G Mahé
- Unité de Médecine Vasculaire, Centre Hospitalier Universitaire de Rennes, 35000 Rennes, France
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18
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Sevil F, Colak A, Ceviz M, Kaya U, Becit N. The Effectiveness of Endovenous Radiofrequency Ablation Application in Varicose Vein Diseases of the Lower Extremity. Cureus 2020; 12:e7640. [PMID: 32399372 PMCID: PMC7216314 DOI: 10.7759/cureus.7640] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We aimed to determine the outcome, complications, and quality of life effects of radiofrequency ablation (RFA) in the treatment of superficial venous insufficiency. A total of 134 extremities from 100 patients were evaluated in this retrospective study performed at the Cardiovascular Surgery Department of Atatürk University Faculty of Medicine. Treatment success was determined by occlusion. The clinical, etiologic, anatomic, and pathophysiologic (CEAP) and venous clinical severity score (VCSS) scores of patients were assessed pre- and postoperatively to evaluate clinical outcome and quality of life. The pain was assessed with the Wong-Baker score. Complications and their frequency were assessed and recorded. Treatment success, as measured by occlusion rate, was 99% percent. Prior to treatment, the CEAP clinical score was C2 (81.0%), while after treatment, it was C0 (54.0%) (p<0.001). The pretreatment median VCSS score was 5 (min-max: 1-9) while the post-treatment median was 1 (min-max: 1-3) (p<0.001). The mean pain score was 1.34; only one patient reported a score of 6 while the minimum score was 1. A total of 15 complications occurred; only one was a major complication (deep vein thrombosis or DVT) while the remaining 14 were minor complications. While longstanding surgical treatments still provide significant success, the RFA technique not only surpasses them in success rate but also in terms of pain, complications, and better patient satisfaction. The results of our study indicate that RFA is an effective and safe option for the treatment of superficial venous insufficiency.
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Affiliation(s)
- Fehimcan Sevil
- Cardiovascular Surgery, Afyon Health Sciences University, Afyon, TUR
| | - Abdurrahim Colak
- Cardiovascular Surgery, Ataturk University School of Medicine, Erzurum, TUR
| | - Münacettin Ceviz
- Cardiovascular Surgery, Ataturk University School of Medicine, Erzurum, TUR
| | - Uğur Kaya
- Cardiovascular Surgery, Ataturk University School of Medicine, Erzurum, TUR
| | - Necip Becit
- Cardiovascular Surgery, Afyon Medical Sciences University, Afyon, TUR
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AlGhofili HH, Aljasser AA, Alyahya IA, Almohsen HA, Alwabel SA, Alhumaid AA, Iqbal K, Altuwaijri TA, Altoijry A. Endothermal heat-induced thrombosis after endovenous laser ablation: A single-center experience. Semin Vasc Surg 2020; 32:89-93. [DOI: 10.1053/j.semvascsurg.2019.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Itoga NK, Rothenberg KA, Deslarzes-Dubuis C, George EL, Chandra V, Harris EJ. Incidence and Risk Factors for Deep Vein Thrombosis after Radiofrequency and Laser Ablation of the Lower Extremity Veins. Ann Vasc Surg 2020; 62:45-50.e2. [PMID: 31201974 PMCID: PMC8555659 DOI: 10.1016/j.avsg.2019.04.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 04/01/2019] [Accepted: 04/07/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND The rates of thromboembolic complications such as deep vein thrombosis (DVT) after venous ablation procedures for symptomatic superficial venous insufficiency are controversial. We sought to describe the risk factors for and incidence of DVT after radiofrequency ablation (RFA) and laser ablation (LA). METHODS We queried the Truven Health Marketscan Database from 2007-16 for patients who underwent RFA or LA and had a follow-up duplex ultrasound within 30 days of the ablation procedure. The primary outcome was DVT at 7 and 30 days identified by International Classification of Diseases-9 and International Classification of Diseases-10 codes. Multivariable regression was used to evaluate the patient and procedural variables associated with a DVT at 30 days, expressed as odds ratios (ORs) with a 95% confidence interval (95% CI). Patients and procedures with a previous DVT diagnosis were excluded. RESULTS A total of 256,999 patients underwent 433,286 ablation procedures: 192,195 (44.4%) RFA and 241,091 LA. Of these, 8,203 (1.9%) had a newly diagnosed DVT within 7 days and 13,347 (3.1%) within 30 days of the procedure. The incidence of DVT decreased over the study period. LA (2.8%) demonstrated a lower incidence of DVT at 30 days compared with RFA (3.4%), P < 0.001. On multivariable regression, LA (OR, 0.82; 95% CI 0.80-0.85) was again associated with a decreased risk for 30-day DVT, as was female gender (OR, 0.74; 95% CI, 0.71-0.77), and sclerotherapy performed on the same day (OR, 0.91; 95% CI, 0.85-0.98). A diagnosis of peripheral artery disease (OR, 1.23; 95% CI, 1.16-1.31) and concomitant stab phlebectomy (OR, 1.43; 95% CI, 1.37-1.49) was associated with an increased risk of DVT within 30 days. CONCLUSIONS The incidence of newly diagnosed DVT within 30 days of an ablation procedure was 3.2%. The risk for DVT decreased in recent years, and LA was associated with an 18% decreased risk compared with RFA.
