Neovascularization: an "innocent bystander" in recurrent varicose veins

The Novel Surgical Technique in the Cyanoacrylate Closure for Incompetent Great Saphenous Veins

OBJECTIVE

The current Instructions for Use (IFU) of cyanoacrylate closure (CAC) is to start initial injection with the catheter tip positioned 5 cm distal to the sapheno-femoral junction (SFJ) to prevent endovenous glue-induced thrombosis (EGIT). However, this defensive design is responsible for the relatively long stump length. Although clinical studies on the long-term recurrence rate are still lacking, the long stump length can predict a higher long-term recurrence rate compared to other surgical methods. The author developed a novel surgical technique that can overcome the weakness of CAC, and the initial outcomes of this technique are described in this article.

METHODS

This study retrospectively reviewed 25 great saphenous vein (GSV) in 20 patients who underwent CAC for incompetent GSV at our hospital. The procedure from puncturing the GSV to insertion of the catheter is the same as the conventional method. Place the catheter tip 2-3 cm below the SFJ before cyanoacrylate injection. After confirming the position of the SFJ with the longitudinal view of the ultrasound, press the GSV directly above the SFJ transversely with the second to fifth fingertips of the left hand. Then, the ultrasound probe is placed against the distal part of the fingertips, and CA injection is performed while GSV is monitored in real time.

RESULTS

The mean stump length immediately after surgery was 19.3 (± 7.8) mm, with a range of .0-38.4 mm. The mean stump length after 1 week was 12.3 (± 7.4) mm and the range was .1-35.4 mm. The mean stump length after 1 month was 15.4 (± 10.1) mm, and the range was .0-35.4 mm. There was no case with EGIT or recanalization.

CONCLUSIONS

The author confirmed the possibility of safely reducing stump length with this novel surgical technique, and expect that this method can help overcome the weakness of CAC.

Anatomical variations of the great saphenous vein at the saphenofemoral junction. A cadaveric study and narrative review of the literature

OBJECTIVES

The great saphenous vein is the lower limb's longest and thickest-walled superficial vein. Its anatomy is complex, while its anatomical variations are widespread. This study aimed to illustrate the anatomy and variations of the great saphenous vein at the saphenofemoral junction.

METHODS

The study was conducted on 75 fresh-frozen cadaveric lower limbs. Cadavers with evidence of prior leg surgery or trauma and any congenital abnormality or gross deformity were excluded. The saphenofemoral junction was studied in detail with emphasis on the number, incidence, draining pattern of tributaries, and duplication of the great saphenous vein.

RESULTS

Out of the 75 cadaveric lower limbs, 57.3% were obtained from males, and 42.7% were obtained from females. The mean age of the cadaveric lower extremities was 66.6 years (range 42-91). The number of tributaries at the saphenofemoral junction varied from 0 to 7, with a mean of 3.8. The most frequent number of branches was 4-5 in 61.3% of cases. The most consistent tributary was the superficial external pudendal vein, while the posterior accessory great saphenous vein was the least frequent tributary. 80% of the branches drained into the saphenofemoral junction directly (53.3%) or by a common trunk (26.7%%). The most frequent common trunk was the superficial epigastric and superficial circumflex iliac vein (10.7%). The rest 20% of the tributaries drained directly into the common femoral vein. The commonest branch reaching the common femoral vein was the superficial external pudendal vein (10.7%). Duplication of the great saphenous vein was observed in 2.7% of the cases.

CONCLUSIONS

There is a significant variation of tributaries at the saphenofemoral junction regarding the number, incidence, draining pattern of branches, and duplication of the great saphenous vein.

Severity of disease and treatment outcomes of anterior accessory great saphenous veins compared with the great saphenous vein

OBJECTIVE

Endovenous therapies are currently the standard of care for the treatment of patients with symptomatic great saphenous vein (GSV) reflux. The effectiveness and long-term outcomes of these therapies for anterior accessory great saphenous veins (AAGSVs) are poorly defined. The objective of this investigation is to determine treatment outcomes in patients with symptomatic AAGSV reflux compared with patients with symptomatic GSV reflux.

METHODS

Data were prospectively collected in the Center for Vein Restoration's electronic medical record system (NexGen Healthcare Information System, Irvine, Calif) and retrospectively analyzed. Treatment outcomes after a standalone ablation and ablation + phlebectomy were compared in patients with isolated AAGSV and GSV reflux. Treatment outcomes were assessed at 1 month and 6 months postprocedure using the revised Venous Clinical Severity Score (rVCSS) and the 20-item Chronic Venous Insufficiency Quality-of-Life Questionnaire (CIVIQ20) survey for quality of life. Medical and surgical comorbidities, Clinical-Etiological-Anatomical-Pathophysiological classification, body mass index, gender, race, and the average number of procedures performed were all analyzed.

