Vein diameter is a predictive factor for recanalization in treatment with ultrasound-guided foam sclerotherapy

Ultrasound-guided foam sclerotherapy of the saphenous trunks is associated with a low 5-year recurrence rate and improved quality of life in patients with chronic venous disease: A multicenter study

OBJECTIVE

The study attempts to test whether ultrasound-guided foam sclerotherapy (UGFS) is a durable treatment for incompetent great saphenous vein (GSV) and incompetent small saphenous vein (SSV) in primary chronic venous disease (CVD), Clinical-Etiology-Anatomy-Pathophysiology (CEAP) clinical grade 2 to 4 disease. Secondary end points are to evaluate its safety in terms of complications, to compare patients' quality of life before and after the treatment, and to identify risk factors that may predict recurrence of CVD after UGFS.

METHODS

Multicenter retrospective cohort study on 346 patients. The sclerosing agent was sodium tetradecyl sulfate (STS) in foam. The foam was prepared with the double-syringe technique (liquid-to-gas CO2O2 30:70 ratio of 1:4). The sclerosing agent concentrations were 1% for saphenous trunk diameter 4 to 7 mm, 3% for saphenous trunk of >7 mm. Sodium tetradecyl sulfate was injected directly into the GSV/SSV, achieving a total maximum volume of 10 mL per session. A median of two sessions was performed (range, 1-5).

RESULTS

In this cohort, 205 patients were categorized as CEAP C2 (59.2%), and 141 (40.8%) had worse CVD (CEAP ≥3). The median follow-up was 60 months (range, 6-60 months). At the end of follow-up, 296 patients (85.5%) had no truncal reflux, with a 5-year disease-free time (between last procedure and evidence of recurrent disease) of 77.7 ± 2.16%. GSV and SSV showed similar 5-year recurrence-free time rates (69.9% vs 76.8%; P = ns), whereas patients with a diameter of the saphenous trunk of ≤8 mm had lower recurrence than those with >8 mm (91.3% vs 46%; P < .0001). Ninety patients (26%) showed CVD recurrence, occurring at a median of 48 months. A further UGFS treatment was needed in 50 symptomatic patients (14.4%), resulting in an 80% success rate. At univariate analysis, large diameter of the saphenous trunk (P < .0001), male sex (P = .030) and greater number of treatment sessions (P = .009) were identified as significant prognostic factors for recurrence. Immediate complications occurred in 3.7% of patients: seven headache and six visual disturbances. Endovenous foam-induced thrombosis was detected in six patients (2.8%) 1 week after treatment. Cutaneous hyperpigmentation appeared in 37 patients (10.7%). Post-treatment revised Venous Clinical Severity Score and Chronic Venous Disease Quality of Life Questionnaire 14 scores were significantly lower than before treatment (P < .001).

CONCLUSIONS

UGFS of the GSV/SSV is effective, safe in the long term and well-accepted by patients. UGFS is a viable option to surgery and endovenous thermal or nonthermal ablation in the treatment of saphenous trunk incompetence (CEAP clinical grade 2-4).

Clinical outcomes following treatment for small saphenous vein insufficiency: An AVLS PRO venous registry study

BACKGROUND

Compared to the great saphenous vein, there is a relative paucity of data in the literature focused on treating the small saphenous vein (SSV). Our goal was to evaluate and analyze national registry data related to the diagnosis and treatment of the SSV and identify practice patterns and clinical outcomes.

METHOD

Subjects undergoing SSV interventions between April 2014 and March 2023 were identified in the AVLS PRO Venous Registry. Data points included Clinical, Etiological, Anatomical, Pathological (CEAP) classifications; Venous Clinical Severity Score (VCSS), Venous Quality of Life (VVSymQ®) instrument scores, Heaviness, Aching, Swelling, Throbbing, Itching (HASTI) symptoms, and Short Form Health Survey (SF-36.) Duplex ultrasound findings included vein diameter, length, and the overall recanalization rate.

RESULT

A total of 92,175 SSV interventions were identified. Over two-thirds of subjects presented with a CEAP classification of C3 (31%) and C4 (C4 40%). Clinical results demonstrated significant improvement immediately after treatment in the first month and maintained beneficial results at 1 year or longer (p < 0.001.) This improvement was reflected in the significant decrease in VCSS scores (6 ± 3.4 to 5 ± 2.9; p < 0.0001), VVSymQ (9.5 ± 6.0 to 5.9 ± 4.4; p < 0.0001), and HASTI (9.4 ± 5.9 to 6.6 ± 5.2; p < 0.0001). The recanalization rate at any follow-up was 3%; 48% of those occurring within the first year. Predictors associated with recanalization were larger vein diameter (mean 4.0 mm, 95% CI 3.9-4.1, p < 0.0001) and shorter SSV length (mean 15.27 mm, 95 % CI 14.4-16.1, p < 0.0001).