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Affiliation(s)
- Nathan K Itoga
- Division of Vascular Surgery, Stanford University, Stanford, CA.
| | - Kara A Rothenberg
- Division of Vascular Surgery, Stanford University, Stanford, CA; Department of Surgery, University of California San Francisco-East Bay, Oakland, CA
| | | | | | - Venita Chandra
- Division of Vascular Surgery, Stanford University, Stanford, CA
| | - E John Harris
- Division of Vascular Surgery, Stanford University, Stanford, CA
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Grady Z, Aizpuru M, Farley KX, Benarroch-Gampel J, Crawford RS. Surgical resection for suppurative thrombophlebitis of the great saphenous vein after radiofrequency ablation. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2019; 5:532-534. [PMID: 31799481 PMCID: PMC6883314 DOI: 10.1016/j.jvscit.2019.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 06/10/2019] [Indexed: 11/16/2022]
Abstract
Radiofrequency ablation has become one of the most commonly used interventions in the treatment of chronic venous insufficiency. It is performed with minimal analgesic use, tolerable postprocedural pain, and prompt return to activities of daily living. Typical complications, though rare, include failure of total venous occlusion, deep venous thrombosis, skin hyperpigmentation, infection, and skin burn. Here, we report the case of a patient who developed suppurative thrombophlebitis with methicillin-resistant Staphylococcus aureus bacteremia, requiring surgical resection.
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Affiliation(s)
- Zachary Grady
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Matthew Aizpuru
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Kevin X Farley
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Jaime Benarroch-Gampel
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Robert S Crawford
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
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Venous thromboembolism complications after endovenous laser ablation for varicose veins and role of duplex ultrasound scan. J Vasc Surg Venous Lymphat Disord 2019; 7:817-823. [DOI: 10.1016/j.jvsv.2019.06.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 06/09/2019] [Indexed: 12/20/2022]
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Chait J, Kibrik P, Alsheekh A, Ostrozhynskyy Y, Marks N, Rajaee S, Hingorani A, Ascher E. Radiofrequency Ablation Increases the Incidence of Endothermal Heat-Induced Thrombosis. Ann Vasc Surg 2019; 62:263-267. [PMID: 31394220 DOI: 10.1016/j.avsg.2019.05.059] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/09/2019] [Accepted: 05/27/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Endovenous thermal ablation has become the procedure of choice in the treatment of superficial venous reflux disease. The current armamentarium of devices and techniques aimed at the elimination of saphenous reflux offers surgeons and interventionalists a variety of treatment options; however, there is a lack of data comparing the safety of these products. The most concerning complication after endovenous thermal ablation is endothermal heat-induced thrombosis (EHIT) due to the risk of progression to deep venous thrombosis. This study aimed to compare the incidence rate of EHIT between radiofrequency ablation (RFA) and endovenous laser therapy (EVLT). METHODS This was a single-center, office-based, retrospective study over the course of 5 years, in which 3,218 consecutive patients underwent 10,029 endovenous saphenous ablations. The patient cohort was 66.2% female, with an average age of 61.9 years. At the time of each individual intervention, 24, 212, 3,620, 4,806, 200, and 1,167 patients had Clinical-Etiology-Anatomy-Pathophysiology disease 1, 2, 3, 4, 5, and 6, respectively. RESULTS There was a total of 3,983 EVLT and 6,091 RFA procedures. The most common vessel treated was the great saphenous vein, 63.6% of the time, followed by the small saphenous vein (25.6%), accessory saphenous vein (6.1%), and perforator vein (4.6%). There were 186 cases of EHIT, with 137 (73.6%) identified as type 1 as per the Kabnick classification. Endovenous ablation performed via RFA resulted in significantly more cases of EHIT than of EVLT (109 vs. 77; P = 0.034; odds ratio = 1.52), which was confirmed by a multivariate analysis. CONCLUSIONS In the largest single-center study of endovenous saphenous ablations to date, RFA was shown to pose a significantly higher risk of EHIT than of EVLT.
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Affiliation(s)
- Jesse Chait
- Vascular Institute of New York, Brooklyn, NY.
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Hao S, Cox S, Monahan TS, Sarkar R. Double prepuncture as a valuable adjunctive technique for complex endovenous ablation. J Vasc Surg Venous Lymphat Disord 2018. [PMID: 28623986 DOI: 10.1016/j.jvsv.2017.03.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The objective of this study was to characterize the technique and to report the results of double prepuncture used during complex radiofrequency ablation (RFA) in cases of treating multiple incompetent veins or encountering focal obstruction to catheter advancement. METHODS A double prepuncture technique was applied in patients requiring endovascular ablation of multiple veins and patients with great saphenous vein cannulation failure. We treated 13 limbs in 12 patients during a 24-month period with RFA in which the double prepuncture technique was used. Clinical history, operative reports, outcomes, and follow-up were reviewed. RESULTS RFA was performed with the double puncture technique on, collectively, 10 great saphenous veins, 5 small saphenous veins, and 5 anterior accessory saphenous veins. Mean preoperative Clinical, Etiology, Anatomy, and Pathophysiology score was 4.38 ± 1.6. Three limbs required prepuncture because of difficulty in advancing the catheter cephalad through tortuosity and focal obstruction after failure with techniques such as a guidewire, a guide catheter, and manual compression with ultrasound guidance. Ten limbs received planned double prepuncture for multiple adjacent incompetent veins, for which venipuncture and cannulation of the second target vein would be difficult after tumescent application to the first vein. Postoperative ultrasound demonstrated successful closure of all target veins in which the double prepuncture technique was used. One patient had a deep venous thrombosis (7.7%) that resolved without complications. CONCLUSIONS Double prepuncture is a useful technical adjunct both for simultaneous endovenous ablation of multiple adjacent incompetent veins and when catheter passage is impeded. This technique aids in efficient and successful application of endovenous ablation to complex venous anatomy.
