Incidence, classification, and risk factors of endovenous glue-induced thrombosis after cyanoacrylate closure of the incompetent saphenous vein

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.

Phlegmasia cerulea dolens after endovenous cyanoacrylate closure of incompetent small saphenous vein

A previously healthy 70-year-old woman underwent cyanoacrylate closure of an incompetent left small saphenous vein. Six days later, grade 2 treatment-induced thrombosis occurred at the sapheno-popliteal junction. Three days later, the patient presented with pale, cold pain in the left lower extremity. Diffuse thrombosis of the left lower extremity involved the small and great saphenous and deep veins. The patient was admitted and immediately administered heparin with anticoagulant factors, with symptoms began resolving 1 d later. The superficial vein thrombi were resolved. Although a deep venous thrombus remained, symptoms disappeared, and the patient was discharged.

Current practice of cyanoacrylate endovenous ablation: American vein and lymphatic society position statement

BACKGROUND

Cyanoacrylate endovenous ablation and closure of incompetent saphenous veins have become increasingly utilized since its approval for use in the United States in 2015. This increase in usage necessitates a societal update to guide treatment and ensure optimal and consistent patient outcomes.

METHOD

The American Vein and Lymphatic Society convened an expert panel to write an updated Position Statement with explanations and recommendations for the appropriate use of cyanoacrylate endovenous ablation for patients with venous insufficiency.

RESULT

A Position Statement was produced by the expert panel with recommendations for appropriate use, treatment technique, outcomes review, and potential adverse events. Their recommendations were reviewed, edited, and approved by the Guidelines Committee of the Society.

CONCLUSION

This societal Position Statement provides a useful document for reference for physicians and venous specialists to assist in the appropriate use of cyanoacrylate endovenous ablation in the treatment of patients with venous insufficiency.

The trends in venous thromboembolism occurrence and prevention after minimally invasive varicose vein surgery

OBJECTIVES

To assess the trends of VTE occurrence and prevention in varicose vein surgery.

METHOD

The registry-based CAPSIVS trial (NCT03041805) analysis includes results in 1878 lower limbs. The primary outcome is a 28-day symptomatic or asymptomatic DVT revealed with duplex ultrasound.

RESULTS

Any DVT, including EHIT, was observed in 3.4%, while symptomatic in 0.5%. Prophylactic anticoagulation was administrated in 20.4% with LMWH (13.2%) or DOAC (7.1%) for patients with higher VTE risk but did not reduce the events rate. With propensity score matching DOACs were superior to LMWHs (1.5% vs 9.8%). Duration of anticoagulation was essential: the lowest incidence (4.2%) was associated with prophylaxis for up to 7 days, while a single LMWH injection resulted in a DVT rate of 8.8%. With individual VTE history, any anticoagulation duration appeared insufficient.

CONCLUSIONS

Prophylactic anticoagulation after varicose vein surgery should be based on the individual VTE risk and provided for ≥7-30 days.

899 serious adverse events including 13 deaths, 7 strokes, 211 thromboembolic events, and 482 immune reactions: The untold story of cyanoacrylate adhesive closure

OBJECTIVE

The aim was to retrieve and analyse the serious adverse events of venous occlusion systems used in cyanoacrylate adhesive closure (CAC) submitted to regulatory agencies.

METHODS

The Total Product Life Cycle (TPLC) database of the US Food and Drug Administration (FDA), the Database of Adverse Event Notifications (DAEN) of the Australian Therapeutic Goods Administration (TGA), and the Yellow Card database of the UK Medicines and Healthcare Products Regulatory Agency (MHRA) were reviewed. Three Freedom of Information (FOI) requests had to be submitted to the MHRA to obtain data.

RESULTS

The TPLC contained 899 reports which included 13 cases of death, 7 strokes, 211 thromboembolic events, and 482 immune reactions. The DAEN recorded three reportable adverse events, and the MHRA recorded seven adverse incidents including one death.

