Pathogenesis and etiology of recurrent varicose veins

Predicting lack of clinical improvement following varicose vein ablation using machine learning

OBJECTIVE

Varicose vein ablation is generally indicated in patients with active/healed venous ulcers. However, patient selection for intervention in individuals without venous ulcers is less clear. Tools that predict lack of clinical improvement (LCI) after vein ablation may help guide clinical decision-making but remain limited. We developed machine learning (ML) algorithms that predict 1-year LCI after varicose vein ablation.

METHODS

The Vascular Quality Initiative database was used to identify patients who underwent endovenous or surgical varicose vein treatment for Clinical-Etiological-Anatomical-Pathophysiological (CEAP) C2 to C4 disease between 2014 and 2024. We identified 226 predictive features (111 preoperative [demographic/clinical], 100 intraoperative [procedural], and 15 postoperative [immediate postoperative course/complications]). The primary outcome was 1-year LCI, defined as a preoperative Venous Clinical Severity Score (VCSS) minus postoperative VCSS of ≤0, indicating no clinical improvement after vein ablation. The data were divided into training (70%) and test (30%) sets. Six ML models were trained using preoperative features with 10-fold cross-validation (Extreme Gradient Boosting [XGBoost], random forest, Naïve Bayes classifier, support vector machine, artificial neural network, and logistic regression). The primary model evaluation metric was area under the receiver operating characteristic curve (AUROC). The algorithm with the best performance was further trained using intraoperative and postoperative features. The focus was on preoperative features, whereas intraoperative and postoperative features were of secondary importance, because preoperative predictions offer the most potential to mitigate risk, such as deciding whether to proceed with intervention. Model calibration was assessed using calibration plots, and the accuracy of probabilistic predictions was evaluated with Brier scores. Performance was evaluated across subgroups based on age, sex, race, ethnicity, rurality, median Area Deprivation Index, prior ipsilateral varicose vein ablation, location of primary vein treated, and treatment type.

RESULTS

Overall, 33,924 patients underwent varicose vein treatment (30,602 endovenous [90.2%] and 3322 surgical [9.8%]) during the study period and 5619 (16.6%) experienced 1-year LCI. Patients who developed the primary outcome were older, more likely to be socioeconomically disadvantaged, and less likely to use compression therapy routinely. They also had less severe disease as characterized by lower preoperative VCSS, Varicose Vein Symptom Questionnaire scores, and CEAP classifications. The best preoperative prediction model was XGBoost, achieving an AUROC of 0.94 (95% confidence interval [CI], 0.93-0.95). In comparison, logistic regression had an AUROC of 0.71 (95% CI, 0.70-0.73). The XGBoost model had marginally improved performance at the intraoperative and postoperative stages, both achieving an AUROC of 0.97 (95% CI, 0.96-0.98). Calibration plots showed good agreement between predicted and observed event probabilities with Brier scores of 0.12 (preoperative), 0.11 (intraoperative), and 0.10 (postoperative). Of the top 10 predictors, 7 were preoperative features including VCSS, Varicose Vein Symptom Questionnaire score, CEAP classification, prior varicose vein ablation, thrombus in the greater saphenous vein, and reflux in the deep veins. Model performance remained robust across all subgroups.

CONCLUSIONS

We developed ML models that can accurately predict outcomes after endovenous and surgical varicose vein treatment for CEAP C2 to C4 disease, performing better than logistic regression. These algorithms have potential for important utility in guiding patient counseling and perioperative risk mitigation strategies to prevent LCI after varicose vein ablation.

Early outcomes of the Third-generation of ClosureFast radiofrequency ablation for great saphenous vein reflux

Background: This study aimed to assess the safety of the third-generation ClosureFast catheter for radiofrequency ablation (RFA) in the treatment of great saphenous vein (GSV) reflux in patients presenting to a dedicated vein center. Materials and methods: All consecutive patients with incompetent GSV who underwent RFA between December 2023 and May 2024 were retrospectively analyzed. The primary study endpoints were technical success and postoperative complication rate at 30 days. Secondary study endpoints were freedom from GSV recanalization and recurrent varicose vein (RVV) rate over the follow-up. The improvement in symptoms (measured by the Venous Clinical Severity Score [VCSS]) was evaluated. Results: During the study period, 50 limbs were treated in 50 consecutive patients (mean age 55.8±13.4 years; 56% women; CEAP 2-4; VCSS >5). The technical success rate was achieved in 100% of cases. There was no significant incidence of 30-day complications. There were no instances of deep venous thrombosis or puncture site thermal injury. One patient (2%) had hyperpigmentation; two patients (4%) had ecchymosis; 4 patients (8%) had pain. At a mean follow-up of 2.9±1.4 months, GSV occlusion and freedom from reintervention rates were both 100% within 1 week and 30 days respectively. No patients had RVV over the follow-up. The VCSS score had decreased a median of 3.5 (IQR: 2.4-5) points from baseline (p<0.01). The mean CEAP class had decreased to 1.59 points from baseline, reflecting a shift towards milder disease categories (C0-C2). Conclusions: The third generation of RFA is safe and effective to ablate the GSV with a low complication rate in the perioperative period. However, durability over the follow-up and further studies with larger cohorts of patients are still needed to confirm these outcomes.

Research on the Application of Continuous Nursing Model in Postoperative Rehabilitation of Patients With Lower Extremity Varicose Veins

This study investigates the effectiveness of a continuous nursing model in the postoperative rehabilitation of patients with lower extremity varicose veins. Using a randomised controlled trial design, we compared the outcomes of patients receiving continuous nursing care with those receiving routine care. The study included 120 patients divided equally into control and experimental groups. Outcomes were measured in terms of rehabilitation quality (wound healing time, lower extremity functional scale scores, complication rates) and quality of life (QoL). Significant improvements were seen in the experimental group across multiple measures, including faster wound healing (p < .05), better functional recovery (p < .01) and higher QoL scores (p < .01). These findings suggest that implementing a continuous nursing model can significantly enhance the postoperative rehabilitation and overall well-being of patients with lower extremity varicose veins.

Pregnancy as a possible reason for recurrent varicosity after laser crossectomy

BACKGROUND

Pregnancy is one of the most important factors which promote the development and recurrence of varicose veins.

METHODS

Altogether 38 limbs of 33 women were evaluated who underwent laser crossectomy following childbirth and after that received US follow-up. Surgery was performed between October 2008 and October 2019. Timespan between surgery and pregnancy was 22.7±20.49 months. In 34 cases GSV, 2 SSV and in 2 cases GSV and perforator veins were treated. Diameter of treated veins was 6.26±3.25 mm. In most cases 1550 nm diode laser equipment and radial fiber was used (70%). Tip of the laser fiber was 1.0 later 0.5 cm to the femoral vein. Mean delivered energy was 100 J/cm along the saphenous veins and approximately double that near the SFJ.

RESULTS

Before gravidity there were flush closures of the SFJ with the femoral vein in 26 cases (EHIT1). In 12 cases there were stumps whose length was mean 7.5±3.73 mm. Between surgery and pregnancy none of them had any recurrency clinically nor with US. After delivery there were recurrent C2 varicosities in 18 cases (47.4%). Pathology of them were as follows: neo vascularization - 6; acc. ant. varicosity -5; perforator vein insufficiency -4 and recanalization -3 cases. This means that in 14/38 cases (36.8%) the SFJ became insufficient which contributed to recurrency. Few results are available about the impact of pregnancy on recurrency after varicose vein surgery.

CONCLUSIONS

Our results suggest that recurrent varicosity results are acceptable using laser crossectomy. We couldn't judge if any of the used techniques could influence those very strong factors which cause recurrent varicosity during pregnancy.

Long-term outcomes of mechanochemical ablation using the Clarivein device for the treatment of great saphenous vein incompetence

OBJECTIVE

The short-term anatomical success rates of mechanochemical ablation using the Clarivein device (Merit Medical) in the treatment of great saphenous vein (GSV) incompetence are high. However, the anatomical success rates seem to drop over time. The aim of this study was to determine the long-term outcomes of GSV treatment using the Clarivein and to assess whether specific anatomical features better correlate with clinical or quality of life (QoL)-related outcomes.

METHODS

This is a single-center, prospective cohort study in follow-up of a multicenter, randomized controlled trial using Clarivein with liquid polidocanol for the treatment of GSV incompetence. The primary outcome was anatomical success (AS), defined as complete occlusion or a recanalized segment, irrespective of reflux, of <10 cm in length. In addition, reflux-free anatomical success (RF-AS) was determined, and defined as complete occlusion or a recanalized segment with <10 cm of reflux. Clinical success was assessed using the Venous Clinical Severity Score (VCSS), and QoL was assessed using the Dutch version of the Aberdeen Varicose Vein Questionnaire (DAVVQ) and the 36-Item Short Form Health Survey (SF-36). Subgroup analyses were performed based on whether AS or RF-AS was achieved or not.