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Affiliation(s)
- Scarlett Hao
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - Samantha Cox
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - Thomas S Monahan
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Md; Department of Surgery, Baltimore Veterans Affairs Medical Center, Baltimore, Md
| | - Rajabrata Sarkar
- Department of Surgery, Baltimore Veterans Affairs Medical Center, Baltimore, Md.
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Garcia R, Labropoulos N. Duplex Ultrasound for the Diagnosis of Acute and Chronic Venous Diseases. Surg Clin North Am 2018; 98:201-218. [DOI: 10.1016/j.suc.2017.11.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Evans J, Mong R, Satiani B. The Perioperative Role of Duplex Venous Scanning in Endovenous Laser Therapy. ACTA ACUST UNITED AC 2018. [DOI: 10.1177/154431670703100107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Varicose veins that emerge as a result of the venous valvular incompetence of the great saphenous vein (GSV) are a common chronic condition affecting millions of people. When invasive treatment is necessary, surgical removal of the GSV and varicosities has been the standard procedure to relieve symptoms. Recent advances in laser technology have resulted in endovenous laser therapy as an alternative to open surgery by ablating the GSV. Duplex venous ultrasound is a critical part of preoperative planning, intraoperative safe execution of the procedure and postoperative care. It is necessary that the vascular surgeon and the sonographer work in tandem and have experience in intraoperative duplex venous scanning to achieve an optimal outcome.
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Affiliation(s)
- Julie Evans
- Department of Surgery Vascular Laboratory at Vein Solutions & Vascular Labs at the Ross Heart Hospital, the Ohio State University, Columbus, Ohio
| | - Renee Mong
- Department of Surgery Vascular Laboratory at Vein Solutions & Vascular Labs at the Ross Heart Hospital, the Ohio State University, Columbus, Ohio
| | - Bhagwan Satiani
- Department of Surgery Vascular Laboratory at Vein Solutions & Vascular Labs at the Ross Heart Hospital, the Ohio State University, Columbus, Ohio
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Stone PA, Armstrong PA, Shames ML, Back MR, Johnson BL, Flaherty SK, Bandyk DF. Impact of Postoperative Duplex Surveillance after Radiofrequency Ablation of the Greater Saphenous Vein. ACTA ACUST UNITED AC 2018. [DOI: 10.1177/154431670603000201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose Radiofrequency ablation (RFA) is an effective therapeutic option for the treatment of greater saphenous vein (GSV) insufficiency; however, recent reports have begun to document an associated incidence of postprocedural deep venous thrombosis (DVT) of up to 16%. We evaluated our incidence of DVT after RFA and the role of venous duplex ultrasonography (VUS) in the assessment and treatment of GSV reflux. Methods During a 17-month period, 62 lower extremities with symptomatic GSV reflux were evaluated by VUS in 51 patients (74% women; mean age 51 years, range 25–83 yrs). Clinical history and examination focusing on risk factors for venous insufficiency and DVT were obtained along with a complete preoperative bilateral lower-extremity VUS in all patients. All procedures were completed by performing an intraoperative VUS to confirm patency of the GSV and common femoral veins before and after RFA. All patients received outpatient complete lower-extremity VUS within 5 days of the procedure to assess technical success of the procedure and superficial and deep venous patency. Results Fifty (98%) of patients completed RFA, with one patient undergoing high ligation of the GSV because of our inability to pass a guidewire and catheter into the proximal GSV. Duplex ultrasound confirmed successful RFA of the GSV in all limbs treated. Stab phlebectomy was performed in 33 (53%) limbs for associated clusters of large varicose veins. Two postoperative DVTs occurred (2/62,3.2%), both of which were identified as a floating thrombus in the common femoral vein and which subsequently were treated with percutaneous catheter-directed suction thrombectomy without the need for extended anticoagulation therapy. Conclusion Duplex venous scanning is an important component in the diagnosis and treatment of GSV insufficiency. VUS not only is necessary to direct the success of these catheter-based ablative procedures but is mandatory to confirm the absence of extended DVT after the procedure is completed. Our series has recorded a relatively low incidence of DVT and demonstrates that early recognition and aggressive treatment of nonocclusive common femoral DVT after RFA can obviate the need for long-term anticoagulation and potentially the sequelae of deep venous thrombosis.