RESULTS

From January 2015 to December 2018, 31,186 patients and 49,193 limbs were assessed. Of these, 91 patients/103 limbs had isolated AAGSV reflux, and 7704 patients/10,371 limbs had isolated GSV reflux. There were 95% and 75% women in the isolated AAGSV and GSV groups, respectively (P ≤ .001). For the ablation-only patients, AAGSV (n = 57 patients/61 limbs) and GSV (n = 5349 patients/7191 limbs), there were no differences in preintervention (7.0 ± 2.0 vs 6.8 ± 2.8, P = .99), 1-month (4.0 ± 2.4 vs 3.9 ± 2.8, P = .99), and 6-month (3.9 ± 2.6 vs 3.9 ± 2.9, P = .55) rVCSS scores. Similar results were observed when ablations and phlebectomies were performed (AAGSV [n = 34 patients/42 limbs] and GSV [n = 1848 patients/2491 limbs]). CIVIQ20 scores for patients with isolated AAGSV and GSV were 53.3 ± 19.6 vs 50.6 ± 18.8 (P = .43) preintervention, 37.2 ± 17.6 vs 35.7 ± 15.9 (P = .91) at 1 month, and 41.3 ± 21.7 vs 35.1 ± 15.7 (P = .36) at 6 months, respectively. Postprocedure scores within groups improved at 1 and 6 months (P ≤ .02); however, 6-month AAGSV CIVIQ20 scores after an ablation increased slightly compared with 1-month scores and were not different to preintervention GSV scores (P = .07). When phlebectomies were performed with ablations, 6-month CIVIQ20 scores were similar between groups (P = .72). There was no difference in the average number of ablations in patients with phlebectomies in the AAGSV or GSV group (1.24 ± 0.44 vs 1.35 ± 0.49, P = .15).

CONCLUSIONS

Endovenous therapies for the treatment of symptomatic AAGSVs demonstrate similar outcomes to patients with symptomatic GSV reflux. For standalone ablations, the rVCSS scores are similar between the groups; however, CIVIQ20 scores increase to preintervention levels in standalone ablation AAGSV patients at 6 months. This increase disappears when phlebectomies are performed with ablations. Based on these data, patients with symptomatic AAGSV treated with ablation also require treatment of the associated tributaries (varicosities) to achieve similar outcomes to patients with GSV, and this calls into question the effectiveness of ablation for isolated AAGSV reflux.

Clinical Results 5 Years after Great Saphenous Vein Stripping

Background: As a standard treatment for the varicose vein of the great saphenous vein (GSV) type, endovenous ablation (EVA) is the main approach. However, as a background to this, in Europe and the United States, neovascularization (Neo) following high ligation (HL) of the saphenofemoral junction (SFJ) at the time of GSV stripping has been emphasized as one of the reasons for the high rate of recurrence. However, in Japan, almost no similar mid- or long-term results of GSV stripping have been reported. Patients and Methods: From September 2011 to March 2014 when EVA was not my surgical option, 413 consecutive legs of patients underwent GSV stripping by myself using the same procedure. The patients were contacted by phone 5 years later, and recurrent varices after surgery (REVAS) and reoperation (REDO) were investigated. A total of 270 legs of the 391 living cases (69%) underwent venous ultrasonography (VUS). HL of the SFJ was performed via central flash ligation with towing and pulling out of the peripheral side branches containing the accessory saphenous veins. In principle, GSV stripping was performed using the invagination method in the range of the entire reflux region from the HL cut section to the confluent section of the side branch causing branch varicose veins. The range of stripping was to the upper thigh in 3 legs, to the middle thigh in 3 legs, to the lower thigh in 7 legs, to the knee in 46 legs, to the upper calve in 83 legs, to the middle calve in 52 legs, and over the full length in 76 legs. Stab avulsion was performed as much as possible for the side-branch varices. On VUS, the SFJ's stump of GSV, the presence of side-branch remnants and their reflux, the presence or absence of Neo, and the recurrent lesions in other sites were evaluated. REVAS were classified as follows: Level 1, symptomatic recurrent lesion for which surgery is indicated; Level 2, asymptomatic recurrent lesion possibly requiring future surgery; and Level 3, asymptomatic recurrent lesion that is unlikely to require future surgery. Results: Of the 391 legs of patients who could be contacted, REDO was performed in 23 (6%), including 15 limbs, immediately after this investigation, and symptomatic REVAS were observed in 29 (7%). In 270 legs examined by VUS, REVAS were diagnosed as follows: 29 legs with Level 1 lesion, 40 legs with Level 2 lesion, and 27 legs with Level 3 lesion. Level 1 REVAS that occurred at the SFJ were observed only in 3 legs (1.1%), Level 1 REVAS due to incompetent perforating veins (IPVs) were observed in 14 legs (5%), and Level 1 solitary tributary varices were observed in 9 legs (3%). Conclusion: In this study, REVAS at the SFJ were significantly less than those in the past reports. It has been shown that REVAS due to IPVs or solitary tributary varices were more important than those at the SFJ. (This is a translation of Jpn J Phlebol 2019; 30(3): 259-265.).

Minor tributary veins of the common femoral vein near the saphenofemoral junction - A postmortem study

OBJECTIVES

Recurrent varicose veins after surgery are a frequent burden and the saphenofemoral junction is the most common source of reflux. Pre-existing branches of the common femoral vein near the saphenofemoral junction, which may increase due to haemodynamic or other reasons, could play a role in the development of recurrent varices. There exist only a few anatomical data about the prevalence of these minor venous tributaries of the common femoral vein near the saphenofemoral junction. Therefore, this study aimed to elucidate their frequency and distribution.