CONCLUSION

CAC is associated with serious adverse events including death. These events are under-reported in the medical literature and only sub-optimally reported to the regulatory agencies.

Polymerisation of cyanoacrylates: The effect of sclero-embolic and contrast agents

OBJECTIVES

The objective is to investigate the interaction of sclero-embolic and contrast agents with the polymerisation of medical grade n-butyl-cyanoacrylates.

METHODS

An in vitro spectrophotometric absorbance method was developed to detect changes in light transmission to measure n-BCA polymerisation. The initiation and the rate-of-polymerisation of mixtures of n-BCA with sclero-embolic and contrast agents were investigated.

RESULTS

Initiation of polymerisation: VENABLOCK™ and HISTOACRYL® were the fastest agents to polymerise, while VENASEAL™ was the slowest. Rate of polymerisation: Hypertonic saline inhibited the polymerisation of all n-BCAs, while hypertonic glucose prolonged the polymerisation rate. ETHANOL and detergent sclerosants had no effect. Contrast agents OMNIPAQUE™ and ULTRAVIST® initiated and prolonged the polymerisation of n-BCA, but in contrast, LIPIODOL® failed to initiate the process.

CONCLUSIONS

The commercially available medical cyanoacrylates differ in their polymerisation rates. These polymerisation rates are further affected when these products are used in conjunction with other compounds, such as sclero-embolic and contrast agents.

Surgical Treatment of Persistent Glue Extension Into Common Femoral Vein Following Endovenous Glue Ablation

Endovenous glue-induced thrombosis (EGIT) is a known complication of endovenous ablation therapy using cyanoacrylate closure glue to treat saphenous insufficiency, where glue extends into the common femoral vein (CFV), causing partial or complete occlusion. We report a case of class III EGIT (over 50% occlusion of CFV) in a young, healthy female who could not tolerate medical therapy. EGIT was treated with high ligation of the great saphenous vein and CFV patch repair. This is a safe option for patients who cannot tolerate anticoagulation therapy due to complications, physical or psychological limitations, or both.

The correlation between Caprini score and the risk of venous thromboembolism after varicose vein surgery

BACKGROUND

The study aims to identify the incidence of symptomatic and asymptomatic venous thromboembolism (VTE) after minimally invasive varicose vein surgery and to assess the predictability of the Caprini risk score (CRS).

METHODS

CAPrini Score In Venous Surgery (NCT03041805) is a registry-based prospective study that enrolls patients undergoing minimally invasive open (high ligation, stripping, miniphlebectomy) and endovascular (thermal and non-thermal ablation) surgery on varicose veins. The main inclusion criteria are CRS assessment before intervention and a duplex ultrasound scan performance within 2-4 weeks after surgery. The primary outcome is a combination of asymptomatic or symptomatic DVT, including EHIT of class 2-4 and PE.

RESULTS

Totally 1878 records with defined outcomes were analyzed. The mean age of patients was 46.9±13.3 years; 66% were female. Endovenous laser ablation was performed in 88%. Varicose tributaries were treated in 40%, perforating veins in 3.9% of cases. CRS ranged from 1 to 12 (mean of 4.0±1.5). Prophylactic anticoagulation was prescribed in 20%. The primary outcome was reported in 63 cases (3.4%; 95% CI, 2.7-4.3%), comprising asymptomatic (N.=29, 1.5%) or symptomatic (N.=10, 0.5%) DVT or EHIT (n=28, 1.6%). No PE was reported. A significant correlation was found between CRS and VTE incidence (P=0.001). Under logistic regression CRS (OR, 1.3; 95% CI, 1.1-1.6) along with treatment of tributaries (OR, 6.3; 95% CI, 3.0-13.0) and perforating veins (OR, 10.7; 95% CI, 3.8-30.2) were associated with VTE in the absence of prophylactic anticoagulation.

CONCLUSIONS

The incidence of VTE after ablation of superficial veins is 3.4%, predominantly due to asymptomatic EHIT and DVT, and significantly correlates with CRS.