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Affiliation(s)
- Patrick A. Stone
- Department of Vascular and Endovascular Surgery University of South Florida
| | - Paul A. Armstrong
- Department of Vascular and Endovascular Surgery University of South Florida
| | - Murray L. Shames
- Department of Vascular and Endovascular Surgery University of South Florida
| | - Martin R. Back
- Department of Vascular and Endovascular Surgery University of South Florida
| | - Brad L. Johnson
- Department of Vascular and Endovascular Surgery University of South Florida
| | - Sarah K. Flaherty
- Department of Vascular and Endovascular Surgery University of South Florida
| | - Dennis F. Bandyk
- Department of Vascular and Endovascular Surgery University of South Florida
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28
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Santler B, Goerge T. Die chronische venöse Insuffizienz - Eine Zusammenfassung der Pathophysiologie, Diagnostik und Therapie. J Dtsch Dermatol Ges 2018; 15:538-557. [PMID: 28485867 DOI: 10.1111/ddg.13242_g] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 04/11/2017] [Indexed: 01/06/2023]
Abstract
Die chronische Venenerkrankung ist eine weit verbreitete Krankheit, die in späteren Stadien mit einer Vielzahl an Symptomen, aber auch Komplikationen wie dem Ulcus cruris, einhergeht. Dies wiederum hat weitreichende Auswirkungen auf die Lebensqualität der Patienten wie auch auf das Gesundheitssystem. Für die Diagnostik der chronischen Venenerkrankungen steht eine Auswahl an Verfahren zur Verfügung, wobei sich die farbkodierte Duplexsonographie als Goldstandard etabliert hat. Im Bereich der Therapie kam es in den letzten Jahrzehnten zu großen Fortschritten, sodass heute auch Alternativen zum klassischen Stripping durch die endoluminalen Verfahren zur Verfügung stehen. Die Wahl der Therapieoption ist jedoch weiterhin stark abhängig von mehreren Faktoren, unter anderem von den anatomischen Gegebenheiten und dem Krankheitsstadium. Im folgenden Artikel werden die Anatomie und Pathophysiologie, sowie die aktuellen Standards der Diagnostik und Therapie zusammengefasst.
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Affiliation(s)
- Bettina Santler
- Klinik für Hautkrankheiten - Allgemeine Dermatologie und Venerologie, Universitätsklinikum Münster
| | - Tobias Goerge
- Klinik für Hautkrankheiten - Allgemeine Dermatologie und Venerologie, Universitätsklinikum Münster
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Santler B, Goerge T. Chronic venous insufficiency - a review of pathophysiology, diagnosis, and treatment. J Dtsch Dermatol Ges 2018; 15:538-556. [PMID: 28485865 DOI: 10.1111/ddg.13242] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 04/11/2017] [Indexed: 01/20/2023]
Abstract
Chronic venous disease is a common disorder associated with a variety of symptoms in later disease stages but also with complications such as venous leg ulcer. This, in turn, has substantial socioeconomic effects and significantly impacts patients' quality of life. While there are a number of diagnostic procedures available, color-flow duplex ultrasound has become the gold standard. As regards therapeutic options, major advances have been made in recent decades. Today, there are alternatives to saphenofemoral ligation and stripping of the great saphenous vein, including endovenous thermal ablation techniques. However, treatment selection continues to depend on many factors such as individual anatomical circumstances and disease stage. The following article provides an overview of the anatomy and pathophysiology as well as current diagnostic and therapeutic standards.
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Affiliation(s)
- Bettina Santler
- Department of Dermatology and Venereology, University Hospital Münster, Münster, Germany
| | - Tobias Goerge
- Department of Dermatology and Venereology, University Hospital Münster, Münster, Germany
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Aurshina A, Ascher E, Victory J, Rybitskiy D, Zholanji A, Marks N, Hingorani A. Clinical correlation of success and acute thrombotic complications of lower extremity endovenous thermal ablation. J Vasc Surg Venous Lymphat Disord 2018; 6:25-30. [DOI: 10.1016/j.jvsv.2017.07.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 07/07/2017] [Indexed: 11/16/2022]
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31
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Rivaroxaban versus fondaparinux for thromboprophylaxis after endovenous laser ablation. J Vasc Surg Venous Lymphat Disord 2017; 5:817-823. [DOI: 10.1016/j.jvsv.2017.04.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 04/26/2017] [Indexed: 11/19/2022]
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32
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Rivaroxaban for thrombosis prophylaxis in endovenous laser ablation with and without phlebectomy. J Vasc Surg Venous Lymphat Disord 2017. [DOI: 10.1016/j.jvsv.2016.12.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Korepta LM, Watson JJ, Mansour MA, Chambers CM, Cuff RF, Slaikeu JD, Wong PY. Outcomes of a single-center experience with classification and treatment of endothermal heat-induced thrombosis after endovenous ablation. J Vasc Surg Venous Lymphat Disord 2017; 5:332-338. [DOI: 10.1016/j.jvsv.2016.12.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 12/09/2016] [Indexed: 10/19/2022]
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34
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Giant Spontaneous Greater Saphenous Vein Aneurysm. Ann Vasc Surg 2017; 42:302.e11-302.e14. [PMID: 28389282 DOI: 10.1016/j.avsg.2016.12.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 11/12/2016] [Accepted: 12/12/2016] [Indexed: 11/23/2022]
Abstract
Venous aneurysm, a rare venous anomaly, poses increased risk of distal thromboembolic event. Superficial venous aneurysm, such as greater saphenous vein aneurysm, is an uncommon subset with nonspecific symptoms and often a delay in diagnosis. Symptomatic patients or patients with a thromboembolic event may benefit from surgical intervention with low morbidity. This case report describes an isolated spontaneous greater saphenous vein aneurysm which was successfully ligated and resected for symptomatic relief and prevention of distal thromboembolism.