METHOD

A total of 59 veins from 35 anatomical donors were dissected. The common femoral vein with the adherent parts of the profunda femoris vein and the great saphenous vein was exposed and analysed ex situ. The number of minor tributaries to the common femoral vein was counted and their distances to the saphenofemoral junction as well their diameters were measured.

RESULTS

We could identify up to 10 minor tributaries of the common femoral vein below the level of the great saphenous vein as far as 6 cm distally and up to four veins above the level as far as 5 cm proximally. The mean diameters of these vessels ranged from 0.5 to 11.7 mm. Most of these vessels were located near the saphenofemoral junction and 3 cm distally. Directly opposite to the opening of the great saphenous vein we could find at least one minor tributary of the common femoral vein in 57%.

CONCLUSIONS

There exist a vast number of minor tributaries of the common femoral vein and they are mainly located near the saphenofemoral junction. Nevertheless, their role in the development of recurrent varices is still unclear and further studies are necessary.

Feasibility and technique of endovenous laser ablation (EVLA) of recurrent varicose veins deriving from the sapheno-femoral junction-A case series of 35 consecutive procedures

Aim

To assess the feasibility and technical success of endovenous laser ablation (EVLA) of recurrent varicose veins arising from the former sapheno-femoral junction (SFJ).

Methods

We retrospectively analyzed all EVLA procedures treated in our institution by one surgeon between March 2019 and April 2020 and selected all consecutive cases with SFJ recurrence occuring after surgical high ligation and stripping or endovenous thermal ablation for incompetence of the great saphenous vein (GSV) in superficial venous insufficiency. The feasibility, technical success as determined by duplex ultrasound on the postoperative visit, complications and rate of endothermal heat-induced thrombosis (EHIT) were recorded. A subgroup definition was performed based on sonographic morphology of the recurrence and resulting strategy of ablation.

Results

Thirty-five limbs with SFJ recurrence in 34 patients were treated with EVLA in order to shut down the highest refluxing point. In 22 interventions, it was required to switch off a short stump or a neovascularization by direct puncture (Subgroup 1). In 13 treatments, the presence of residual GSV segments, or persistent, varicose transformed major tributaries like the anterior accessory great saphenous vein, enabled cannulation and advancing the laser fiber from distal to the former SFJ (Subgroup 2). The EVLA procedures could be successfully carried out in all 35 cases. There were no major complications, no thromboembolism or EHIT, and no local groin complications. In one case, the patient developed a phlebitic response that required temporary medication. Technical success was achieved with 34/35 treatments (97.1%). When comparing the subgroups, the morphological pattern of the SFJ recurrence and the resulting technique of puncture, cannulation and ablation did not influence the result.

Conclusions

The results of this case series suggest that SFJ recurrences can also be successfully treated in situations where there are tortuous or short stumps that require direct puncture and ablation.

The use of high venous ligation as an adjunct to endovenous therapy in the management of great saphenous vein incompetence: A systematic review and meta-analysis of randomized controlled trials

Background

In recent years, endovenous intervention has emerged as a minimally invasive alternative to open venous surgery. However, endovenous intervention does not formally disconnect the deep and superficial venous systems and it is hypothesized that recurrence may be greater in the absence of high venous ligation. This study aims to compare the efficacy of a hybrid endovenous approach with adjuvant high venous ligation and standard operative intervention in the management of great saphenous incompetence.

Methods

In March 2018, Medline and Embase were systematically searched for relevant randomized controlled trials. All randomized controlled trials comparing a hybrid approach with standard operative intervention were included. Studies were required to include at least one pre-defined outcome. Data were extracted and assessed by two independent reviewers. Pooled risk ratios were calculated using a random effects model. Additional subgroup analyses were performed.

Results

Eight randomized controlled trials including 1244 patients were analysed. Pooled standardized data revealed no difference in overall recurrence (pooled RR = 1.00 [95% CI = 0.57, 1.77]), major operative morbidity (RR = 0.43 [95% CI = 0.06, 2.89]), or re-interventions (RR = 0.94 [95% CI = 0.12, 7.24]) for the hybrid group compared with standard operative intervention alone. Subgroup analysis revealed comparable short-, medium- and long-term recurrence rates between both cohorts. Furthermore, no difference in recurrence was identified when the hybrid approach was compared to open surgery alone (RR = 1.01 [95% CI = 0.63, 1.61]) or endovenous monotherapy (RR = 0.67 [95% CI = 0.04, 12.24]).

Conclusion

The use of a hybrid approach in the management of great saphenous incompetence appears to offer no recurrence, re-intervention or morbidity benefit when compared to standard operative intervention.

New Method of Flush Saphenofemoral Ligation that is Expected to Inhibit Varicose Vein Recurrence in the Groin: Flush Ligation Using the Avulsion Technique Method

Recently, with the spread of laser ablation therapy, it has been called into question whether flush ligation of the great saphenous vein (GSV) reduces varicose vein recurrence after surgery. Because we thought such recurrence was caused by a narrow branch resection area, we developed a new method of flush ligation (the avulsion technique method). Materials and Methods: A total of 214 limbs in 180 patients whose GSV had become varicose were studied. In our procedure, we dissect the GSV, lift its proximal stump, and expose the tributaries. We pull out the distal side of the tributaries without ligature as far as possible. We evaluate the area of subcutaneous ecchymosis within a 15-cm radius of the inguinal incision visually on the third post-operative day. Results: We were able to pull out over 10 cm per branch by this method. The area of subcutaneous ecchymosis was mostly less than 10%. No hematoma or pain was observed after the operation. Conclusion: This method was safe, with subcutaneous ecchymosis occurring only rarely. We expect this method to reduce saphenofemoral junction recurrence after the operation. (This is a translation of Jpn J Phlebol 2017; 28: 11–16.)