Complications of cyanoacrylate adhesive closure therapy in chronic venous insufficiency: A single center, single-surgeon study

OBJECTIVES

In this study, we present the complication data of patients we treated for chronic venous insufficiency (CVI) with cyanoacrylate adhesive closure (CAC) therapy for 2 years.

METHODS

Complications of 382 CAC procedures performed by the same surgeon were reviewed retrospectively.

RESULTS

Independent of patients, depending on the payment system of the state; two hundred twenty-three (58.4%) of 382 procedures were performed using the Venex system, and the Variclose system was used in 159 (41.6%) patients. A phlebitis-like reaction occurred in 46 (12%) patients, induration in 18 (4.7%) patients, hyperpigmentation in five (1.3%) patients, abscesses in four (1%) patients, cellulitis in three (0.8%) patients, and granuloma in one (0.3%) patient. In addition, as serious complications, deep vein thrombosis (DVT) developed in three patients and pulmonary embolism in one of these patients. Interestingly, temporary blindness was also observed in one patient.

CONCLUSIONS

Although CAC therapy is a reliable method, its complications should not be ignored. Its use by experienced surgeons reduces the risk of complications.

Natural history and role of anticoagulation in the management of endovenous glue-induced thrombus

OBJECTIVE

The natural history of endovenous glue-induced thrombus (EGIT) resolution and the role of anticoagulation (AC) and/or anti-platelet (AP) agents in their management is currently ill-defined. The goal of this investigation is to determine the clinical behavior of EGITs and whether or not AC or AP affects treatment outcomes.

METHODS

We performed a retrospective review of all endovenous ablations utilizing cyanoacrylate glue (CAG) from January 2020 to December 2021 at the Center for Vein Restoration. Patients were divided into two groups: (1) patients who developed an EGIT (EGIT/CAG) and (2) patients treated with CAG and no EGIT development (CAG). Demographics, medical/surgical histories, revised Venous Clinical Severity Score (rVCSS), Chronic Venous Insufficiency Quality of Life Questionnaire (CIVIQ), CEAP, EGIT category, type of anticoagulation, resolution time, location of any deep vein thrombosis (DVT) were analyzed, catheter tip distance, treatment length and proximal thigh diameters were all analyzed. EGITs were categorized as follows: EGIT 1: thrombus extension into the deep vein covering less than 25% of the luminal area; EGIT 2: thrombus between 25% and 49%; EGIT 3: thrombus between 50% and 74%; and EGIT 4: total occlusion. Our protocol is to perform post-procedure duplex scans within 3 to 7 days after endovenous ablations to assess for post-intervention DVTs.