RESULTS

A total of 109 patients (115 limbs) were included. The mean follow-up time was 8.4 ± 0.9 years (range, 5.5-10.3 years). AS was seen in 60.5% of limbs, and RF-AS was seen in 72.8% of limbs. Compared with baseline, the overall mean VCSS improved from 5.3 ± 2.4 to 4.1 ± 2.4, and the overall median DAVVQ score from 13.5 (interquartile range [IQR], 8.7-20.0) to 10.5 (IQR, 5.3-16.2) (P < .001). Improvement in VCSS was only significant in patients with successful treatment: from 5.5 ± 2.7 to 3.7 ± 2.5 (P < .001) if AS was achieved and from 5.0 ± 1.7 to 4.5 ± 1.9 (P = .20) if AS was not achieved. The same results were found for DAVVQ scores: improvement from13.5 (IQR, 8.7-20.6) to 10.3 (IQR, 3.0-14.5) (P < .01) if AS was achieved and from 12.9 (IQR, 8.3-19.3) to 10.8 (IQR, 6.7-18.2) (P = .35) if AS was not achieved. Regarding the overall SF-36 scores, the domains of vitality, mental health, and general health worsened significantly.

CONCLUSIONS

In over 8 years of follow-up, the anatomical success rate after the treatment of GSV incompetence using the Clarivein device decreased to 60.5%. However, clinical scores and disease-specific QoL still improved significantly compared with baseline. We found no convincing evidence that the absence of reflux correlates better with clinical and QoL-related outcomes compared with recanalization irrespective of reflux.

Technique and early results of endovenous laser ablation in morphologically complex varicose vein recurrence after small saphenous vein surgery

BACKGROUND

Recurrences after varicose vein treatment occur frequently and represent a significant health and economic problem. In contrast to primary treatments of superficial truncal venous insufficiency, their management is often more difficult. Here we assessed the technical feasibility and early results of endovenous laser ablation (EVLA) for recurrences with stumps or subfascial meandering varices after small saphenous vein (SSV) surgery.

METHODS

This single-center retrospective study included 45 consecutive EVLA procedures from July 2019 to December 2021 in 40 patients (19 male, 21 female, mean age 62.8 ± 12.7 years). Patients had clinically relevant recurrent varicose veins after SSV surgery, with clinical, etiologic, anatomic and pathophysiologic (CEAP) classification stage of C2S or higher. We categorized the recurrences morphologically according to duplex sonographic criteria. Ablations were done with a 1470 nanometers laser and dual ring radial fibers and aimed at thermal closure as proximal as possible to the upper inflow. Analyses were performed by descriptive statistics and the Kaplan-Meier method. The primary outcome analyzed was the technical success, defined by thermal occlusion not requiring re-intervention during the observation period. The secondary outcome was the occurrence of postoperative complications.

RESULTS

A complex morphology with residual stumps or tortuous venous connections to the popliteal vein was present in 35 cases (77.8%). Immediate technical success at the first postoperative visit after a median of 11 days (interquartile range 8-13 days) was 97.8%. During the follow-up period (median 77 days, interquartile range 13-256 days), 6 limbs (13.3%) required redo EVLA due to symptomatic persistent or newly presenting reflux. The median freedom from re-recurrence was 791 days. Otherwise, no medical or surgical complications requiring specific treatment were observed, particularly no endothermal heat-induced thrombosis (EHIT) or other thrombotic complications, and no nerve damage.

CONCLUSION

According to our pilot data, EVLA is technically feasible for complex popliteal variceal recurrence, although the success rate appears substantially lower than for primary treatment of truncal venous insufficiency.

Safety of synchronous prophylactic ablation of the anterior saphenous vein in patients undergoing great saphenous vein thermal ablation- 6 months follow-up data of the SYNCHRONOUS study

BACKGROUND

The SYNCHRONOUS-study investigates simultaneous ASV-ablation with great saphenous vein (GSV) treatment in endovenous laser ablation (EVLA) for preventing varicose vein recurrence. This sub-study examines complication rates associated with prophylactic ASV-ablation.

METHODS

Among 1173 patients with refluxing GSV, 604 underwent GSV-ablation only, and 569 received additional ASV-ablation. Complication rates were compared over 6 months.

RESULTS

Approximately 80% of patients were complication-free with minor bruising and dysesthesia being most common complications. After 6 months, additional prophylactic ASV-ablation did not increase the rate of complications compared to GSV-only treatment.

CONCLUSION

The 6-months follow-up data suggests that prophylactic ASV-closure, alongside GSV-treatment, is safe, with similar complication rates to GSV-only EVLA.

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.

A prognostic nomogram for recurrence survival in post-surgical patients with varicose veins of the lower extremities

Varicose veins of the lower extremities (VVLEs) are prevalent globally. This study aims to identify prognostic factors and develop a prediction model for recurrence survival (RS) in VVLEs patients after surgery. A retrospective analysis of VVLEs patients from the Third Hospital of Nanchang was conducted between April 2017 and March 2022. A LASSO (Least Absolute Shrinkage and Selection Operator) regression model pinpointed significant recurrence predictors, culminating in a prognostic nomogram. The model's performance was evaluated by C-index, receiver operating characteristic (ROC) curves, calibration plots, and decision curve analysis (DCA). The LASSO regression identified seven predictors for the nomogram predicting 1-, 2-, and 5-year RS. These predictors were age, body mass index (BMI), hypertension, diabetes, the Clinical Etiological Anatomical Pathophysiological (CEAP) grade, iliac vein compression syndrome (IVCS), and postoperative compression stocking duration (PCSD). The nomogram's C-index was 0.716, with AUCs (Area Under the Curve scores) of 0.705, 0.725, and 0.758 for 1-, 2-, and 5-year RS, respectively. Calibration and decision curve analyses validated the model's predictive accuracy and clinical utility. Kaplan-Meier analysis distinguished between low and high-risk groups with significant prognostic differences (P < 0.05). This study has successfully developed and validated a nomogram for predicting RS in patients with VVLEs after surgery, enhancing personalized care and informing clinical decision-making.

Factors influencing recurrent varicose vein formation after radiofrequency thermal ablation for truncal reflux performed in two high-volume venous centers

OBJECTIVE

Recanalization of the saphenous vein trunk after endovenous radiofrequency ablation (RFA) is often associated with recurrent varicose veins (RVVs) or recanalization. This study aimed to assess the long-term results of RFA of the great saphenous vein (GSV) and identify the risk factors for GSV recanalization and RVVs during follow-up for patients presenting to dedicated outpatient vein centers.

METHODS

All consecutive patients with incompetent GSVs who underwent RFA between 2009 and 2019 were retrospectively analyzed. The primary study end points were freedom from GSV recanalization and the RVV rate during follow-up. The secondary study end points were the postoperative complication rate and the risk factors for GSV recanalization and RVVs. Univariate and multivariate analyses were performed to identify the potential risk factors for GSV recanalization and RVVs.

RESULTS

During the study period, 1568 limbs were treated in 1300 consecutive patients (mean age, 53.5 ± 12.9 years; 71.9% women; CEAP [clinical, etiology, anatomy, pathophysiology] C2-C6; venous clinical severity score >5). Technical success was achieved in 99.7% of cases. At a mean follow-up of 57.2 ± 25.4 months, the GSV occlusion and freedom from reintervention rates were 100% and 100% within 1 week, 97% and 95.7% at 1 year, 95.2% and 93.1% at 3 years, and 92.4% and 92.8% at 5 years, respectively. The recurrence rate was 10% (n = 158) during the follow-up period. On multivariate analysis, a direct confluence of the accessory saphenous vein into the saphenofemoral junction (odds ratio [OR], 1.561; 95% confidence interval [CI], 1.0-7.04; P = .032), a history of pregnancy >2 (OR, 3.68; 95% CI, 1.19-11.36; P = .023), C4 (OR, 6.41; 95% CI, 1.36-30.28; P = .019), and preoperative GSV diameter >10 mm (OR, 1.82; 95% CI, 1.65-4.03; P = .043) were risk factors for GSV recanalization. Moreover, age >70 years (OR, 1.04; 95% CI, 1.01-1.06; P = .014) and incompetent perforator veins (OR, 1.17; 95% CI, 0.65-2.03; P = .018) were also risk factors for RVVs.