Great uncertainty regarding treatment of varicose vein recurrence

Introduction: Although varicose vein recurrence is common and 10–30 % of all varicose vein surgery is done for recurrence of some sort, there are very few studies that can guide us to the best re-treatment option. With the introduction of minimal invasive endovenous treatments there is a variety of possible options besides traditional open surgical techniques.

Method: The Scandinavian Venous Forum held a symposium at the GSP meeting in Lü-beck 2012 and this review article is based on data from the presentations at that symposium. Further data has been added regarding new knowledge that was not available a year ago, from PubMed search and article references.

Results: The most common reasons for recurrence are discussed and also the discrepancy between neovascularization (NV) and recurrence due to technical failures. It is likely that NV is the most commonly duplex detected type of recurrence following open groin surgery, less common early after endovascular techniques. However, technical or tactical failures are the most common reasons for redo surgery because of symptomatic recurrence. NV seldom leads to symptomatic recurrences and thus a need for re- treatment. There is a risk that the stumps left following endovenous treatments will become a source for symptomatic recurrence after 5–10 years and indications of that have been reported in the few available 5 year RCT-reports following laser treatments. Treatment of recurrence due to stumps in the groin can be done safely within a reasonable operating time through a medial approach and the stump itself can generally not be treated with any of the endovenous alternative methods. Foam treatment can be used for most other recurrent veins but the durability is unknown. Endovascular thermal ablation can only be used for reopened or remaining saphenous veins and accessory saphenous veins while tributaries have to be treated by stab excisions or foam.

Conclusion: Long term reports of results of redo surgery are limited but suggest reasonably good results from open surgical intervention and are non-existent for the endovenous techniques. So far groin recurrence seems best treated surgically by an indirect approach, preferably medial. More studies are needed to find the best treatment regime for varicose vein recurrence in general and hybrid procedures might be the way forward by combinations of different techniques.

Femoral vein valve incompetence as a risk factor for junctional recurrence

Background

Recurrent varicose veins occur up to 80% of procedures. The sapheno-femoral junction can be involved in more than 50% of cases. A detailed pathophysiological explanation of the phenomenon is still missing. The aim of the present work is to evaluate the role of femoral vein incompetence as risk factor for sapheno-femoral junction recurrence.

Methods

Three-hundred-eighty-one patients presenting an incompetent great saphenous vein system and eventually also an incompetent femoral tract (C2-6EpAsdPr) underwent a great saphenous vein high ligation with flush ligation also of the incompetent tributaries along the leg, sparing the saphenous trunk. Pre-operatively, all patients underwent a sonographic evaluation assessing the superficial and deep venous systems, including a detailed analysis of the iliac-femoral vein tract above the sapheno-femoral junction. A retrospective statistical analysis assessed the recurrence risk associated with iliac-femoral vein tract incompetence.

Results

In a 5.5 ± 1.9 years follow-up, great saphenous vein trunk reflux recurrence was detected in 45/381 (11.8%) cases. The reflux source was found in a reconnected sapheno-femoral stump in 11/45 cases (24.5%), in the pelvic network in 8/45 cases (17.8%), in a neovascularization process in 7/45 (15.5%) and in a newly incompetent great saphenous vein tributary in 19/45 (42.2%). At the pre-operative assessment, iliac-femoral vein tract reflux was present in 7 (26.9%) of the 26 cases who developed a sapheno-femoral junction recurrence and in 25 (7%) of the 355 patients who did not demonstrate sapheno-femoral junction recurrence (odds ratio: 4.8; confidence interval 95%: 1.8–12.6; p < .003).

Discussion

Despite many technical diagnostic and therapeutic refinements, varicose veins recurrence remains a frequent event. The present investigation points out the association among iliac-femoral vein tract incompetence and sapheno-femoral junction recurrences after high ligation.

Endovenous laser treatment of groin and popliteal varicose veins recurrence

Objectives Recurrent varicose veins following surgery is a common, complex and costly problem in vascular surgery. Treatment for RVV is technically more difficult to perform and patient satisfaction is poorer than after primary interventions. Nevertheless, traditional vein surgery has largely been replaced by percutaneous office-based procedures, and the patients with recurrent varicose veins have not benefited from the same advantages. In this paper, we propose an endovascular laser treatment that allows reducing the invasiveness and complications in case of SFJ and SPJ reflux after ligation and stripping of the great and small saphenous vein. Methods 8 SFJ and 1 SPJ stumps were treated by endovascular laser treatment in out-patient clinic. Endovascular laser treatment was performed with a 1470 nm diode laser and a 400 µc radial slim™ fiber. Intraoperative ultrasoud was used to guide the fiber position and the delivery of tumescent anesthesia. The gravity of chronic venous disease was determined according to the CEAP classification and the severity of symptoms was scored according to the revised Venous Clinical Severity Score (VCSS). Results The average linear endovenous energy density was 237 J/cm. Patients return to daily activities after a mean of 1.9 days after. The VCSS improved drastically from a mean of 8 pre-interventional to 1 at day 30 and until one year. During the follow-up period (mean 8 months, range: 5-17 months), all the stumps except one were occluded. All patients were very satisfied or satisfied with the method. No severe complications occurred. Conclusions Office-based endovascular laser treatment of groin and popliteal recurrent varicose veins with 1470 nm diode laser and radial-slim fiber is a safe and highly effective option, with a high success rate in the early post-operative period.