CONCLUSION

Treatment of SSV insufficiency improved clinical outcomes by both patient and physician-derived outcome measures. Only 3% of SSV demonstrated recanalization, and nearly half occurred within the first year following the procedure. Predictors of recanalization included larger pre-procedure vein diameters and treatment of a shorter length of SSV.

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.

Assessment of residual stumps 12 months after saphenectomy without high ligation of the saphenofemoral junction

Background

Currently, the first-choice option recommended for varicose vein surgery is thermal ablation of the saphenous vein, but this procedure is not available on the Brazilian National Health Service (SUS - Sistema Único de Saúde). In an effort to improve results, surgical techniques have been developed to mimic the new technologies, without their high costs. The most prominent such method involves conventional saphenectomy, without ligation of tributaries.

Objectives

To assess progression of the residual stump after saphenectomy without high ligation of the saphenofemoral junction but with stump invagination and to assess the behavior of anterior/posterior accessory veins.

Methods

Prospective intervention study. A total of 52 limbs were treated with saphenectomy without high ligation of the saphenofemoral junction followed by invagination of the residual stump. Patients were assessed preoperatively and at 7 days, and 3, 6, and 12 months postoperatively using vascular ultrasonography with Doppler to analyze the length of the residual stump, the diameters of the residual stump and the anterior/posterior accessory vein, reflux in the accessory vein, and presence of neovascularization. Statistical analysis involved calculation of means, standard deviations, medians, minimum and maximum values, frequencies, and percentages, and Fisher's test and the binomial test.

Results

There was evidence of a significant time effect on residual stump diameter (p < 0.001) and length (p = 0.002), but the same was not observed with relation to diameter (p = 0.355) or reflux of the anterior accessory vein. Neovascularization was found in 7 (14.3%) limbs.

Conclusions

After use of the technique described, the residual stump retracted, its diameter reduced over the 1 year postoperative period, and it did not transfer reflux to the accessory vein. Neovascularization rates were in line with the literature.

Radiofrequency Ablation for Axial Reflux Associated with Foam Sclerotherapy for Varicosities in One-Step Approach: A Prospective Cohort Study Comprising Large Diameters Saphenous Veins

OBJECTIVE

This study assessed the outcomes and impact on the quality of life following one-step outpatient radiofrequency ablation (RFA) and ultrasound guided foam sclerotherapy (USGFS) for large reflux with varicosities in the great saphenous vein (GSV).

DESIGN

Prospective, single-centre, analytical cohort.

MATERIALS AND METHODS

Thirty symptomatic patients having reflux in the GSV and varicosities (CEAP C3 to C6) were treated with RFA and USGFS simultaneously, in a single-step procedure, from March 2016 to December 2016. They were followed up at 1 week, 6 months, 1 and 3 years. Clinical outcomes, changes in the Quality of Life (QOL) questionnaires SF-36™, VCSS and AVVQ, evolutive vein occlusion rates were assessed by duplex ultrasound, and ulcer closure was checked.

RESULTS

The sample was divided into two groups: (Group 1) GSV diameter ≥13.0 mm (median 19.0 [14-24]), 17 subjects, and (Group 2) GSV diameter ≤12.9 mm (median 10.3 [10-12]), 16 subjects. No major adverse event was observed, and the postoperative minor adverse event rates were similar between the two groups. A significant improvement was observed in VCSS and AVVQ from the preoperative levels to the sixth month and the third-year follow-up. Twelve of 13 ulcers had healed at 1 year and remained closed until 3 years. The entire sample had a significant increase in all short form 36 domains, except for mental health in the Group 2 (GSV ≥ 13.0 mm). Overall first week occlusion rate for the whole sample was 90.9% and 69.7% at the 3-year follow-up. No difference in occlusion rate was observed between the two groups at any time.

CONCLUSION

Exclusively outpatient combined techniques were safe and feasible in this study with no major adverse events, despite the large diameters of the GSV or ulcer presence. Within 3 years, both diameter groups showed equivalent improvement in all QOL parameters, satisfactory axial occlusion, and maintained ulcer closure.

Ultrasound-guided foam sclerotherapy for primary small saphenous vein insufficiency

BACKGROUND

We performed this single-centre prospective study, aimed to analyse the safety and efficacy of ultrasound-guided foam sclerotherapy for primary isolated small saphenous vein (SSV) insufficiency.

METHODS

From June 2017 to June 2019, patients with primary SSV insufficiency and receiving ultrasound-guided foam sclerotherapy were included in this study. The collected data included demographics of patients, clinical treatment results, occlusion rate and the patient's venous clinical severity score (VCSS) before and after surgery at 6-month follow-up.