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Radiofrequency ablation with concomitant stab phlebectomy increases risk of endovenous heat-induced thrombosis. J Vasc Surg Venous Lymphat Disord 2017; 5:200-209. [DOI: 10.1016/j.jvsv.2016.10.081] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 10/17/2016] [Indexed: 12/13/2022]
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36
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Eduardo Jiménez C, Quiroga F. Radiofrecuencia en el tratamiento de las varices de los miembros inferiores. Estudio prospectivo en 176 pacientes en Bogotá. ANGIOLOGIA 2017. [DOI: 10.1016/j.angio.2016.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Jayakumar P, Robinson C, Maruthupandian D, Ganesh R. Pulmonary Embolism following Radiofrequency Ablation for Varicose Vein Treated with Thrombolytic Therapy: A Case Report and Review of Literature. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2017. [DOI: 10.4103/ijves.ijves_1_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Cost analysis and implications of routine deep venous thrombosis duplex ultrasound scanning after endovenous ablation. J Vasc Surg Venous Lymphat Disord 2017; 5:126-133. [DOI: 10.1016/j.jvsv.2016.07.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 07/08/2016] [Indexed: 12/23/2022]
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Abstract
Varicose veins affect one-quarter to one-third of Western adult populations and consume an increasing amount of health care resources. Much of this increased utilization has been driven by the advent of minimally invasive technology including endovenous thermal ablation, foam sclerotherapy, and more recently mechanicochemical and cyanoacrylate glue ablation. This has largely been driven by patient and physician preferences in the absence of robust evidence that one therapy is truly superior to another. This partially arises from misunderstandings about appropriate outcomes measures and what truly constitutes effective treatment of varicose veins. Technical outcomes, such as saphenous closure rates, have frequently been used as surrogates for effective treatment but are poorly correlated with symptom improvement, quality of life, and risk of recurrence. Although there does appear to be a trend towards higher recurrence with ultrasound-guided foam sclerotherapy, the data are occasionally conflicting and there does not appear to be substantial differences between the various modalities. Similarly, there do not appear to be major differences in late quality of life measures between these treatment options. As long-term differences in recurrence and quality of life are small, overall cost effectiveness is driven primarily by initial treatment costs and ultrasound-guided foam sclerotherapy is the most cost-effective strategy in many models. However, there continues to be substantial uncertainty surrounding cost estimates and other factors of importance to the patient may ultimately drive treatment decisions. The benefits of some adjuncts to the treatment of axial superficial reflux, such as the concurrent versus staged management of tributary varicosities, remain ill-defined while that of others, such as routine post-procedural ultrasound surveillance and compression, need critical re-evaluation.
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Affiliation(s)
- Mark H Meissner
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA, USA
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40
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Nguyen T, Bergan J, Min R, Morrison N, Zimmet S. Curriculum of the American College of Phlebology. Phlebology 2016. [DOI: 10.1258/026835506779613534] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- T Nguyen
- Dermatology, Mohs Micrographic & Dermatologic surgery, Procedural Dermatology, University of Texas-MD Anderson Cancer Center, Houston, TX, USA
| | - J Bergan
- Department of Surgery, UCSD School of Medicine, San Diego, CA, USA
| | - R Min
- Department of Radiology, Cornell University School of Medicine, New York, NY, USA
| | - N Morrison
- Morrison Vein Institute, Scottsdale AZ, USA
| | - S Zimmet
- Zimmet Vein and Dermatology, Austin, TX, USA
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Rikimaru H. Thrombosis of the Saphenous Vein Stump after Varicose Vein Surgery. Ann Vasc Dis 2016; 9:188-192. [PMID: 27738460 DOI: 10.3400/avd.oa.16-00044] [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: 05/10/2016] [Accepted: 06/02/2016] [Indexed: 11/13/2022] Open
Abstract
We evaluated thrombus extension in the proximal stump of the saphenous vein at 6 days, 4 weeks, and 16 weeks after saphenous vein surgery performed between July 2013 and March 2014 (18 patients, 29 limbs, and 31 stumps) using duplex ultrasonography. All thrombotic events were classified as endovenous heat-induced thrombosis (EHIT). Thrombus was observed in 27 stumps (87.1%), with only four (12.9%) stumps remaining without thrombus on postoperative day 6. Thrombus as EHIT class 2 was observed in one stump and as EHIT class 3 in another; in the remaining 25 stumps, it was observed as EHIT class 1 postoperatively. No further extension of thrombus was found at 4 and 16 weeks after surgery. The rate of thrombus formation in the proximal stump of the saphenous vein after conventional surgery is comparatively higher than that after thermoablation techniques. Further studies are required to determine adequate evaluation methods and appropriate therapies for stump thrombosis after varicose vein surgery. (This article is a translation of J Jpn Coll Angiol 2015; 55: 105-110).