CONCLUSIONS

RFA is a safe technique to ablate the GSV with a low complication rate and durability during 5 years of follow-up. However, patients with a high clinical score and those with direct confluence of the accessory saphenous vein into the saphenofemoral junction experienced higher long-term GSV recanalization and RVV rates.

Evaluating the Prevalence and Risk Factors of Varicose Veins in Surgeons and Operating Room Staff at Buraidah Center Hospital

Background Varicose veins (VVs), which are characterized by visible, convoluted veins in the lower limbs, are a prevalent disorder that afflicts a substantial portion of the population. The purpose of this cross-sectional study was to look at the prevalence and risk factors for VVs among surgeons and operating room personnel at Buraidah Central Hospital in Saudi Arabia. They usually become worse over time once they develop, which highlights the importance of early intervention and preventive actions. Methodology Data from 91 participants were collected from diverse healthcare professionals between August 2023 and September 2023 via an online questionnaire covering demographics, health, and occupational factors. The chi-square and Fisher's exact tests were employed to examine the correlation between these variables and the occurrence of VVs. Results The data analysis revealed that several specific factors displayed notable associations. Occupations as Surgical Physicians, OR Staff, or Nurse (p=0.009), the number of days worked in the operating room (p=0.040), the role in the operating room, especially those mainly standing (p=0.001), contraceptive pill usage (p=0.000), and vaginal delivery (p=0.037) displayed statistically significant relationships with VVs. In contrast, factors like gender, age group, ethnicity, family history of VVs, social status, smoking habits, exercise frequency, BMI, lifting heavy objects, and years in the field did not reveal substantial associations with VVs, as indicated by p-values exceeding 0.05. Conclusion The study identified a low VV diagnosis prevalence, with an equal distribution among male and female respondents. Key factors that contribute to the risk of developing VVs include the number of days worked in the operating room, the role in the operating room, a family history of VVs, contraceptive pill usage, and the method of delivery.

Endovenous laser treatment vs conventional surgery for great saphenous vein varicosities: A propensity score matching analysis

BACKGROUND

Varicosis is a common venous condition, which is typically treated surgically. However, selection of the optimal surgical approach can be challenging. Previous studies comparing endovenous laser treatment (EVLT) and conventional surgery were retrospective and observational in nature and the results may therefore have been influenced by selection bias and the presence of other confounding factors. In this study, we used propensity score matching to reduce selection bias when comparing EVLT and conventional surgery for the treatment of varicose great saphenous veins.

AIM

To compare the perioperative and postoperative outcomes of EVLT and conventional surgery in patients with great saphenous vein varicosis.

METHODS

We retrospectively reviewed the records of 1063 patients treated for primary varicosis of the great saphenous vein at the Second Affiliated Hospital of Xuzhou Medical University between January 2009 and December 2019. Among them, 56 patients were excluded owing to additional small saphenous varicose vein involvement, 81 owing to recurring varicose veins, 83 owing to complicated varicose veins (CEAP clinical classification C5-C6), and 6 owing to perioperative phlebitis. Finally, 772 patients were enrolled in this study. Standard demographic and clinicopathological data were collected from the medical records of the patients. For propensity score matching, 522 patients (261 who underwent EVLT and 261 who underwent conventional surgery) were randomly matched 1:1 by age, sex, onset time, smoking status, presence of diabetes, family history, stress therapy, C class, and the affected leg.

RESULTS

Of the 772 patients included in the study, 467 underwent EVLT and 305 underwent conventional surgery. There were significant differences in age, onset time, smoking and diabetes status, and family history between the two groups. Following propensity score matching, no significant differences in patients' characteristics remained between the two groups. ELVT was associated with a shorter operation time and hospital stay than conventional surgery, both before and after propensity score matching. There were no differences in complications between the two groups after propensity score matching. Patients who underwent EVLT had a higher recurrence rate during the two-year follow-up period than those who underwent conventional surgery (33.33% vs 21.46%, χ2 = 11.506, P = 0.001), and a greater percentage of patients who underwent EVLT experienced pain one week after the procedure (39.85% vs 19.54%, P = 0.000).

CONCLUSION

EVLT may not always be the best option for the treatment of great saphenous vein varicosis.

PREVAIT after modern open surgery and endothermal ablation: a systematic review

INTRODUCTION

Presence of varices after operative treatment (PREVAIT) is a common finding after varicose vein surgery, and has been shown to significantly reduce the quality of life of those it affects. As such, long-term results after varicose vein interventions have to be taken into account when choosing a technique. This study aims to systematically review current evidence on the recurrence of varicose veins after three different techniques: conventional surgery (HLS), endovenous laser ablation (EVLA) and radiofrequency ablation (RFA).

EVIDENCE ACQUISITION

A literature search was performed on the PubMed and Web of Science databases, which returned 546 studies. Fourteen studies were included. Data were extracted using predefined forms.

EVIDENCE SYNTHESIS

A total of 2795 patients were included, for a total of 3056 legs treated. 503 legs (16.5%) were treated by HLS, 1791 (58.6%) by EVLA and 762 (25.0%) by RFA. PREVAIT was reported in 34.4% for patients treated by HLS, for a mean follow-up comprised between 18 months and 5 years; 16.6% by EVLA, for a mean follow-up between 112 days and 5 years and 6.7% of those treated by RFA, for a mean follow-up between 106 days and 5 years. Regarding patterns of recurrence, the development of new varicose veins was the most commonly reported mechanism of recurrence after HLS (range: 29.8-91%) and EVLA (range: 40-81.6%), but not RFA, where recanalization of the occluded saphenous trunk accounted for up to 67.0% of the cases. Only one study reported quality of life related recurrence, and included patients treated by HLS and EVLA, but not RFA. Aberdeen Varicose Vein Questionnaire (AVVQ) score, physical functioning domains of the SF-36 score and patient satisfaction were significantly worse in patients with clinical recurrence. Re-intervention rates after recurrence were reported in 5 studies, ranging between 7.7% and 37.7% for HLS and 0-57.0% for EVLA. Only one study reported data on re-intervention for RFA patients, which was 6.67%.

CONCLUSIONS

Recurrence is a reliable indicator of long-term efficacy of a varicose vein treatment and appears to occur more frequently after HLS. Although there are several mechanisms of recurrence, the development of new varicose veins was the most commonly observed. There is clear heterogeneity among definitions of recurrence and follow-up periods in literature.

Risk factors for short and long-term great saphenous vein recanalization in patients treated with endovenous radiofrequency ablation

PURPOSE

The aim of this retrospective single-center study is to describe and analyze short-, mid-, and long-term risk factors for great saphenous vein (GSV) recanalization after endovenous radiofrequency ablation (RFA).

MATERIALS AND METHODS

All consecutive patients with GSV incompetence and varicose veins underwent RFA were enrolled between 2009 and 2018. Data on demographic, pre- and postoperative color Doppler scan (CDUS) findings, perioperative complications, and follow-up were prospectively collected. Primary outcome was GSV recanalization rate at 1 week after RFA. Secondary outcomes were postoperative complication rate, as well as GSV recanalization rate at 1, 3, and 5 years after RFA. Risk factors for recanalization were also analyzed, for each follow-up assessment, identifying differences in recanalized (Rec) and non-recanalized (nRec) groups.

RESULTS

During the study period, 1297 patients were treated. Among these, 1265 had at least 1 week of follow-up. Mean follow-up time was 3.0 ± 1.9 years. Recanalization rate at 1 week, 1, 3, and 5 years was 2.4%, 4.3%, 9.3%, and 17.5%, respectively. After multivariate analysis for each follow-up evaluation, CEAP classes C4 and 5, as well as preoperative GSV diameter >6 mm and history of smoking were found to be independent predictors of recanalization. Furthermore, age >61 years and postoperative complications such as pigmentation, edema, and paresthesia were found to be dependent risk factors.

CONCLUSION

RFA remains a safe and durable technique to ablate incompetent GSV. Despite this, particular attention should be paid to patients with high CEAP classes to avoid short and long-term recanalization.

Impact of a synchronous prophylactic treatment of the anterior accessory saphenous vein on the recurrent varicose vein rate in patients undergoing thermal ablation of an insufficient great saphenous vein (SYNCHRONOUS-Study): study protocol for a prospective, multicentre, controlled observational study

INTRODUCTION

To date, there are no prospective studies evaluating the prevention of recurrent veins by the simultaneous treatment of a sufficient anterior accessory saphenous vein (AASV) in patients undergoing endovenous laser ablation (EVLA) of an insufficient great saphenous vein (GSV). This study will provide important information about the impact of the AASV on the development of recurrent veins after EVLA of the GSV. Additionally, it will be clarified whether patients benefit from a preventive ablation of a sufficient AASV.