RESULTS

A total of 26 patients (14 women and 12 men) underwent ultrasound-guided sclerotherapy in 26 lower limbs, and were followed up at 1 week, 1 month and 6 months after surgery. Short-term complications included two severe pain during injection, one with vasovagal syncope, four with hyperpigmentation and two phlebitis. During 6-month follow-up, 22 were found to have complete thrombosis, and four showed partial thrombosis. There was a clear inverse relationship between SSV occlusion and SSV diameter (r = -0.502, P < 0.05), and pre-operative VCSS evaluation (r = -0.598, P < 0.05). At the same time, there was a weak inverse relationship between SSV occlusion and the volume of foam used (r = -0.357, P < 0.05). The pre-procedural VCSS score was 8.42 ± 3.25 and the post-procedural VCSS score was 7.16 ± 3.14. Deep vein thrombosis, nerve injury and other important complications did not occur.

CONCLUSIONS

This study shows that ultrasound-guided foam sclerotherapy is a safe and effective method for symptomatic SSV insufficiency, with less adverse reactions and better effects.

Five-year extension study of patients from a randomized clinical trial (VeClose) comparing cyanoacrylate closure versus radiofrequency ablation for the treatment of incompetent great saphenous veins

OBJECTIVE

The proprietary cyanoacrylate closure (CAC) system vs radiofrequency ablation (RFA) trial (VenaSeal Sapheon Closure System Pivotal Study [VeClose]) showed that CAC, a nontumescent, nonthermal, nonsclerosant ablation technique, was effective and noninferior to RFA in vein closure with good 36-month outcomes. Conducted under a separate protocol, the aim of this extended follow-up was to assess the long-term safety and effectiveness of CAC and RFA for the treatment of incompetent great saphenous veins (GSV) at 5 years (60 months) of follow-up.

METHODS

This 60-month extension study was conducted for all patients who completed the randomized VeClose study and who were willing to participate. The pivotal VeClose study included patients with symptomatic moderate to severe varicosities (Clinical, Etiology, Anatomy, and Pathophysiology [CEAP] class C2-C4b) and symptomatic GSV incompetence who were randomly assigned (1:1) to either CAC or RFA. The primary outcome measure of this 60-month extension study was complete closure of the target vein, with planned exploratory analysis of noninferiority. Secondary outcomes included CEAP class; completion of the Venous Clinical Severity Score, EuroQol-Five Dimension survey, and Aberdeen Varicose Vein Questionnaire; patient satisfaction with treatment; adverse events (AEs) related to target GSV; and details of adjunctive procedures.

RESULTS

A total of 89 patients completed the 60-month visit, which included 47 from the CAC group, 33 from the RFA group, and 9 CAC roll-in patients. No new recanalization events have been observed in the groups between 36 and 60 months of follow-up. At 60 months, Kaplan-Meier estimates for freedom from recanalization in the randomized CAC and RFA groups were 91.4% and 85.2%, respectively, demonstrating noninferiority of CAC compared with RFA. Both groups demonstrated sustained improvements in EuroQol-Five Dimension and quality of life measures through 60 months. Whereas patients assigned to C0 or C1 clinical class were excluded from the original study, more than half of all returning patients (64% [57/89]) were now assigned to C0 or C1, suggesting an improved clinical class from baseline. Furthermore, 41.1% of returning CAC patients and 39.4% of returning RFA patients are presently at least two CEAP clinical classes lower than at baseline. No long-term device- or procedure-related serious AEs occurred in either group between 36- and 60-month follow-up.

CONCLUSIONS

CAC and RFA were effective in achieving complete target vein closure of the GSV at long-term follow-up, with CAC demonstrating continued noninferiority to RFA. CAC was also associated with sustained improvements in symptoms and quality of life, lower CEAP class, and high level of patient satisfaction without serious AEs between 36 and 60 months.

Short Term Outcome of Adjunct Foam Sclerotherapy for Varicose Veins in Patients Subjected to RFA at Dhulikhel Hospital, Nepal

Background

Varicose veins are dilated, tortuous, superficial veins usually seen on lower limbs. Various surgical modalities are available for varicose veins including open surgery (Trendelenburg operation), Endovenous Laser Ablation (EVLA), Radiofrequency Ablation (RFA) and Sclerotherapy. The aim of this study is to look for the outcome of adjunct sclerotherapy for varicose veins done as an adjunct with Radio Frequency Ablation.

Objective

To know the possible outcome regarding benefits and complications of adjunct sclerotherapy with Radio Frequency Ablation.

Methodology

We combined Radio Frequency Ablation of varicose veins with necessary phlebectomy and perforator ligation and performed adjunct sclerotherapy for residual significant varicosities with polidocanol (2%) mixed with 2 ml NS and 2 cc of air (Tessari method) to patients undergoing varicose vein surgery in between 2016 and 2017. Records on complications were enquired immediately following surgery and on 1^st follow up done within 3-5 days of the procedure.

Results

Among 256 limbs subjected to varicose veins surgery 51 limbs were given adjunct sclerotherapy. Among them, five limbs had perivenous spillage with some localized swelling while there was allergic reaction in one patient as immediate postprocedural complication. Nine limbs had painful thrombosed veins during early follow-up.

Conclusions

Adjunct sclerotherapy showed complication rate of roughly one tenth and one fifth of the treated cases in immediate and early postoperative follow-up.