RESULTS

During the study period, 2374 patients received 4321 CAG procedures. EGITs were observed in 133 patients (3.1%): EGIT 1 (n = 57); EGIT 2 (n = 35); EGIT 3 (n = 19); and EGIT 4 (n = 22). All EGITs were identified by surveillance scanning. No patient presented with limb or pulmonary symptoms suggestive of VTE. The average age, rVCSS, and CIVIQ 20 of the entire cohort was 65.3 ± 14.2 years, 8.2 ± 2.8, and 48 ± 18.3, respectively with 89 females and 44 males. For EGIT 1, 56 of 57 (98%) resolved at 4.2 ± 5.1 weeks, with one patient lost to follow-up. AC/AP regimen included two aspirin (ASA), one Eliquis, 5 Xarelto, and nothing in 49 patients (86%). For EGIT 2, 27 of 35 (77%) resolved at 4.4 ± 3.4 weeks, one was unresolved, six regressed to EGIT 1, and one remained an EGIT 2 at the last follow-up examination. AC/AP regimens included seven ASA, three Eliquis, three Xarelto, one Coumadin, and nothing in 21 patients (60%). For EGIT 3, 12 were in the common femoral vein (CFV), three in the popliteal vein (POPV), one in the external iliac vein, and three in the gastrocnemius veins. Nine of nineteen (47%) resolved at 6 ± 5.9 weeks, four regressed, one migrated to the proximal CFV, three became chronic, and two were lost to follow-up. AC/AP regimens included three ASA, three Eliquis, seven Xarelto, and nothing in six patients (32%). AC/AP compared with no AC/AP had no effect on clot resolution (P = .3). Of the 22 EGIT 4, one was in the CFV, two were in the POPV, and 18 (82%) were remote calf vein DVTs (15 gastrocnemius, one peroneal [PV], and three posterior tibial veins [PTVs]). The CFV EGIT became chronic, one POPV resolved, and one was lost to follow-up. For the gastrocnemius clots, five became chronic, eight resolved, and two were lost to follow-up. For the PTV clots, one resolved, one became chronic, and one was lost to follow-up. The PV clot became chronic. AC/AP regimen included four ASA, five Eliquis, six Xarelto, and nothing in seven patients. AC/AP compared with no AC/AP had no effect on clot resolution (P = .9). The average proximal thigh diameter (millimeters, mm), vein length treated (mm), and catheter distance (mm) from the junction were the following: EGIT 1 (5.9 ± 2.4, 37.5 ± 17.6, and 5.2 ± 1), EGIT 2 (5.9 ± 1.7, 38 ± 16.9, 4.79 ± 0.71), EGIT 3 (5.1 ± 2.6, 27.9 ± 16.6, and 5.26 ± 1.4), and EGIT 4 (5 ± 1.7, 29.9 ± 15.8, and 5.39 ± 2.18), respectively. Treatment length alone was significantly shorter in EGIT 3 and 4, compared with EGIT 1 and 2 (P ≤ .05). Catheter distance from the junction was longer in EGIT 1, 3, and 4 patients compared with CAG patients (P ≤ .02).

CONCLUSIONS

Regardless of EGIT class or severity, the majority of EGITs are not associated with clot extension or migration and tend to resolve or regress. For EGIT class 1 and 2 patients, AC or AP therapy is not necessary, as 86% and 60%, respectively, resolved with observation alone by 4 weeks. For EGIT 3, 68% resolved or regressed regardless of AC or AP use. The majority of EGIT 4 were remote calf vein DVTs. EGIT 3 and 4 associated with the saphenofemoral/popliteal junction are rare. When compared with CAG patients, proximal thigh diameters and treatment lengths were larger and longer in EGIT 1 and 2 patients. Catheter proximity to the junction was not associated with a higher incidence of EGIT formation.

Type IV Hypersensitivity Reaction after Cyanoacrylate Venous Closure

BACKGROUND

Nonthermal endovenous closure techniques are routinely utilized to treat superficial axial venous reflux. Cyanoacrylate closure is a safe and effective modality implemented for truncal closure. However, an adverse reaction of type IV hypersensitivity (T4H), unique to cyanoacrylate, is a known risk. This study aims to evaluate the real-world incidence of T4H and examine risk factors that may predispose its development.

METHODS

A retrospective review between 2012- and 2022 was performed at four tertiary US institutions to examine patients who underwent cyanoacrylate vein closure of their saphenous veins. Patient demographics, comorbidities, CEAP (Clinical [C], Etiological [E], Anatomical [A], and Pathophysiological [P]) classification, and periprocedural outcomes were included. The primary endpoint was development of T4H post procedure. Logistic regression analysis for risk factors predictive of T4H was performed. Variables with a P-value of <0.05 were deemed significant.

RESULTS

595 patients underwent 881 cyanoacrylate venous closures. Mean age was 66.2 ± 14.9, and 66% of patients were female. There were 92 (10.4%) T4H events in 79 (13%) patients. Oral steroids were administered to 23% for persistent and/or severe symptoms. There were no systemic allergic reactions to cyanoacrylate. Multivariate analysis revealed younger age (P = 0.015), active smoking status (P = 0.033), and CEAP 3 (P < 0.001) and 4 (P = 0.005) classifications as independent risk factors associated with development of T4H.