METHODS AND ANALYSIS

This is a multicentre, prospective, controlled, exploratory clinical study in 1150 patients with a medical indication for EVLA of a refluxing great saphenous vein. Patients will be enrolled into two study groups: in half of the patients EVLA will be performed on the insufficient GSV only. In the other half of the patients EVLA will be performed on the insufficient GSV and additionally on the sufficient AASV. Within seven study visits, patients will be followed-up over a time period of 5 years. Primary study endpoint is the recurrence rate; secondary endpoints include inter alia, complication rate, postoperative pain intensity, quality of life and patient satisfaction.

ETHICS AND DISSEMINATION

Before initiation of the study, the protocol was presented and approved by the independent ethics committee of the medical faculty of the University of Heidelberg (Ethics approval number S-596/2018). This study was prospectively registered at the German Clinical Trial Register (https://www.germanctr.de/). Research findings will be disseminated in a peer-reviewed journal and at relevant conferences.

TRIAL REGISTRATION NUMBER

German Clinical Trial Registry (DRKS00015486).

Endoglin and Other Angiogenesis Markers in Recurrent Varicose Veins

Background: Surgery on varicose veins (crossectomy and stripping) may lead to recurrence, with clinical and socioeconomic repercussions. The etiopathogenesis of varicose veins has yet to be fully understood. Objective: Study the expression of endoglin and other molecules involved in the neovascularisation process in patients suffering from this disease. Methods: Total of 43 patients that have undergone surgery for varicose veins (24 primary and 19 recurrent). Endoglin and other molecules were identified on the venous wall (proximal -saphenofemoral junction- and distal), via real-time RT-PCR, and in serum, via ELISA: endoglin (Eng), vascular endothelial growth factor (VEGF-A), its receptors 1 and 2 (VEGFR1 or FLT1), (VEGFR2 or FLK), and the hypoxia-inducible factor (HIF-1A). All the patients signed a consent form. Results: The recurrent group recorded a higher expression of Eng, VEGF-A, VEGFR1, and VEGFR2 at the level of proximal venous wall compared to the primary group. HIF-1A did not record any differences. As regards the determination of the distal venous wall, no markers recorded differences between the groups. Among the serum determinations, only sFLT1 recorded a significant drop among the patients with recurrent varicose veins. Conclusions: Patients with recurrent varicose veins record a higher expression of endoglin and other markers of angiogenesis in proximal veins. Endoglin in the blood (sEng) serves no apparent purpose in recurrent varicose veins.

Cardiac Doppler Parameters and Progress in Clinical Manifestation of Primary Lower Extremity Varicose Veins: A Prospective Study in China

Objective

To investigate the features of cardiac Doppler parameters in patients with primary lower extremity varicose veins in China.

Materials and Methods

We performed a prospective statistical analysis of cardiac Doppler parameters between 129 Chinese patients with varicose veins and normal controls. Furthermore, we evaluated the relationship between cardiac Doppler and the progress or severity of lower extremity varicose veins.

Results

Compared with normal controls, patients with primary varicose veins had significantly lower early mitral and tricuspid diastolic inflow and annular velocities (E- and e′-waves), significantly higher late mitral and tricuspid diastolic inflow and annular velocities (A- and a′-waves), significantly higher mitral systolic annular velocities (s′-wave), and significantly lower mitral and tricuspid E/A ratio. There was no significant association between deep venous reflux (DVR) of the lower extremities and cardiac Doppler parameters. The relationship between Clinical Etiological Anatomical Pathophysiological (CEAP) clinical class and cardiac Doppler parameters showed on that: In comparison with normal control, all cardiac Doppler parameters of C2 clinical class patients were basically unchanged, but the cardiac Doppler parameters of the C3 or higher CEAP class patients changed. Hence, we found a potential CEAP grade cut-off value (C3) linked to statistical changes in cardiac Doppler parameters.

Conclusion

Cardiac Doppler parameters in patients with primary varicose veins could indeed be different from those of normal people, especially for C3 class or higher CEAP clinical class patients. Therefore, for those patients, pre-operative echocardiography can be used to evaluate cardiac hemodynamic changes, but large-scale clinical promotion requires further large sample studies.

Comparison of Modified Above-Knee and Conventional Surgery with the Stripping of the Great Saphenous Vein of Varicose Veins of the Lower Extremities: A Retrospective Study

OBJECTIVE

To compare the clinical effects of modified above-knee and conventional surgery with the stripping of the great saphenous vein of varicose veins of the lower extremities.

METHODS

Clinical data of patients with a varicose vein of the lower extremity from May 2016 to May 2018 were collected. A retrospective study was conducted on the patients receiving modified above-knee and conventional surgery with the great saphenous vein stripping. The baseline characteristics and long-term follow-up data were compared between the groups.

RESULTS

There were no significant differences in baseline characteristics between the two groups (P > 0.05). The surgeries were successfully performed by the same group of surgeons under local anesthesia and neuraxial anesthesia. The hospital stay, operation time, intraoperative blood loss, total length, and number of incisions in the above-knee group were comparable to those in the conventional surgery group (P > 0.05). The incidence of saphenous nerve injury and subcutaneous hematoma in the above-knee group was lower than that in the conventional surgery group (P < 0.05). There were no significant differences in recurrent varicose vein incidences (P > 0.05). After surgery, the venous clinical severity score (VCSS) and chronic venous insufficiency questionnaire (CIVIQ-14) scores of both groups were higher than those before operation (P < 0.05). There was no significant difference in VCSS score or CIVIQ-14 scores between the two groups postoperation (P > 0.05). At 24 months after surgery, the above-knee group (71.8%) and conventional surgery group (73.2%) resulted in changes of at least two CEAP-C clinical classes lower than baseline, respectively.

CONCLUSION

The modified above-knee technique can ensure clinical outcomes, reduce intraoperative blood loss and complication incidences, and shorten the operative time. This gives evidence that the modified above-knee technique is worthy of clinical application.

Treatment of Recurrent Symptomatic Saphenous Trunk Reflux with Catheter Directed Foam Sclerotherapy and Tumescent Anaesthesia

Objective

The aim was to assess short and midterm efficacy and safety of catheter directed foam sclerotherapy (CDFS) with tumescent anaesthesia in patients with recurrent symptomatic saphenous reflux.

Methods

This was a prospective observational study (February 2018 to February 2019) including 21 consecutive patients referred with recurrent symptomatic varicose veins. Standing duplex ultrasound (DUS) with saphenous vein diameter measurement 3 cm from the terminal valve was performed pre-operatively. All the patients were operated on under local anaesthesia. By ultrasound guided puncture a hydrophilic 0.035″ guidewire and 5F Berenstein catheter were inserted through a 5F introducer sheath. Peri-saphenous tumescent anaesthesia (PSTA) was performed under ultrasound guidance. Sclerosant foam was prepared with sodium tetradecyl sulphate 3% or polidocanol 3% using the Tessari method. Concomitant phlebectomies were performed in 52%. Clinical evaluation and DUS were performed pre- and post-operatively at one week, six months, and 12 months.

Results

There were 11 men and 10 women (median age 52 years; interquartile range [IQR] 43 – 61). The great saphenous vein was treated in 18 patients. The median vein diameter was 6.8 mm (IQR 4.7 – 8.9). Previous procedures were Cure conservatrice et Hemodynamique de l'Insuffisance Veineuse en Ambulatoire (CHIVA), mechanochemical ablation, thermal ablation, and cyanoacrylate closure. The distribution of the clinical class (Clinical Etiology Anatomy Pathophysiology [CEAP] classification) was 16 C2, three C3, and two C4 limbs. Immediate technical success was 100%. There were no complications in the early post-operative period. The median follow up was eight months (IQR 5 – 10). The occlusion rate demonstrated by DUS was 100% (21/21) at one week, 100% (21/21) at six months, and 86% (18/21) at 12 months. The median post-procedural vein diameter at one week, six months, and 12 months was 4.8 mm (IQR 3.9 – 6), 4.3 mm (IQR 3.5 – 5.5), and 4 mm (IQR 3 – 4.9), respectively.

Conclusion

Combination CDFS with PSTA achieves good short and medium term venous occlusion rates, associated with few complications in patients with recurrent symptomatic saphenous reflux.

•

The objective was to assess short and midterm efficacy and safety of catheter directed foam sclerotherapy with tumescent anaesthesia in patients with recurrent symptomatic saphenous trunk reflux.