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Affiliation(s)
- Hiroto Rikimaru
- Department of Vascular Surgery, Tome City Hospital, Tome, Miyagi, Japan
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Sydnor M, Mavropoulos J, Slobodnik N, Wolfe L, Strife B, Komorowski D. A randomized prospective long-term (>1 year) clinical trial comparing the efficacy and safety of radiofrequency ablation to 980 nm laser ablation of the great saphenous vein. Phlebology 2016; 32:415-424. [PMID: 27422781 DOI: 10.1177/0268355516658592] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose To compare the short- and long-term (>1 year) efficacy and safety of radiofrequency ablation (ClosureFAST™) versus endovenous laser ablation (980 nm diode laser) for the treatment of superficial venous insufficiency of the great saphenous vein. Materials and methods Two hundred patients with superficial venous insufficiency of the great saphenous vein were randomized to receive either radiofrequency ablation or endovenous laser ablation (and simultaneous adjunctive therapies for surface varicosities when appropriate). Post-treatment sonographic and clinical assessment was conducted at one week, six weeks, and six months for closure, complications, and patient satisfaction. Clinical assessment of each patient was conducted at one year and then at yearly intervals for patient satisfaction. Results Post-procedure pain ( p < 0.0001) and objective post-procedure bruising ( p = 0.0114) were significantly lower in the radiofrequency ablation group. Improvements in venous clinical severity score were noted through six months in both groups (endovenous laser ablation 6.6 to 1; radiofrequency ablation 6.2 to 1) with no significant difference in venous clinical severity score ( p = 0.4066) or measured adverse effects; 89 endovenous laser ablation and 87 radiofrequency patients were interviewed at least 12 months out with a mean long-term follow-up of 44 and 42 months ( p = 0.1096), respectively. There were four treatment failures in each group, and every case was correctable with further treatment. Overall, there were no significant differences with regard to patient satisfaction between radiofrequency ablation and endovenous laser ablation ( p = 0.3009). There were no cases of deep venous thrombosis in either group at any time during this study. Conclusions Radiofrequency ablation and endovenous laser ablation are highly effective and safe from both anatomic and clinical standpoints over a multi-year period and neither modality achieved superiority over the other.
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Affiliation(s)
- Malcolm Sydnor
- 1 Section of Interventional Radiology, Department of Radiology, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - John Mavropoulos
- 2 Department of Dermatology, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Natalia Slobodnik
- 1 Section of Interventional Radiology, Department of Radiology, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Luke Wolfe
- 3 Department of Surgery, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Brian Strife
- 1 Section of Interventional Radiology, Department of Radiology, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Daniel Komorowski
- 1 Section of Interventional Radiology, Department of Radiology, Virginia Commonwealth University Health System, Richmond, VA, USA
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Beale RJ, Mavor AID, Gough MJ. Minimally Invasive Treatment for Varicose Veins: A Review of Endovenous Laser Treatment and Radiofrequency Ablation. INT J LOW EXTR WOUND 2016; 3:188-97. [PMID: 15866814 DOI: 10.1177/1534734604272245] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Varicose veins are a common problem, conventionally treated by an operation. Within the last few years, minimally invasive techniques have been developed as alternatives to surgery in an attempt to reduce morbidity and improve recovery time. Radiofrequency ablation and endovenous laser ablation are the most promising of these new techniques. This review article looks at the evidence for these techniques and the clinical experience to date and discusses their role in the future treatment of varicose veins.
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Affiliation(s)
- Rosie J Beale
- The Vascular Surgical Unit, The General Infirmary at Leeds, Leeds, UK
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Abstract
Chronic venous insufficiency (CVI) is the most common vascular disease and represents a significant health care problem in the United States. Reflux of the great saphenous vein is the most common cause of this condition, whose symptoms include varicose veins, leg swelling, skin discoloration, and ulceration. The traditional treatment of this condition is saphenofemoral ligation with stripping of the saphenous vein followed by varicose vein removal, if necessary. Recent advances in minimally invasive endovenous therapy have led to the development of catheter-based radiofrequency ablation (RFA) of the saphenous vein, which has gained an increasing acceptance in clinical practice. Endovenous RFA was introduced into clinical practice in Europe in 1998 and in the United States in 1999. Since then, over 250,000 procedures have been performed worldwide. Procedure safety and efficacy are well understood, with over 60 publications on the subject in the peer review literature, including four randomized trials comparing this technology with traditional vein stripping surgery. With the advent of tumescent anesthesia, the majority of RFA procedures are now performed in an office setting. This article examines the current technology using RFA in saphenous vein ablation with the Closure catheter system. Procedural techniques and clinical outcome using RFA in saphenous vein ablation are discussed. Clinical data comparing RFA versus saphenous vein stripping are also examined. Lastly, the clinical utility of a new RFA catheter, ClosureFAST, is discussed. ClosureFAST is a new generation of RFA catheter and has exhibited significant improvement in the ease of use and the procedure speed over the previous generation catheters while maintaining the favorable patient recovery profile seen with the RFA technology.
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Affiliation(s)
- Alan M. Dietzek
- *The Linda and Stephen R. Cohen Chair in Vascular Surgery, Danbury Hospital Medical Arts Center, Danbury, CT
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Prevention and Treatment of Lower Limb Deep Vein Thrombosis after Radiofrequency Catheter Ablation: Results of a Prospective active controlled Study. Sci Rep 2016; 6:28439. [PMID: 27329582 PMCID: PMC4916462 DOI: 10.1038/srep28439] [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: 03/03/2016] [Accepted: 06/06/2016] [Indexed: 01/07/2023] Open
Abstract
We conducted a prospective, single-center, active controlled study from July 2013 to January 2015, in Chinese patients with rapid ventricular arrhythmia who had received radiofrequency catheter ablation (RFCA) treatment to determine formation of lower extremity deep vein thrombosis (LDVT) post RFCA procedure, and evaluated the effect of rivaroxaban on LDVT. Patients with asymptomatic pulmonary thromboembolism who had not received any other anticoagulant and had received no more than 36 hours of treatment with unfractionated heparin were included. Post RFCA procedure, patients received either rivaroxaban (10 mg/d for 14 days beginning 2–3 hours post-operation; n = 86) or aspirin (100 mg/d for 3 months beginning 2–3 hours post-operation; n = 90). The primary outcome was a composite of LDVT occurrence, change in diameter of femoral veins, and safety outcomes that were analyzed based on major or minor bleeding events. In addition, blood flow velocity was determined. No complete occlusive thrombus or bleeding events were reported with either of the group. The lower incidence rate of non-occluded thrombus in rivaroxaban (5.8%) compared to the aspirin group (16.7%) indicates rivaroxaban may be administered post-RFCA to prevent and treat femoral venous thrombosis in a secure and effective way with a faster inset of action than standard aspirin therapy.