CONCLUSIONS

This real-world multicenter study shows the overall incidence of T4H to be 10%. CEAP 3 and 4 patients of younger age and smokers predicted a higher risk of T4H to cyanoacrylate.

Incidence and Clinical Impact of Endovenous Glue-Induced Hypersensitivity Among Patients Who Underwent Endovenous Cyanoacrylate Ablation Procedures: A Registry-Based Cohort Study

BACKGROUND

The characteristics of endovenous glue-induced hypersensitivity (EGIH) remain unclear.

OBJECTIVE

To assess the clinical impacts on patients with EGIH after endovenous cyanoacrylate-glue ablation (CA).

MATERIALS AND METHODS

A prospectively designed endovenous CA-specific registry was created, and a total of 335 limbs from 173 patients who underwent endovenous CA were enrolled for a cohort study.

RESULTS

Symptomatic EGIH was observed in 55 (31.8%) patients. Beyond the target vein area, systemic side effects were noted in 5.8% of the treated patients after CA. The median onset time was 13 postoperative days (range: 1-35 days). The median duration was 7 days, but about 10.9% of the affected patients experienced symptoms lasting longer than 4 weeks. In the EGIH and non-EGIH groups, significant improvements in venous clinical severity score and Chronic Venous Insufficiency Quality of Life Questionnaire-14 scores were observed 3 months postoperatively. The development of EGIH did not affect the postoperative patient-reported satisfaction scores ( p = .524).

CONCLUSION

EGIH is observed in a substantial proportion of patients. The side effects do not affect the clinical outcomes and patient-reported outcome measures. Further studies are required on the detailed pathogenesis and definition of EGIH.

Cyanoacrylate glue reactions: A systematic review, cases, and proposed mechanisms

OBJECTIVE

Cyanoacrylate glue closure was first used in humans 10 years ago to treat venous reflux of the axial veins. Studies have since shown its clinical efficacy in vein closure. However, great need exists to elucidate further the types of specific adverse reactions that cyanoacrylate glue can cause for better patient selection and to minimize these events. In the present study, we systematically reviewed the literature to identify the types of reported reactions. In addition, we explored the pathophysiology contributing to these reactions and proposed the mechanistic pathway with inclusion of actual cases.

METHODS

We searched the literature for reports of reactions following cyanoacrylate glue use in patients with venous diseases between 2012 and 2022. The search was performed using MeSH (medical subject headings) terms. The terms included cyanoacrylate, venous insufficiency, chronic venous disorder, varicose veins, vein varicosities, venous ulcer, venous wound, CEAP (clinical, etiologic, anatomic, pathophysiologic), vein, adverse events, phlebitis, hypersensitivity, foreign body granuloma, giant cell, endovenous glue-induced thrombosis, and allergy. The search was limited to the literature reported in English. These studies were evaluated for the type of product used and the reactions noted. A systematic review, in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) method, was performed. Covidence software (Melbourne, VC, Australia) was used for full-text screening and data extraction. Two reviewers reviewed the data, and the content expert served as the tiebreaker.

RESULTS

We identified 102, of which, 37 reported on cyanoacrylate use other than in the context of chronic venous diseases and were excluded. Fifty-five reports were determined appropriate for data extraction. The adverse reactions to cyanoacrylate glue were phlebitis, hypersensitivity, foreign body granuloma, and endovenous glue-induced thrombosis.

CONCLUSIONS

Although cyanoacrylate glue closure for venous reflux is generally a safe and clinically effective treatment choice for patients with symptomatic chronic venous disease and axial reflux, some adverse events could be specific to the properties of the cyanoacrylate product. We propose mechanisms for how such reactions can occur based on histologic changes, published reports, and case examples; however, further exploration is necessary to confirm these theories.