•

Ultrasound guided foam sclerotherapy is the endovenous modality with the highest recanalisation rate compared with other techniques when treating patients with primary superficial venous reflux. Although the combination of catheter directed foam sclerotherapy with tumescent perivenous anaesthesia is a more complex procedure, this modification can increase the probability of success in terms of vein occlusion for patients with recurrent symptomatic saphenous reflux.

•

An occlusion rate 86% at 12 months is reported, but the “reflux free” ratio accounts for 95%. No relevant complications occurred in the early post-operative period. Patients did not report any neurological, pulmonary, or cardiac symptoms intra-operatively, or in the following hours or days.

Clinical assessment of endovenous thermal ablation combined with concomitant phlebectomy for the treatment of lower limb varicose veins with or without poor glycemic control

BACKGROUND

This study aimed to investigate the clinical results of endovenous thermal ablation combined with stab phlebectomy for unilateral varicose veins based on diabetic management.

METHODS

The study reviewed 501 patients who underwent endovenous thermal ablation combined with stab phlebectomy for unilateral varicose veins, including 337 nondiabetics (control group) and 164 diabetics. Diabetics with hemoglobin A1c ≥7% were classified as the poor glycemic control group, and hemoglobin A1c <7% as the good glycemic control group. Surgical outcomes were assessed by Venous Clinical Severity Score. The Chronic Venous disease quality of life Questionnaire was used to assess the quality of life.

RESULTS

Lower limb varicose veins can be treated successfully with endovenous thermal ablation combined with stab phlebectomy in patients with or without poor glycemic control, accompanied by a significant improvement in health status. For patients with initial varicose veins (preoperative Venous Clinical Severity Score <10), the results revealed satisfactory improvements in Venous Clinical Severity Score and quality of life among the control, poor glycemic control, and good glycemic control groups. Patients with advanced varicose veins (preoperative Venous Clinical Severity Score ≥10) also showed an obvious amelioration concerning venous symptoms and quality of life. However, the extent of improvement varied among the 3 groups. Patients subjected to advanced varicose veins with the condition of poor glycemic control exhibited a less desirable improvement in postoperative health conditions compared with the control and good glycemic control groups, especially in edema relief and ulcer healing.

CONCLUSION

Endovenous thermal ablation combined with stab phlebectomy is safe and effective in the treatment of varicose veins with or without poor glycemic control. Clinical attempts at hemoglobin A1c management may contribute to improved clinical outcomes in patients with advanced varicose veins.

Detection of residual varicose veins with near infrared light in the early period after varicose surgery and near infrared light assisted sclerotherapy

OBJECTIVES

Varicose veins that cannot be seen with the naked eye can be easily detected with Near Infrared (NIR) light. With a minimally invasive procedure performed with NIR light guided, the need for reoperation is reduced, while optimal treatment of venous insufficiency and symptoms is provided. In this study, the detection of residual varicose veins after varicose vein surgery using NIR light and the results of treatment of sclerotherapy were investigated.

METHODS

In this retrospective study, treatment and clinical outcomes of patients' who underwent NIR light-guided foam sclerotherapy for Clinical-Etiology-Anatomy-Pathophysiology (CEAP) (C1, C2) stage residual varicose veins after surgical varicose treatment between 2014 and 2017 were examined. Data of patients who underwent foam sclerotherapy with NIR light were collected and analyzed.

RESULTS

A total of 151 patients and 171 lower extremity varicose veins were treated with surgery. 55 (35.7%) of the patients were male, and 96 (62.3%) were female. Their age ranges from 20 to 64, with an average age of 45.38. 4 (2.6%) of the patients had phlebectomy. 137 of patients (90.7%) had ligation of perforated veins, phlebectomy, and great saphenous vein (GSV) stripping, 10 of patients (6.6%) had GSV stripping, perforating vein ligation, phlebectomy, and small saphenous vein (SSV) surgery. No residual leakage was observed in the controls of GSV, SSV, and perforating veins by duplex ultrasonography (DUS). In the first month after varicose surgery, an average of 1.64 ± 1.05 sessions of sclerotherapy was applied to patients with CEAP C1, C2 stage residual varicose veins. 70 patients had one session of sclerotherapy, 37 patients had two sessions of sclerotherapy, 20 patients had three sessions of sclerotherapy, and 11 patients had four sessions of sclerotherapy administrated. The need for complementary therapy was required for all female patients; 13 of the male patients did not require complementary sclerotherapy. While single-session sclerotherapy was applied to most male patients (32 (58.18%), 10 (18.18%) patients received two sclerotherapy sessions. After completing sclerotherapy, 7 (4.63%) patients had superficial venous thrombosis, and 13 (8.60%) patients had hyperpigmentation.

CONCLUSION

Surgical treatment is a safe and effective technique in venous insufficiency. Nevertheless, residual varicose veins may remain, and these can be detected noninvasively with NIR light. Foam sclerotherapy with NIR light is a minimally invasive and safe treatment method for small residual varicose veins after the operation. We think that sclerotherapy with NIR light as a complementary treatment is a practical, reliable, and demanding treatment for clinical improvement, especially in female patients.

Ultrasound-assisted varicose vein surgery and endovenous laser ablation using 1470-nm laser for treatment of great saphenous vein incompetence has similar outcomes at 1 year: A single-center prospective randomized study

BACKGROUND

Technical errors are the most common preventable cause of recurrence after high ligation and stripping procedures for the treatment of great saphenous vein incompetence. Ultrasound-assisted varicose vein surgery (UAVS) uses intraoperative ultrasound during high ligation and stripping to minimize such failures, although no data have been reported regarding its use during open surgery. The present study compared the short-term outcomes of UAVS and endovenous laser ablation (EVLA) with a 1470-nm laser.

METHODS

The present prospective randomized study was conducted from January 2019 to December 2019. We compared 40 patients who had undergone UAVS under regional anesthesia with an equal number of patients who had undergone EVLA under tumescent anesthesia. Both groups received 1 week of standardized postoperative analgesia. The improvements in the pain score, venous clinical severity score, and recurrence at 6 months and 1 year were studied.

RESULTS

No significant differences were found in either clinical or radiologic great saphenous vein recurrence after UAVS compared with EVLA at 1 year. The mean pain score at 8 hours after the procedure was higher in the UAVS group (3.7 ± 1.2 vs 2.9 ± 1.0; P = .03). At 1 week, the score was higher in the EVLA group (1.8 ± 0.7 vs 1.4 ± 0.5; P = .01). At 6 months, the venous clinical severity score had improved from 9.2 ± 3.7 to 2.4 ± 1.4 in the UAVS group and from 9.3 ± 3.2 to 2.1 ± 0.8 in the EVLA group (P = .64). At 1 year, the corresponding scores were 1.3 ± 0.7 and 1.4 ± 0.6 (P = .21).

CONCLUSIONS

UAVS has high technical success, making it a suitable alternative to EVLA using a 1470-nm laser.

Midterm varicose vein recurrence rates after endovenous laser ablation: comparison of radial fibre and bare fibre tips

OBJECTIVES

We evaluated and compared midterm recurrence results of our patients with great saphenous vein insufficiency who were treated with a 1470-nm diode laser using 2 different types of fibre catheter kits.

METHODS

A total of 61 consecutive patients were treated between 2013 and 2014 with a bare fibre (BF) tip (BF group) and 60 consecutive patients were treated with a radial fibre (RF) tip (RF group) from 2014 to 2016. First-year venous clinical severity scores (VCSSs) were compared with VCSS before endovenous laser ablation and at the first-month follow-up. Patients were examined for recurrence and classified according to the system developed by Stonebridge.

RESULTS

There was no significant difference between the 2 groups in terms of VCSS. Examination with Doppler ultrasonography showed no recurrence in the RF group, whereas recurrences were detected in 6 patients in the BF group, which was statistically significant (P = 0.028). All of the recurrences were type 1b (incompetent tributaries) varicose vein recurrences. The VCSS of the patients with recurrence were the same as the scores of patients without recurrence (0.5 ± 0.55).

CONCLUSIONS

Varicose vein recurrence was more often seen in the BF group than in the RF group. Recanalization-induced and neovascularization-induced recurrences were not found in either group. Saphenofemoral side branch-induced recurrence was more significant in the group treated with the BF tip.

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.).

Cellular senescence at the saphenofemoral junction in patients with healthy, primary varicose and recurrent varicose veins - A pilot study

OBJECTIVES

Cellular senescence could play a role in the development of venous disease. Superficial venous reflux at the saphenofemoral junction is a common finding in patients with primary varicose veins. Furthermore, reflux in this essential area is associated with higher clinical stages of the disease and recurrent varicose veins. Therefore, this pilot study aimed to investigate cellular senescence in the immediate area of the saphenofemoral junction in patients with healthy veins, primary varicose veins and additionally in patients with recurrent varicose veins due to a left venous stump.