Randomized trial of radiofrequency ablation versus conventional surgery for superficial venous insufficiency: if you don't tell, they won't know

OBJECTIVES:

This study compared radiofrequency ablation versus conventional surgery in patients who had not undergone previous treatment for bilateral great saphenous vein insufficiency, with each patient serving as his own control.

METHOD:

This was a randomized controlled trial that included 18 patients and was carried out between November 2013 and May 2015. Each of the lower limbs of each patient was randomly assigned to undergo either radiofrequency ablation or conventional surgery. Clinical features (hyperpigmentation, hematoma, aesthetics, pain, skin burn, nerve injury, and thrombophlebitis) were evaluated at one week, one month, and six months postoperatively. Hemodynamic assessments (presence of resection or occlusion of the great saphenous vein and recurrent reflux in the sapheno-femoral junction and in the great saphenous vein) were performed at one month, six months, and 12 months postoperatively. The independent observer (a physician not involved in the original operation), patient, and duplex ultrasonographer were not made aware of the treatment done in each case. Clinicaltrials.gov: NCT02588911.

RESULTS:

Among the clinical variables analyzed, only the aesthetic evaluation by the physicians was significant, with radiofrequency ablation being considered better than conventional surgery (average, 0.91 points higher: standard deviation: 0.31; 95% confidence interval: -1.51, -0.30; p=0.003). However, in our study, we observed primary success rates of 80% for radiofrequency ablation and 100% for conventional surgery.

CONCLUSIONS:

If the physician is not required to inform the patient as to the technique being performed, the patient will not be able to identify the technique based on the signs and symptoms. Our study revealed that both techniques led to high levels of patient satisfaction, but our results favor the choice of conventional surgery over radiofrequency ablation, as patients who underwent conventional surgery had better hemodynamic assessments.

American College of Phlebology Guidelines – Treatment of refluxing accessory saphenous veins

The American College of Phlebology Guidelines Committee performed a systematic review of the literature regarding the clinical impact and treatment of incompetent accessory saphenous veins. Using an accepted process for guideline developments, we developed a consensus opinion that patients with symptomatic incompetence of the accessory great saphenous veins (anterior and posterior accessory saphenous veins) be treated with endovenous thermal ablation (laser or radiofrequency) or ultrasound-guided foam sclerotherapy to eliminate symptomatology (Recommendation Grade 1C).

[Surgery of varicose vein insufficiency]

The basis of surgery of great saphenous vein insufficiency is the concept of "privat circulation" coined by Trendelenburg in 1891. It was only logical that the dissection of the insuffcient vein or it's partial or complete resection could bring about healing. Over the years varicose vein stripping was modified to finally result in the highly effectiv concept of crossectomy and stripping. For decades this was the Goldstandard in surgery of varicose vein insufficiency. All the other minimally invasive therapeutic techniques which have been developed in the last decades had to compete with crossectomy and stripping. Thanks to progress in technical development the classic stripping procedure has been replaced by highly effectiv, minimally invasiv procedures, at least in the western industrialisied countries. For a minority of patients with specific anatomical pathologies as well as countries with limited health resources vein stripping remains a surgical standard procedure.

Anatomy of the lymph node venous networks of the groin and their investigation by ultrasonography

OBJECTIVE

To describe the anatomy of the lymph node venous networks of the groin and their assessment by ultrasonography.

MATERIAL AND METHODS

Anatomical dissection of 400 limbs in 200 fresh cadavers following latex injection as well as analysis of 100 CT venograms. Routine ultrasound examinations were done in patients with chronic venous disease.

RESULTS

Lymph node venous networks were found in either normal subjects or chronic venous disease patients with no history of operation. These networks have three main characteristics: they cross the nodes, are connected to the femoral vein by direct perforators, and join the great saphenous vein and/or anterior accessory great saphenous vein. After groin surgery, lymph node venous networks are commonly seen as a dilated and refluxing network with a dystrophic aspect. We found dilated lymph node venous networks in about 15% of the dissected cadavers.

CONCLUSION

It is likely that lymph node venous networks represent remodeling and dystrophic changes of a normal pre-existing network rather than neovessels related to angiogenic factors that occur as a result of an inflammatory response to surgery. The so-called neovascularization after surgery could, in a number of cases, actually be the onset of dystrophic lymph node venous networks.Lymph node venous networks are an ever-present anatomical finding in the groin area. Their dilatation as well as the presence of reflux should be ruled out by US examination of the venous system as they represent a contraindication to a groin approach, particularly in recurrent varicose veins after surgery patients. A refluxing lymph node venous network should be treated by echo-guided foam injection.