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Shutze WP, Kane K, Fisher T, Doud Y, Lassiter G, Leuking R, Nguyen E, Shutze WP. The effect of wavelength on endothermal heat-induced thrombosis incidence after endovenous laser ablation. J Vasc Surg Venous Lymphat Disord 2016; 4:36-43. [PMID: 26946893 DOI: 10.1016/j.jvsv.2015.08.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 08/17/2015] [Indexed: 11/20/2022]
Abstract
OBJECTIVE We hypothesized that the incidence of endothermal heat-induced thrombosis (EHIT) depends on the laser wavelength used in endovenous laser ablation (EVLA) of the saphenous veins. METHODS We identified patients undergoing EVLA in our office from 2005 to 2014 with an 810-nm (hemoglobin-specific) or 1470-nm (water-specific) laser. We reviewed the records for age, sex, body mass index, Clinical, Etiologic, Anatomic, and Pathophysiologic (CEAP) class, vein diameter, vein(s) treated, adjunctive phlebectomy, energy delivered, laser pullback times, and EHIT (closure level ≥3) development. The Fisher exact test and Pearson χ(2) test were used to evaluate the association between EHIT and the categoric variables. Logistic regression was used to evaluate the relationship between EHIT and the continuous variables. RESULTS There were 1439 veins ablated in 1109 patients (769 female, 340 male). The great saphenous vein (GSV) was treated in 1332, the small saphenous vein (SSV) in 78, and both in 29 (22 procedures on accessory veins were excluded). The CEAP C class for these patients was 1 in 0, 2 in 616, 3 in 522, 4 in 150, 5 in 51, and 6 in 98, and was not recorded in 2. EHIT occurred in 76 cases (5.28%), in 73 after GSV ablation and in three after SSV ablation. The 810-nm laser was used in 1144 procedures, and EHIT developed in 69 patients (6.0%). The 1470-nm laser was used in 295 procedures, with EHIT developing in seven patients (2.4%; P = .0122 by Fisher exact test). The average energy delivered to the EHIT group (3517 ± 1998.1 J) was higher than for the non-EHIT group (2825.1 ± 1491.2 J; P = .0002). The average vein diameter was larger in the EHIT group (9.3 ± 3.8 mm) than in the non-EHIT group (7.2 ± 3.3 mm; P = .0001). EHIT occurred in 59 of 837 cases (6.6%) undergoing simultaneous stab phlebectomy compared with 17 of 525 cases (3.1%) undergoing only EVLA (P = .0049). Statistical analysis confirmed the association between EHIT and CEAP class was significant (P = .0001). No differences were seen for age, body mass index, sex, combined bilateral, and multiple or simultaneous GSV and SSV ablations between the two groups. A multivariate analysis confirmed that CEAP class, vein diameter, adjunctive phlebectomy, and laser wavelength were indeed risk factors for post-EVLA EHIT and that energy delivered and pullback time were not. CONCLUSIONS Water-specific laser fiber wavelength (1470 nm) reduces the risk of EHIT compared with a hemoglobin-specific wavelength (810 nm). CEAP class, simultaneous phlebectomy, and vein diameter >7.5 mm are associated with increased risk of EHIT after EVLA.
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Affiliation(s)
- William P Shutze
- Division of Vascular Surgery, Baylor University Medical Center, Dallas, Tex.
| | - Katherine Kane
- Division of Vascular Surgery, Baylor University Medical Center, Dallas, Tex
| | - Tammy Fisher
- Department of Surgery, Baylor Scott and White Health, Dallas, Tex
| | - Yahya Doud
- Department of Surgery, Baylor Scott and White Health, Dallas, Tex
| | - Grace Lassiter
- Texas A&M Health Science Center College of Medicine, Bryan, Tex
| | - Richard Leuking
- Texas A&M Health Science Center College of Medicine, Bryan, Tex
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Gaspar RJ, Castro AN, Simões MDJ, Plapler H. Real time echo-guided endolaser for thermal ablation without perivenous tumescence. J Vasc Bras 2015. [DOI: 10.1590/1677-5449.07214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abstract Background There is no consensus in the medical literature on the ideal procedure for endovenous laser application. Objective To assess the safety and efficacy of real time echo-guided endovenous laser for thermal ablation of great saphenous vein (GSV) incompetence, without perivenous tumescence. Methods Thirty-four limbs of patients with CEAP clinical scores of 2 to 6 and bilateral incompetence of the saphenofemoral junction (SFJ) and GSV, confirmed by Echo-Doppler, underwent endovenous laser therapy and were followed for 1 year. Laser ablation was performed using a 600 µ bare optical fiber introduced endovenously close to the malleolus along the full extent of the GSV in an anterograde direction, using a standardized echo-Doppler-guided AND? 15 watt continuous mode 980 nm diode laser with real-time monitoring of thermal ablation of the whole target vein. Adverse effects and complications were recorded. Results Hyperesthesia, cellulitis, and fibrous cord, all transitory, developed in 2.9% of the 34 limbs treated; 8.8% developed hypoesthesia in the perimalleolar region, which was transitory and had no clinical consequences; there were no cases of deep venous thrombosis. Immediate occlusion was achieved in 100% of the 34 saphenous veins that underwent photocoagulation, although one exhibited recanalization without reflux at 1-month follow-up. After 6 months and 1 year, occlusion was 100% according to echo-Doppler findings. Conclusions Real-time echo-guided 980 nm endovenous laser ablation without perivenous tumescence provided controlled thermal ablation with safe, effective, immediate and medium-term GSV occlusion and can therefore be recommended as a method for the treatment of chronic venous disease.