METHODS

We analyzed vein specimens of the great saphenous vein immediately at the saphenofemoral junction. Healthy veins were collected from patients who underwent arterial bypass reconstructions. Samples with superficial venous reflux derived from patients who received high ligation and stripping or redo-surgery at the groin, respectively. Sections were stained for p53, p21, and p16 as markers for cellular senescence and Ki67 as a proliferation marker.

RESULTS

A total of 30 samples were examined (10 healthy, 10 primary varicose, and 10 recurrent varicose veins). We detected 2.10% p53⁺ nuclei in the healthy vein group, 3.12% in the primary varicose vein group and 1.53% in the recurrent varicose vein group, respectively. These differences were statistically significant (p = 0.021). In the healthy vein group, we found 0.43% p16⁺ nuclei. In the primary varicose vein group, we found 0.34% p16⁺ nuclei, and in the recurrent varicose vein group, we found 0.74% p16⁺ nuclei. At the p < 0.05 level, the three groups tended to be significant without reaching statistical significance (p = 0.085). There was no difference in respect of p21 and Ki67.

CONCLUSION

We found significantly higher expression rates of p53 in primary varicose veins at the saphenofemoral junction than in healthy veins. p16 expression tended to be increased in the recurrent varicose vein group. These preliminary findings indicate that cellular senescence may have an impact in the development of varicose veins or recurrence. Further studies addressing this issue are necessary.

Efficiency of Prophylactic Ablation of the Tributary Venous Pathways Draining Around the Saphenofemoral Junction to Decrease the Rate of Future Varicose Vein and Symptoms Occurence

BACKGROUND

There are various other collaterals draining into the venous system around the saphenofemoral junction in addition to the great saphenous vein. We aimed to determine the efficiency of prophylactic ablation of tributary veins in long term varicose vein and symptom recurrence.

METHODS

Two hundred and sixty-three consecutive patients whom underwent radiofrequency ablation therapy for the treatment of superficial venous reflux disease were investigated. There were 129 patients who received isolated great saphenous vein ablation (Group A) where as 134 patients underwent ablation of the other tributary veins in addition to the great saphenous vein (Group B) between June 2015 and January 2017. The tributary superficial veins; refluxing and/or not refluxing, draining into the saphenofemoral junction were selectively catheterized and ablated in Group B. Patients are followed at least 1 year after the procedures regulary and researched for recurrence of varciose veins and symptoms.

RESULTS

Gender, mean age, body mass index, diameter of the great saphenous veins, small saphenous vein disease, and grade of deep venous insufficiency did not differ significantly between the two groups. The mean number of tributary veins were similar in both groups (n: 1.9 ± 0.4 in Group A vs. n: 1.8 ± 0.7 in Group B) which were detected preoperatively as well as during the procedure. The mean number of ablated tributary venous pathways could be 1.4 ± 0.6 in Group B. During the follow up period symptoms related with varicose veins recurred in 19 patients in Group A where as in 7 patients in Group B (P < 0.05). Three of these symptomatic patients in Group B were the ones in whom the tributary pathways could not be catheterized ablated where as 14 patients in Group A were diagnosed with newly refluxing tributary pathways. All the symptomatic patients in both groups were managed medically and/or with additional interventions.

CONCLUSION

The absence of any fascial unsheathing and the parietal weakness are suggestive of a lower resistance of the tributary veins wall, so collapse and size of veins make it more complex to catheterization regarding to great saphenous vein. Ablation of the tributary superficial venous pathways during the treatment of great saphenous vein reflux disease decreased the rate of recurrence of superficial venous reflux disease and patients symtoms in our modest cohort.

Stump Length Changes after Endovenous Cyanoacrylate Closure or Radiofrequency Ablation for Saphenous Vein Incompetence

Purpose

The aim of this study was to analyze changes in stump length over time in patients with saphenous vein incompetence treated with cyanoacrylate closure (CAC) or radiofrequency ablation (RFA).

Methods

Materials and We retrospectively analyzed data collected from patients with saphenous vein incompetence who underwent either CAC or RFA at Seoul National University Hospital between November 2015 and December 2018. The stump lengths were measured using duplex ultrasonography (DUS) within 1 month and 6 months after treatment. The Venous Clinical Severity Score (VCSS) and Aberdeen Varicose Vein Questionnaire (AVVQ) score were used to assess clinical outcomes.

Results

A total of 97 veins (64 great saphenous veins and 33 small saphenous veins) were analyzed. The stump length was not significantly different between the two groups at <1 month (P=0.311). However, the stump length in the CAC group was significantly longer than that in the RFA group at 6 months (P=0.004). At 6 months, the mean change in stump length was 1.41±2.28 cm in the CAC group and 0.51±0.54 cm in the RFA group (P=0.006). The VCSSs and AVVQ scores significantly improved after both procedures but were not significantly different between the two groups.

Conclusion

DUS at 6 months after treatment showed that the stump length in the CAC group increased more than that in the RFA group. No other factors affected the changes in stump length.

Systematic review of ambulatory selective variceal ablation under local anesthetic technique for the treatment of symptomatic varicose veins

OBJECTIVE

The ambulatory selective variceal ablation under local anesthesia (ASVAL) technique subscribes to the "ascending" theory of varicose vein etiology, which recommends primary ambulatory phlebectomy as a treatment for tributary varicosities and truncal vein incompetence. This systematic review explores the efficacy and safety of the ASVAL technique for the treatment of symptomatic varicose veins.

METHODS

A comprehensive search of the Medline and Embase databases and the Cochrane Register of Controlled Trials in May 2019 revealed 11 original articles that were qualitatively reviewed. The primary outcome was the absence from recurrent varicose veins at 1-year follow-up. Secondary outcomes were resolution of great saphenous vein (GSV) reflux on duplex ultrasound, change in GSV diameter, objective and subjective clinical improvement in chronic venous disease, and patient-reported outcome measures.

RESULTS

A total of 2106 limbs underwent intervention in 1734 patients reported in two randomized controlled trials, one case control study, three cohort studies, and five case series. Varicosity recurrence at 1 year ranged from 0.5% to 13.5% in patients. Of 1622 limbs with diagnosed GSV incompetence before intervention, 1114 were competent at 1 year (mean, 68.2% [±12.62%]). All studies measuring GSV diameter reported statistically significant reductions in vein size.

CONCLUSIONS

ASVAL may be considered as a minimally invasive treatment for early stages of chronic venous disease in the presence of truncal reflux. The evidence base should be strengthened by prospective randomized controlled trials that follow standardized procedures and report according to recognized measures of quality of life alongside clinical and hemodynamic data.

Postsclerotherapy compression: A systematic review

BACKGROUND

Compression after sclerotherapy is commonly used, although the evidence base for this practice is unclear. This study aims to summarize and assess the evidence for compression therapy after sclerotherapy to inform clinical practice.

METHODS

A systematic review was performed according to PRISMA guidelines via Medline and EMBASE databases (1946 to December 31, 2019) by two reviewers. Full-text, English-language studies comparing compression type and/or duration in adult chronic venous disease patients undergoing liquid or foam sclerotherapy were included.

RESULTS

Nine studies were identified: five using liquid sclerotherapy, three foam sclerotherapy and one using both. Studies had short follow-up periods (6-24 weeks) and reported on clinical outcomes, quality of life, side effects and complications. In C1 patients undergoing liquid sclerotherapy, any duration of stocking use significantly decreased telangiectasia and reticular vein number and size compared with no compression. No significant difference in clinical symptoms or quality of life was seen when comparing compression duration after liquid or foam sclerotherapy in tributary or truncal veins in C2 to C6 patients. Greater superficial vein resolution was seen with stockings compared with bandages in C2 patients undergoing liquid sclerotherapy to tributary veins. A comparison of stockings vs bandaging revealed differing thrombophlebitis rates but no significant difference in pigmentation. In C2 to C6 patients undergoing foam sclerotherapy, use of 35 mm Hg stockings significantly improved post-treatment symptoms compared with 23 mm Hg stockings. This review was limited by heterogeneity of outcome measurements and the variety of comparisons between compression types and durations.

CONCLUSIONS

Postsclerotherapy compression may have beneficial clinical outcomes at short-term follow-up; however, evidence is lacking regarding its type, class, length, and duration. Further trials are required to guide the optimal management of postsclerotherapy patients.

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.