Thrombotic complications after radiofrequency and cyanoacrylate endovenous ablation: Outcomes of a multicenter real-world experience

OBJECTIVE

Chronic venous insufficiency (CVI) affects >40% of the U.S. population; thus, intervention for symptomatic venous disease comprises a large portion of many vascular practices. The treatment of superficial CVI has evolved from open surgical treatment to minimally invasive endovenous closure, including both thermal and nonthermal techniques. Thrombotic complications of thermal ablation have been well reported, with an overall complication rate of <2%. However, a paucity of high-powered, real-world data is available on the thrombotic outcomes of nonthermal techniques. In the present study, we compared the incidence of endovenous heat-induced thrombosis (EHIT) and endovenous glue-induced thrombosis (EGIT) in a large cohort of patients with CVI.

METHODS

A retrospective review was conducted at two tertiary-level institutions of patients who had undergone superficial endovenous ablation from 2018 to 2021. The patient demographics, comorbidities, and periprocedural outcomes were collected through medical record review. A Caprini risk assessment model score was assigned using the information available from the electronic medical records. The patients were categorized by procedure type (ClosureFast [Medtronic Inc, Minneapolis, MN] radiofrequency ablation [RFA] vs VenaSeal [Medtronic Inc] cyanoacrylate glue closure [CAG]). The primary end point was the incidence of EHIT or EGIT. The secondary end point was the incidence of deep vein thrombosis and/or pulmonary embolism.

RESULTS

A total of 803 patients had undergone 1096 procedures during the study period. Their mean age was 62 ± 15 years, and 67% were women. Of the 1096 procedures, 700 were RFA and 396 were CAG procedures, with a combined closure rate of 98% by postprocedure duplex ultrasound at 7 days. The average Caprini score was 5.2 ± 1.8 (RFA, 5.0; vs CAG, 5.4; P < .001). The incidence of EHIT and EGIT was 1.9% and 1.3%, respectively (P = .57). The deep vein thrombosis rate was 0.1% in the RFA cohort and 0.3% in the CAG cohort (P = .81). A comparative analysis of thermal vs nonthermal techniques was performed. A univariate analysis of the risk factors for EHIT and EGIT revealed no significant factors predisposing to thrombotic events.

CONCLUSIONS

The results from the present study have demonstrated the safety of RFA and CAG closure techniques for CVI, with lower thrombotic rates than previously reported. Further work might help to identify how these results can be achieved across all venous ablative techniques for CVI, even for patient populations with advanced venous disease and possibly a greater than average risk of thrombotic events.

Modification of protocol with one extra drop of endovascular cyanoacrylate improved closure rates in incompetent great saphenous veins

Introduction

Great saphenous vein diameter (GSV) of >8 mm was predictor of recanalization following Venaseal cyanoacrylate treatment. The aim of this study was to report our modified protocol with a single extra-drop for treatment for GSV>8 mm, and comparative duplex results in closure rates.

Methods

Patients in our single-centre registry treated with Venaseal were followed up by serial duplex examinations at week 1 and month(s)- 1, 6, 12, 18, 24, and then annually. The primary endpoint was successful obliteration of the GSV, secondary endpoints were closure distance from Saphenofemoral junction (SFJ), presence of endovenous glue-induced thrombosis (EGIT) or deep vein thrombosis.

Results

A total of 243 legs in 123 consecutive patients with duplex-proven SFJ/GSV incompetence were included in this study between September 2014 and October 2020. The median duplex follow-up period of this cohort of patients was 24 (range 0.2–58) months. Comparing closure rates in GSV diameter ≥8 mm treated with normal protocol, the ‘extra-drop protocol’ significantly improved closure rates ( p = .034). However, the closure rates of ≥8 mm GSV treated with ‘extra-drop protocol’ was still not as good as GSV <8 mm ( p < .001). There were no statistically significant differences in the stump distance between the three groups and no difference in the occurrence of EGIT. There were no deep vein thrombosis.

Conclusion

Our experience showed that VenaSeal cyanoacrylate worked best in GSV<8 mm diameter. Even in GSV diameter of ≥8 mm which has a higher recanalization rate on follow-up duplex, our modified extra-drop protocol significantly improved the closure rates, and did not predispose to development of EGIT.