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Affiliation(s)
- Ricardo José Gaspar
- Universidade Federal de São Paulo, Brazil; Sociedade Brasileira de Angiologia e Cirurgia Vascular, Brazil; Instituto Vascular Ricardo Gaspar, Brazil
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Goodyear SJ, Nyamekye IK. Radiofrequency ablation of varicose veins: Best practice techniques and evidence. Phlebology 2015; 30:9-17. [DOI: 10.1177/0268355515592771] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Scope of the review This article systematically reviews the practice of radiofrequency ablation of lower limb varicose veins. We present the clinical evidence and best practice techniques for currently available devices. Methods Manufacturer’s instructions-for-use were requested for all radiofrequency devices. The MEDLINE and EMBASE databases were searched using the following keywords: ‘varicose veins’ AND ‘radiofrequency’ OR ‘radio frequency’ OR ‘Venefit’ OR ‘ClosureFAST’ OR ‘RFiTT’ OR ‘EVRF’ OR ‘VeinCLEAR’, generating 240 articles. Titles and abstracts were screened, yielding 63 articles directly relevant to the scope of the review. Reference lists for publications were also searched to identify further manuscripts of relevance. The Cochrane Database and current National Institute for Clinical and Healthcare Excellence guidelines for varicose veins were also searched from relevant articles. Results Four radiofrequency ablation (RFA) systems are currently commercially available. Generic practice methods (common to all RF systems) and device-specific techniques are described. The weight of current evidence relates to the use of Covidien Venefit™ (formerly VNUS ClosureFAST™), which clearly demonstrates clinical advantages over open surgery at least to 2 years follow up. However, contemporary studies of the radiofrequency-induced thermal therapy device (RFiTT®), show that in experienced hands, clinical equivalence to the Venefit™ procedure can be achieved. The evidence base for EVRF® and VeinCLEAR™ devices is currently weak and absent, respectively. Conclusions Despite widespread uptake of RFA and acceptance of its clinical advantages over open surgery there is a paucity of Class 1 A evidence. This results from incongruent reporting of clinical outcome measures within existing literature. Similarly, lack of long-term follow-up studies precludes comparison of the durability of short- and medium-term advantages of RFA with the longer term results of open surgery. There remains scope for a large prospective high-quality trial to assess the clinical, anatomical and cost-effectiveness outcomes for the four commercially available RFA devices, with a particular focus on long-term follow up.
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Affiliation(s)
- Stephen J Goodyear
- Department of Vascular Surgery, Worcestershire Royal Hospital, Charles Hastings Way, Worcester, UK
| | - Isaac K Nyamekye
- Department of Vascular Surgery, Worcestershire Royal Hospital, Charles Hastings Way, Worcester, UK
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Pirozzi KM, Creech CL, Meyr AJ. Assessment of Anatomic Risk During Syndesmotic Stabilization With the Suture Button Technique. J Foot Ankle Surg 2015; 54:917-9. [PMID: 25940637 DOI: 10.1053/j.jfas.2015.04.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Indexed: 02/03/2023]
Abstract
The suture button technique represents an accepted method of fixation for acute or chronic injury to the tibiofibular syndesmosis. The objective of the present investigation was to assess the anatomic risk to the superficial medial neurovascular structure with insertion of a syndesmotic suture button and to measure the distance of the button to the greater saphenous vein during a standardized insertion. A syndesmotic suture button was inserted with a standardized technique in 20 fresh frozen cadaveric limbs. Of 20 suture buttons, 14 (70.0%) were inserted posterior to the greater saphenous vein, 2 (10.0%) were inserted anterior to the greater saphenous vein, and 4 (20.0%) were inserted directly onto the greater saphenous vein. A total of 11 suture buttons (55.0%) were inserted with some entrapment of a medial neurovascular structure. The absolute mean ± standard deviation distance of the suture button to the greater saphenous vein was 4.88 ± 4.44 mm. The results of the present investigation have indicated that a risk of entrapment of superficial medial neurovascular structures exists with insertion of a suture button for syndesmotic fixation and that a medial incision should be used to ensure that structures are not entrapped.
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Affiliation(s)
| | - Corine L Creech
- Resident, Temple University Hospital Podiatric Surgical Residency Program, Philadelphia, PA
| | - Andrew J Meyr
- Associate Professor, Department of Podiatric Surgery, Temple University School of Podiatric Medicine, Philadelphia, PA.
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Venous duplex and pathologic differences in thrombus characteristics between de novo deep vein thrombi and endovenous heat-induced thrombi. J Vasc Surg Venous Lymphat Disord 2015; 3:184-9. [DOI: 10.1016/j.jvsv.2014.08.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 08/23/2014] [Indexed: 01/01/2023]
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