A randomized controlled noninferiority trial comparing radiofrequency with stripping and conservative hemodynamic cure for venous insufficiency technique for insufficiency of the great saphenous vein

OBJECTIVE

The quality of available evidence regarding new minimally invasive techniques to abolish great saphenous vein reflux is moderate. The present study assessed whether radiofrequency ablation (RFA) was noninferior to high ligation and stripping (HLS) and conservative hemodynamic cure for venous insufficiency (CHIVA) for clinical and ultrasound recurrence at 2 years in patients with primary varicose veins (VVs) due to great saphenous vein (GSV) insufficiency.

METHODS

We performed a randomized, single-center, open-label, controlled, noninferiority trial to compare RFA and 2 surgical techniques for the treatment of primary VVs due to GSV insufficiency. The noninferiority margin was set at 15% for absolute differences. Patients aged >18 years with primary VVs and GSV incompetence, with or without clinical symptoms, C2 to C6 CEAP (Clinical, Etiologic, Anatomic, Pathophysiologic) clinical class, and GSV diameter >4 mm were randomized with a 1:1:1 ratio to RFA, HLS, or CHIVA. The rate of clinical recurrence at 24 months was the primary endpoint and was analyzed using a delta noninferiority margin of 15%. Ultrasound recurrence, safety, and quality of life were secondary endpoints.

RESULTS

From December 2012 to June 2015, 225 limbs had been randomized to RFA, HLS, or CHIVA (n = 74, n = 75, and n = 76). Clinical follow-up and Doppler ultrasound examinations were performed at 1 week and 1, 6, 12, and 24 months postoperatively. No differences in postoperative complications or pain were observed among the three groups. RFA was noninferior to HLS and CHIVA for clinical recurrence at 24 months, with an estimated difference in recurrence of 3% (95% confidence interval [CI], -4.8% to 10.7%; noninferiority P = .002) and -7% (95% CI, -17% to 3%; P < .001), respectively. For ultrasound recurrence, RFA was noninferior to CHIVA, with an estimated difference of -34% (95% CI, -47% to -20%; noninferiority P < .001) at 24 months. However, noninferiority could not be demonstrated compared with HLS (5.9%; 95% CI, -4.1 to 15.9; P = .073). No differences were found in quality of life among the three groups.

CONCLUSIONS

RFA was shown to be noninferior in terms of clinical recurrence to HLS and CHIVA in the treatment of VVs due to GSV insufficiency.

Association between right heart diastolic function and clinical presentation of chronic venous disease and primary varicose veins of lower extremities

Aim

This study examines the association between right heart diastolic function and clinical presentation of chronic venous disease and primary varicose veins of lower extremities.

Material and methods

We performed retrospective analysis of clinical, peripheral venous Duplex and tricuspid Doppler (early diastolic inflow E-wave, late diastolic inflow A-wave, ratios of E to A waves, early diastolic annular e′-wave, late diastolic annular a′-wave and systolic annular s′- wave) data of 85 patients, 133 legs with primary varicose veins.

Results

We found following significant (p-value < 0.05) associations between tricuspid Doppler and clinical presentation of chronic venous disease and primary varicose veins: Clinical Etiological Anatomical Pathophysiological clinical class influenced late diastolic inflow velocities (C6 class A-wave +11.2 cm/s or +27% in comparison with C2), late diastolic annular velocities (C6 class a′-wave +3.3 cm/s or +22% in comparison with C2), systolic annular velocities (C6 class s′-wave +3.7 cm/s or +27% in comparison with C2) and E/A ratios (C6 class E/A ratio −0.22 or −21% in comparison with C2). Recurrent varices in comparison with previously untreated are associated with significantly lower late diastolic inflow velocities (A-wave −4.4 cm/s or −9%) and preserved E/A ratios. Age significantly influenced tricuspid Doppler (E-, A-, e′-, a′-waves and E/A ratios) in patients with chronic venous disease.

Conclusion

Clinical presentation of primary varicose veins and chronic venous disease can be associated with the right heart diastolic function: C6 Clinical Etiological Anatomical Pathophysiological class in comparison with C2 is associated with increased right ventricular filling and impaired ventricular relaxation – right heart diastolic dysfunction; recurrent varices in comparison with previously untreated are associated with reduced right ventricular filling and preserved right heart diastolic function. Older age is the most important risk factor for varicose veins and chronic venous disease possible due to significant changes in right ventricular filling and in right heart diastolic function with age.

[Pros and cons of classic crossectomy with stripping compared to endoluminal treatment : Competition or team play?]

The chronic venous insufficiency (CVI) of the leg veins is one of the most common diseases in our society. Thus, it is important to know the clinical picture of CVI and the pros and cons of the different treatment options. Of the various treatments available for varicose veins (conservative therapy, operative procedures, endoluminal techniques, foam sclerotherapy), an evidence-based, treatment option should be individually chosen for each patient. In this article, the pros and cons of surgery are compared with endoluminal therapy in order to draw practical conclusions for the treatment decision.

Weighted Gene Co-expression Network Analysis for RNA-Sequencing Data of the Varicose Veins Transcriptome

Objective

Varicose veins are a common problem worldwide and can cause significant impairments in health-related quality of life, but the etiology and pathogenesis remain not well defined. This study aims to elucidate transcriptomic regulations of varicose veins by detecting differentially expressed genes, pathways and regulator genes.

Methods

We harvested great saphenous veins (GSV) from patients who underwent coronary artery bypass grafting (CABG) and varicose veins from conventional stripping surgery. RNA-Sequencing (RNA-Seq) technique was used to obtain the complete transcriptomic data of both GSVs from CABG patients and varicose veins. Weighted Gene Co-expression network analysis (WGCNA) and further analyses were then carried out with the aim to elucidate transcriptomic regulations of varicose veins by detecting differentially expressed genes, pathways and regulator genes.

Results

From January 2015 to December 2016, 7 GSVs from CABG patients and 13 varicose veins were obtained. WGCNA identified 4 modules. In the brown module, gene ontology (GO) analysis showed that the biological processes were focused on response to stimulus, immune response and inflammatory response, etc. Kyoto encyclopedia of genes and genomes (KEGG) pathway analysis showed that the biological processes were focused on cytokine-cytokine receptor interaction and TNF signaling pathway, etc. In the gray module, GO analysis showed that the biological processes were skeletal myofibril assembly related. The immunohistochemistry staining showed that the expression of ASC, Caspase-1 and NLRP3 were increased in GSVs from CABG patients compared with varicose veins. Histopathological analysis showed that in the varicose veins group, the thickness of vascular wall, tunica intima, tunica media and collagen/smooth muscle ratio were significantly increased, and that the elastic fiber/internal elastic lamina ratio was decreased.

Conclusion

This study shows that there are clear differences in transcriptomic information between varicose veins and GSVs from CABG patients. Some inflammatory RNAs are down-regulated in varicose veins compared with GSVs from CABG patients. Skeletal myofibril assembly pathway may play a crucial role in the pathogenesis of varicose veins. Characterization of these RNAs may provide new targets for understanding varicose veins diagnosis, progression, and treatment.

Surgical treatment of recurrent varicose veins in the lower limbs associated with endovascular treatment of iliac vein stenosis

OBJECTIVE

We present our experience with endovascular surgery for recurrent varicose veins (RVV) of the lower limbs combined with the iliac vein compression syndrome (IVCS).

MATERIALS AND METHODS

This study was a retrospective analysis of 6 patients with RVVs combined with IVCS who were admitted to our hospital between January 2007 and December 2014. Transfemoral venography was performed to confirm IVCS. Balloon dilation and stent placement were successful in all 6 patients. The varicose veins were treated by traditional surgery after the endovascular therapy. The visual analog pain scale (VAS) score and venous clinical severity score (VCSS) were collected before surgery and at 6-months follow-up, and were analyzed using the paired student t-test. Patency of the iliac vein was assessed via duplex Doppler ultrasound.

RESULTS

The rate of technical success was 100%. There was a significant (p < .001) improvement in VCSS postoperatively. During the 6-month follow-up period, no RVVs were observed and the rate of iliac vein patency was 100%. Importantly, VAS ratings also decreased significantly (p < .001) during the follow-up.

CONCLUSION

Endovascular surgery for IVCS combined with traditional surgery focused on varicose veins is an effective procedure for treating RVVs of the lower limbs associated with IVCS within 6 months.

Ligation of the saphenofemoral junction tributaries as risk factor for groin recurrence

OBJECTIVE

The aim of this study was to compare the recurrence rate after high ties performed with or without sparing of the saphenofemoral junction tributaries.