Einflussfaktoren auf oberflächliche und tiefe Beinvenenthrombosen nach Schaumverödung von Krampfadern

HINTERGRUND

Bei einer Schaumsklerosierungstherapie von Varizen können als Nebenwirkungen sowohl tiefe (TVT) als auch oberflächliche Beinvenenthrombosen (OVT) auftreten. Noch weitgehend unklar sind die Risikofaktoren, welche die Entstehung einer OVT oder TVT nach Schaumsklerosierung begünstigen. Das Ziel dieser retrospektiven Analyse war, anhand eines größeren Kollektivs von Patienten mit thromboembolischen Komplikationen sowohl patienten- als auch eingriffsbezogene Risikofaktoren für thromboembolische Komplikationen durch eine Schaumsklerosierung herauszuarbeiten.

PATIENTEN UND METHODIK

Insgesamt wurden 170 Patienten untersucht, die eine Schaumsklerosierung erhielten. Vor dem Stichtag 17. März 2020 wurden die letzten 85 Patienten mit thromboembolischen Komplikationen als Studiengruppe A und die letzten 85 Patienten ohne thromboembolische Komplikationen als Kontrollgruppe B nach Sklerosierung mit aufgeschäumtem Sklerosierungsmittel erfasst und verglichen.

ERGEBNISSE

Patienten mit thromboembolischen Komplikationen hatten häufiger eine Thrombophilie (11/85 vs. 3/85). Die mittleren BMI-Werte waren in Gruppe A (25,9 ± 5,1) signifikant niedriger als in Gruppe B (28,0 ± 7,2) (P = 0,034). Thromboembolische Komplikationen zeigen sich nach Schaumsklerosierung eher am Unterschenkel (61/105) als am Oberschenkel (1/13) (P < 0,001) dabei häufiger nach dorsaler als nach ventraler Schaumsklerosierung (39 von 47 vs. 5 von 40, P < 0,001). Von den 39 thromboembolischen Komplikationen am dorsalen Unterschenkel waren 23 Muskelvenenthrombosen.

SCHLUSSFOLGERUNG

Das Risiko für Muskelvenenthrombosen nach Schaumsklerosierung ist vor allem bei schlanken Patienten, welche am dorsalen Unterschenkel sklerosiert werden, erhöht.

Factors influencing superficial and deep vein thrombosis after foam sclerotherapy in varicose veins

BACKGROUND

Side effects of foam sclerotherapy for varicose veins can include both deep (DVT) and superficial leg vein thrombosis (SVT). The risk factors that favor the development of SVT or DVT after foam sclerotherapy are still largely unclear. The aim of our retrospective analysis was to use a larger group of patients with thromboembolic complications to identify both patient-related and procedure-related risk factors for thromboembolic complications from foam sclerotherapy.

PATIENTS AND METHODS

A total of 170 patients who received foam sclerotherapy were examined. With reference to a cut-off date, March 17th, 2020, the 85 most recent patients with thromboembolic complications (study group A) were included and compared to the most recent 85 patients without thromboembolic complications (control group B), after sclerotherapy with foamed sclerosant.

RESULTS

Patients with a thromboembolic complication were more likely to have thrombophilia (11/85 vs. 3/85). The mean BMI values in group A (25.9 ± 5.1) were significantly lower than in group B (28.0 ± 7.2) (P = 0.034). Thromboembolic complications were more likely to appear after foam sclerotherapy on the lower leg (61/105) than on the thigh (1/13) (P < 0.001), particularly after dorsal than after ventral foam sclerotherapy (39 of 47 vs. 5 of 40, P < 0.001). Of the 39 thromboembolic complications on the dorsal lower leg, 23 were muscle vein thromboses.

CONCLUSION

The risk of muscle vein thrombosis after foam sclerotherapy is especially increased in slender patients with sclerosed, dorsal lower legs.