Significance of Reflux Abolition at the Saphenofemoral Junction in Connection with Stripping and Ablative Methods

Saphenous reflux interferes with the physiological decrease in pressure and induces ambulatory venous hypertension. Elimination of reflux is achieved by flush ligation at the incompetent saphenofemoral junction and stripping of the great saphenous vein, which is the basis of the conventional surgical therapy. Endovenous ablative methods substitute stripping by thermal of chemical destruction of the saphenous trunk; they usually refrain from saphenofemoral junction ligation. Short-term and medium-term results up to 5 years, achieved after endovenous ablation without high ligation, are comparable with those after conventional surgery, which questioned the necessity to ligate the incompetent saphenofemoral junction. Nevertheless, clinical symptoms caused by recurrent reflux occur as a rule not earlier than 8 to 10 years after efficient abolition of reflux. Consequently, randomized studies with long-term follow-ups exceeding 10 years are necessary for trustworthy assessment whether it is justified to abstain from saphenofemoral junction ligation.

Neovascularisation is not an innocent bystander in recurrence after great saphenous vein surgery

INTRODUCTION

This study sought to establish the causes of failure of great saphenous vein surgery among patients in whom there was confidence that accurate saphenofemoral ligation had been carried and the great saphenous vein had been stripped at least to knee level.

METHODS

This was an observational study of 100 limbs (66 patients) operated on by a single surgeon 5-22 years previously (mean: 12 years). The index operation was primary in 54 limbs and for recurrence in 46 limbs. Thirty-two patients were studied having been re-referred for recurrence while 34 were recalled for review. All were examined clinically and with duplex ultrasonography, and all completed questionnaires (Aberdeen varicose vein questionnaire [AVVQ] and EQ-5D-3L). In order to measure the extent of visible recurrence, a scoring system similar to that in the venous clinical severity score was used but with a range of 0-8.

RESULTS

There were visible varicosities in 77 of the 100 limbs. Duplex ultrasonography showed that recurrent saphenofemoral incompetence (SFI) was present in 27% of the limbs. This was judged to result from neovascularisation and was the most common source of reflux. AVVQ scores for the 27 limbs with recurrent SFI (median: 34, interquartile range [IQR]: 20-42) were higher than for the 73 with no recurrent SFI (median: 17, IQR: 11-29), which was a significant difference (Mann-Whitney U test, p<0.01). Analysing clinical scores with chi-squared tests indicated fewer visible varicosities in limbs without recurrent SFI than in those with recurrent SFI (p<0.01).

CONCLUSIONS

Neovascularisation remains poorly understood but it cannot be considered an innocent bystander.

[Quality standards for ultrasound assessment of the superficial venous system of the lower limbs. Report of the French Society for Vascular Medicine]

The quality standards of the French Society for Vascular Medicine for the ultrasound assessment of the superficial venous system of the lower limbs are based on the two following requirements: technical know-how (mastering the use of ultrasound devices and the method of examination); medical know-how (ability to adapt the methods and scope of the examination to its clinical indications and purpose and to rationally analyze and interpret its results).

AIMS OF THE QUALITY STANDARDS

To describe an optimal method of examination in relation to the clinical question and hypothesis; to achieve consistent practice, methods, glossary terminologies and reporting; to provide good practice reference points and to promote a high quality process.

THEMES OF THE QUALITY STANDARD

The three levels of examination. Their clinical indications and goals. The reference standard examination (level 2) and its variants according to clinical needs. The minimal content of the examination report, the letter to the referring physician (synthesis, conclusion and management suggestions) and iconography. Commented glossary (anatomy, hemodynamics, semiology). Technical basis. Ultrasound devices settings. We discuss of use of Duplex ultrasound for the assessment of the superficial veins of the lower limbs in vascular medicine practice.

The hemodynamic paradox as a phenomenon triggering recurrent reflux in varicose vein disease

A curious hemodynamic phenomenon emerging as a consequence of the treatment of varicose veins can offer a reasonable explanation why varicose vein and reflux recurrences occur tenaciously irrespective of the applied therapeutic procedure. Saphenous reflux is the most important hemodynamic factor in varicose vein disease: it is responsible for the hemodynamic disturbance, ambulatory venous hypertension, clinical symptoms, and chronic venous insufficiency. Abolition of saphenous reflux eliminates the hemodynamic disturbance and restores physiological hemodynamic and pressure conditions, but at the same time it unavoidably evokes a pressure difference between the femoral vein and the incompetent superficial veins in the thigh during calf pump activity. The pressure difference increases flow and enhances fluid shear stress on the endothelium in pre-existing minor communicating channels between the femoral vein and the saphenous system in the thigh, which triggers release of biochemical agents nitride oxide and vascular endothelial growth factor; the consequence is enlargement (vascular remodeling) of the communicating channels, and ultimately reflux recurrence. Hence, the abolition of saphenous reflux creates preconditions for the comeback of the previous pathological situation. This phenomenon-starting the same trouble while fixing the problem-has been called hemodynamic paradox; is explains why varicose vein and reflux recurrence can occur after any mode of therapy.

Comparison of endovenous laser ablation and high ligation and stripping for varicose vein treatment: a meta-analysis

Objectives:

To evaluate the efficiency and safety of endovenous laser ablation (EVLA) for primary lower extremity varicosities compared with high ligation and stripping (HLS).