METHODS

There were 867 lower limbs enrolled. All patients underwent a high tie with (group A) or without (group B) ligation of all the junctional tributaries for a great saphenous vein reflux (C2-5EpAsPr). A duplex ultrasound examination detected recurrences.

RESULTS

Median follow-up was 5 years (interquartile range, 3-8 years). Group A had a higher recurrence rate than group B (odds ratio, 7.52; P < .001). Group A recurrences (7.4%), compared with group B (1.1%), presented with a more frequent direct stump reconnection (3.7% vs 0.2%; P < .001) or newly developed pelvic shunts (3% vs 0.5%; P < .001). No significant difference was reported between the two groups in newly incompetent perforating veins.

CONCLUSIONS

Ligation of the junctional tributaries is associated with a higher recurrence risk. Further investigations are needed to determine the hemodynamic role of each single junctional tributary.

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.

A preclinical animal study of a novel, simple, and secure percutaneous vessel occluder for the treatment of varicose veins

BACKGROUND

Secure, permanent occlusion of the great and small saphenous veins, their tributaries, and perforators is critical for the successful treatment of varicose veins. Current minimally invasive methods replacing surgery are all endoluminal and involve heat (radiofrequency or laser), chemicals (sclerosants and glues), or a combination of mechanical and chemical interventions. This study evaluated in a porcine model the performance of a percutaneous delivery of the Amsel Vessel Occluder (AVO; Amsel Medical Corp, Cambridge, Mass) using ultrasound guidance. The AVO has received United States Food and Drug Administration premarket 510(k) clearance for use in open surgical procedures for tubular structures with diameters of 2 to 7 mm.

METHODS

The AVO, a novel mechanical occlusion clip similar to a transfixion suture, is delivered through an 18-gauge hypodermic needle. The AVO is subsequently expanded on either side of the vessel wall, collapsed, and locked together to effect secure vascular occlusion, thus transfixing the targeted vessel. The targeted vessels in five swine (weight >60 kg) under general anesthesia were identified, and the vessel size was measured. Patency of the targeted vessels was confirmed on duplex ultrasound imaging. Each animal provided multiple vessels for percutaneous AVO occlusion. Occlusion was confirmed by duplex ultrasound imaging and by direct examination of the occluded vessel after open surgical exploration.

RESULTS

Thirty vessel occlusions were performed percutaneously, including the common and superficial femoral arteries and veins (n = 24), the carotid artery (n = 4), and the external jugular vein (n = 1) and external jugular vein tributary (n = 1). Measured vessel sizes ranged from 1.8 to 12.7 mm. After vessel transfixion, occlusion was achieved in <30 seconds. A second AVO, if necessary, was delivered to completely occlude the targeted vessel where the vessel was >7 mm diameter (n = 2; external jugular vein, 12.7 mm; carotid artery, 7 mm), or where the initial AVO did not occlude the vessel because of nontransfixion (n = 1). Surgical exposure after occlusion confirmed that all targeted vessels were successfully occluded and demonstrated no evidence of injury to any of the adjacent structures.

CONCLUSIONS

This study confirms that the AVO can be effectively delivered percutaneously under ultrasound guidance to occlude blood vessels in the porcine model and may be a useful, time-saving, and cost-effective adjunct to current primary methods of treating reflux in the saphenous veins, their tributaries, or perforators for the treatment of symptomatic varicose veins.

Midterm Outcome of Mechanochemical Endovenous Ablation for the Treatment of Great Saphenous Vein Insufficiency

PURPOSE

To report the midterm results of mechanochemical ablation (MOCA) for treating great saphenous vein (GSV) insufficiency.

METHODS

In a 1-year period, 85 consecutive patients (median age 51.4 years; 71 women) undergoing MOCA with polidocanol in 104 limbs were enrolled in a prospective registry. The patients were evaluated at baseline and during follow-up (4 weeks and 1, 2, and 3 years) using duplex ultrasound, the CEAP (clinical, etiologic, anatomic and pathophysiologic) classification, the Venous Clinical Severity Score (VCSS), the RAND Short Form 36-Item Health Survey (RAND-SF36), and the Aberdeen Varicose Vein Questionnaire (AVVQ). Primary outcome measures were clinical and anatomic success. Secondary outcome measures included general and disease-specific quality of life and reinterventions.

RESULTS

Technical success (99%) was achieved in all but 1 patient in whom technical problems with the device led to conversion to another method for treatment of 2 limbs. After a median follow-up of 36 months (interquartile range 12.5, 46.3), recanalization occurred in 15 (15%) of 102 successfully treated vein segments. Anatomic success was 92%, 90%, and 87% after 1, 2, and 3 years, respectively. The VCSS improved at all time intervals compared to the preprocedure median. The clinical success at 3 years was 83%. The AVVQ and RAND-SF36 scores showed an improvement at all time intervals compared to baseline values. Between 12 and 36 months, however, a significant deterioration was observed in VCSS, which was accompanied by worsening of disease-specific and general quality of life.

CONCLUSION

In the longest follow-up of MOCA to date, this study shows MOCA to be an effective treatment modality for GSV insufficiency at midterm follow-up, but clinical results seem to drop over time.

Mini-invasive high-tie by clip apposition versus crossectomy by ligature: Long-term outcomes and review of the available therapeutic options

Objective The aim of the present study is to compare a mini-invasive (smaller than 2-cm incision) sapheno-femoral high-tie by clip apposition (HT group) with a traditional high-ligation by ligature (HL group). Methods One hundred fifty chronic venous disease patients were included in group HT and compared with 150 cases constituting the group HL. The main outcome was the sonographic detection of saphenous trunk recurrences. Procedural pain, esthetic satisfaction, and disease specific quality of life were assessed. Results At 4.5 ± 2.4 years follow-up, 8 cases (5.3%) of Great Saphenous Vein reflux reappearance were reported in group HT vs. 19 cases (12.6%) (odds ratio: 2.6; 95% confidence interval: 1.1-6.1; P = 0.04) of group HL. Esthetic satisfaction was scored as high and very high in group HT and HL, respectively (P < .0001). Conclusions Proper high-ligation technique provides satisfying outcomes both in terms of recurrence rate and patient esthetic satisfaction. The different outcomes obtained by the two groups encourage further investigations regarding recurrence pathogenesis.

Role of PTFE Patch Saphenoplasty in Reducing Neovascularization and Recurrence in Varicose Veins

Varicose veins have a high recurrence rate following surgery. Besides poor surgical technique, majority of these recurrences are attributable to neovascularization after both primary and repeat surgery. Authors have studied the effectiveness of a polytetrafluoroethylene (PTFE) patch interposition between the ligated vein stump and the overlying soft tissue at saphenofemoral junction in decreasing recurrence of varicose veins after initial surgery. Study was conducted on 50 patients of varicose veins with saphenofemoral junction incompetence. Patients were randomly divided into two groups, group A and group B alternately. In group A, standard surgical procedure was done followed by PTFE patch application. In group B, same surgical procedure was applied as in group A, with the exception of PTFE patch application. Patients in both groups were given similar postoperative care. A full venous duplex ultrasound assessment was performed in all the patients postoperatively. Neovascularization was observed in five patients (20 %) of group B, while it was not seen in any of the patients in group A at 1-year follow-up. This difference in neovascularization across the two groups was found to be statistically significant with a p value of 0.0251. Hence, authors concluded that patch saphenoplasty helps in reducing recurrence in varicose veins by decreasing neovascularization at saphenofemoral junction.

A review of a new Dutch guideline for management of recurrent varicose veins

In 2013, the new Dutch guideline for "Venous Pathology" was published. The guideline was a revision and update from the guideline "Diagnostics and Treatment of Varicose Veins" from 2009 and the guideline "Venous Ulcer" from 2005. A guideline for "Deep Venous Pathology" and one for "Compression Therapy" was added to the overall guideline "Venous Pathology." The chapter about treatment of recurrent varicose veins after initial intervention was recently updated in 2015 and is reviewed here. The Dutch term "recidief varices" or the French "récidive de varices" should be used analogous to the English term "recurrent varicose veins." The DCOP Guideline Development Group Neovarices concluded that "recidief" in Dutch actually suggests recurrence after apparent successful treatment and ignores the natural progression of venous disease in its own right. So the group opted to use the term "neovarices." In the Dutch guideline, neovarices is meant to be an all embracing term for recurrent varicose veins caused by technical or tactical failure, evolvement from residual refluxing veins or natural progression of varicose vein disease at different locations of the treated leg after intervention. This report reviews the most important issues in the treatment of varicose vein recurrence, and discusses conclusions and recommendations of the Dutch Neovarices Guideline Committee.