Method:

Prospective non-randomized studies and randomized control trials on comparison of EVLA and HLS in treating varicose vein were included in this study. A meta-analysis on the data of suitable 13 clinical trials was performed using the Mantel–Haenszel method and the risk ratio was calculated. Thirteen studies including a total of 2245 limbs were eligible for inclusion. Among them, 1128 limbs were treated with endovenous laser ablation, whereas 1117 were treated with high ligation and stripping. Primary outcome measures were technical success rates and recurrence rates at different follow-up duration and complication rates.

Results:

No significant difference in initial technical success rates, Procedural failures were more common following EVLA compared with conventional surgery at one- and two-year follow-up. However, the duplex-detected and clinical recurrence rate was similar between conventional surgery and EVLA after one and two years. No statistical significance was found in postoperative phlebitis and bruise in EVLA and HLS (17.9% versus 21.5%). However, fewer complications were observed in EVLA compared with HLS, including bleeding and haematoma (1.28% versus 4.83%), wound infection (0.33% versus 1.91%) and paraesthesia (6.73% versus 11.27%).

Conclusions:

EVLA for varicose veins is safe and effective compared with HLS in a two-year range. More randomized controlled studies follow-up results are needed to clarify longterm recurrence (5 years).

[High ligation and vein stripping. The classic procedure]

The guidelines of the Society for Vascular Surgery and the American Venous Forum for management of patients with varicose veins recommend at level 1B endovenous thermal ablation for treatment of saphenous incompetence. High ligation and stripping is recommended only at level 2B. Consequently today most of the surgical procedures in the US are done endoluminally. The situation in Germany is different. The vast majority of the over 300,000 procedures done annually for varicose veins are surgical. In specialized centers in Germany, post-operative failures after high ligation are uncommon. Improper operative approaches seem likely in many of the randomized controlled trials (RCT). After proper high ligation, the results are very good.

Estudo comparativo entre os achados do exame físico, do mapeamento com eco-color Doppler e da exploração cirúrgica na recidiva das varizes de membros inferiores a partir da junção safeno-femoral

CONTEXTO: A recidiva de varizes em membros inferiores é complicação frequente da safenectomia e sua incidência atinge até 80% dos casos. OBJETIVO: Avaliar a sensibilidade do exame físico e do mapeamento com eco-color Doppler no diagnóstico da insuficiência do coto da veia safena magna, em doentes previamente operados, comparando-os com os achados da exploração operatória da junção safeno-femoral. MÉTODOS: Foram estudados prospectivamente 30 doentes envolvendo 37 membros submetidos previamente à safenectomia magna para tratamento de varizes e que foram reoperados por recidiva de varizes na região inguinal ou em face anterossuperior da coxa. Todos os doentes foram submetidos ao mapeamento com eco-color Doppler. Os dados foram comparados com os achados da exploração da crossa da veia safena magna na reoperação. RESULTADOS: A sensibilidade do mapeamento com eco-color Doppler para a presença de insuficiência do coto da veia safena magna foi de 70,3% (26 concordâncias dentre os 37 membros) e resultados falsos negativos ocorreram em 29,7% (11) membros avaliados (p=0,03). A sensibilidade do achado de varizes na região inguinal e na face anteromedial da coxa com a presença de insuficiência do coto da veia safena magna foi de 100% (37 concordâncias dentre os 37 membros) e não houve resultados falsos negativos. CONCLUSÕES: No doente já submetido à safenectomia magna, a presença no exame físico de varizes recidivadas em região inguinal e na face anteromedial da coxa é sugestivo de insuficiência do coto da veia safena magna, devendo-se realizar o mapeamento com eco color Doppler para o adequado planejamento da reexploração da crossa da veia safena magna.

Clinical and technical outcomes from a randomized clinical trial of endovenous laser ablation compared with conventional surgery for great saphenous varicose veins

Background

This report describes the clinical effectiveness and recurrence rates from a randomized trial of endovenous laser ablation (EVLA) and surgery for varicose veins.

Methods

Some 280 patients were randomized equally using sealed opaque envelopes to two parallel groups: surgery and EVLA. Inclusion criteria included symptomatic disease secondary to primary, unilateral, isolated saphenofemoral junction incompetence, leading to reflux into the great saphenous vein (GSV). Outcomes were: technical success, recurrent varicose veins on clinical examination, patterns of reflux on duplex ultrasound examination, and the effect of recurrence on quality of life, assessed by the Aberdeen Varicose Vein Questionnaire (AVVQ). Assessments were at 1, 6, 12 and 52 weeks after the procedure.

Results

Initial technical success was greater following EVLA: 99·3 versus 92·4 per cent (P = 0·005). Surgical failures related mainly to an inability to strip the above-knee GSV. The clinical recurrence rate at 1 year was lower after EVLA: 4·0 versus 20·4 per cent (P &lt; 0·001). The number of patients needed to treat with EVLA rather than surgery to avoid one recurrence at 1 year was 6·3 (95 per cent confidence interval 4·0 to 12·5). Twelve of 23 surgical recurrences were related to an incompetent below-knee GSV and ten to neovascularization. Of five recurrences after EVLA, two were related to neoreflux in the groin tributaries and one to recanalization. Clinical recurrence was associated with worse AVVQ scores (P &lt; 0·001).

Conclusion

EVLA treatment had lower rates of clinical recurrence than conventional surgery in the short term. Registration number: NCT00759434 (http://www.clinicaltrials.gov).

Late follow-up of a randomized trial of routine duplex imaging before varicose vein surgery

Background

Routine preoperative duplex examination led to an improvement in results 2 years after surgery for primary varicose veins. The aim of the present study was to evaluate the impact of preoperative duplex imaging after 7 years, in relation to other risk factors for varicose vein recurrence.

Methods

Patients with primary varicose veins were randomized to operation with (group 1), or without (group 2) preoperative duplex imaging. The same patients were invited to attend follow-up with interview, clinical examination and duplex imaging. Quality of life (QoL) was measured with the Short Form 36 questionnaire.

Results

Some 293 patients (343 legs) were included initially; after 7 years 227 were interviewed, or their records reviewed: 114 in group 1 and 113 in group 2. One hundred and ninety-four legs (95 in group 1 and 99 in group 2) were examined clinically and with duplex imaging. Incompetence was seen at the saphenofemoral junction and/or saphenopopliteal junction in 14 per cent of legs in group 1 and 46 per cent in group 2 (P &lt; 0·001). QoL was similar in both groups. After a mean follow-up of 7 years (and including patients who underwent surgery after the review), 15 legs in group 1 needed reoperation and 38 in group 2 (P = 0·001).

Conclusion

Routine preoperative duplex imaging improved the results of surgery for primary varicose veins for at least 7 years. Registration number: NCT01195623 (http://www.clinicaltrials.gov).

Conventional surgery and endovenous laser ablation of recurrent varicose veins of the small saphenous vein: a retrospective clinical comparison and assessment of patient satisfaction

Objectives

Recurrences of varicosities of the small saphenous vein (SSV) are common. Surgical reintervention is associated with increased complication rates. The aim of the study was to assess the feasibility of endovenous laser ablation (EVLA) in recurrent varicose veins of the SSV and to compare this technique with surgical reintervention.

Methods

All case files of patients treated for SSV varicosities between May 2006 and October 2008 were evaluated and recurrences were selected. Demographics, duplex findings, clinical, aetiological, anatomical and pathological classification, perioperative and follow-up data were all registered. Additionally, a questionnaire focusing on patient satisfaction was taken.

Results

Two hundred and eighty-one patients were treated for varicosities of the SSV, of which 42 were for recurrences. Twenty-six of these were treated with EVLA, all under local anaesthesia, and 16 were surgically treated. Most surgically treated patients were treated under regional anaesthesia (88%). Technical success was achieved in 94% of surgically treated patients and in all EVLA-treated patients. Complications in both groups were mostly minor and self-limiting. Sural nerve neuralgia appeared to be more frequent in the surgically treated group (20% versus 9%). After correction for length of follow-up, the incidence of rerecurrences was not statistically significant between groups.

Conclusion

EVLA is feasible in patients with recurrent varicose veins of the SSV with possibly a lower incidence of sural nerve injury. Patient satisfaction is high for both treatment modalities. Studies with larger samples are indicated to confirm these observations.

Validity of duplex-ultrasound in identifying the cause of groin recurrence after varicose vein surgery

INTRODUCTION

Often groin recurrences after varicose vein surgery are diagnosed and classified with the help of a duplex ultrasound scan. There are, however, no studies indicating if duplex ultrasound scans can reliably distinguish between the different forms of recurrent vessels, ie, neovascularization or a residual stump. To address this issue, we have conducted a prospective study in which ultrasound scan assessment of groin recurrences was compared to the histological classification of the recurrent groin veins.

MATERIALS AND METHODS

All patients undergoing redo-surgery for symptomatic groin recurrences after previous stripping of the greater saphenous vein (GSV) during a 1-year period (May 2006-May 2007) were included in the study. Preoperatively, all patients had a duplex-ultrasound scan examination of the groin vessels. Based on the duplex scan findings, the recurrent veins in the groin were classified as either a residual stump or neovascularization. During the redo-surgery, a specimen of the recurrent groin veins was obtained and underwent histologic evaluation. Based on histologic criteria, the recurrence was also classified as a residual stump or neovascularization.

RESULTS

During the 1-year study period, 125 groin recurrences in 95 consecutive patients (74 female, 21 male, mean age 58.7 years, standard deviation [SD] 10.3 years) were included. In the 119 cases where both duplex-ultrasound scan and histological evaluation were available, a residual stump was seen at the histological examination in 80.7% of cases, a neovascularization in 10.9% of cases, and a combination of both entities in 8.4% of cases. Duplex-ultrasound scan classified the recurrent groin veins as a residual stump in 68.1% of cases, as neovascularization in 26.1%, and as a combination of both in 5.8% of cases. With histological classification as the gold-standard, duplex ultrasound scans reached a sensitivity of 77.1% and a positive predictive value of 91.4% in correctly identifying a residual stump as the cause of recurrence. For the correct classification of neovascularization, sensitivity was 61.5% and the positive predictive value 25.8%, while a combination of both was recognized with a sensitivity of 10% and a positive predictive value of 14.3%.

CONCLUSION

While duplex-ultrasound scan is a reliable tool to diagnose groin recurrences after varicose vein surgery, its validity in classifying the different types of recurrent groin vessels is limited. Especially the correct identification of neovascularization which is poor with a sensitivity of 62% and a positive predictive value of 26%. Histological examination should still be regarded as the gold-standard when trying to differentiate between different types of groin recurrences.