Current Best Practice in the Management of Varicose Veins

This article outlines the current best practice in the management of varicose veins. “Varicose veins” traditionally means bulging veins, usually seen on the legs, when standing. It is now a general term used to describe these bulging veins, and also underlying incompetent veins that reflux and cause the surface varicose veins. Importantly, “varicose veins” is often used for superficial venous reflux even in the absence of visible bulging veins. These can be simply called “hidden varicose veins”. Varicose veins usually deteriorate, progressing to discomfort, swollen ankles, skin damage, leg ulcers, superficial venous thrombosis and venous bleeds. Patients with varicose veins and symptoms or signs have a significant advantage in having treatment over conservative treatment with compression stockings or venotropic drugs. Small varicose veins or telangiectasia without symptoms or signs can be treated for cosmetic reasons. However, most have underlying venous reflux from saphenous, perforator or local “feeding veins” and so investigation with venous duplex should be mandatory before treatment. Best practice for investigating leg varicose veins is venous duplex ultrasound in the erect position, performed by a specialist trained in ultrasonography optimally not the doctor who performs the treatment. Pelvic vein reflux is best investigated with transvaginal duplex ultrasound (TVS), performed using the Holdstock-Harrison protocol. In men or women unable to have TVS, venography or cross-sectional imaging is needed. Best practice for treating truncal vein incompetence is endovenous thermal ablation. Increasing evidence suggests that significant incompetent perforating veins should be found and treated by thermal ablation using the transluminal occlusion of perforator (TRLOP) approach, and that incompetent pelvic veins refluxing into symptomatic varicose veins in the genital region or leg should be treated by coil embolisation. Bulging varicosities should be treated by phlebectomy at the time of truncal vein ablation. Monitoring and reporting outcomes is essential for doctors and patients; hence, participation in a venous registry should probably be mandatory.

Third-generation treatment of varicose veins: cyanoacrylate adhesive closure and mechanochemical ablation

Background: The mainstream of incompetent saphenous veins treatment has dramatically changed from the first-generation conventional high ligation and stripping surgery to the second-generation endovenous thermal ablation as a minimally invasive technique using laser or radiofrequency. The third-generation treatment of nonthermal non-tumescent techniques is already available, including cyanoacrylate adhesive closure (CAC) and mechanochemical ablation (MOCA).Current Concepts: The non-thermal non-tumescent techniques are developed to overcome the complications of thermal ablation, including nerve injury and vein perforation. The technique also reduces the need for painful tumescent anesthesia and postoperative compression. MOCA employs a dual injury using a single-catheter-based delivery system consisting of a mechanical abrasion with a rotating wire and chemical ablation with a sclerosant. CAC is executed by injecting a glue that produces a polymer with the blood and obliterates the lumen. CAC does not need tumescent anesthesia and postoperative compression. Therefore, patient recovery is fast and satisfaction is excellent. However, the new devices are expensive and not included in the medical insurance in Korea, and long-term effects of the new treatments are unproven; therefore, the cost-effectiveness is unconfirmed.Discussion and Conclusion: MOCA and CAC are newly developed minimal invasive treatments for varicose veins. They are reported to be safe and effective techniques. However, further studies are needed to evaluate the long-term outcomes and cost-effectiveness.

Thrombus extension after cyanoacrylate closure of incompetent saphenous veins

BACKGROUND

Cyanoacrylate closure (CAC) is a minimally invasive surgery to treat incompetent saphenous veins. This study aimed to investigate the incidence, the risk factors for, and the management of thrombus extension after cyanoacrylate closure (TEACAC) of incompetent saphenous veins in patients with chronic venous disease.

METHODS

This retrospective study included patients aged >18 years who were diagnosed with chronic venous disease with superficial venous reflux in the great saphenous vein, anterior accessory saphenous vein, or small saphenous vein, and who were treated with CAC at Siriraj Hospital (Bangkok, Thailand) during January 2017 to December 2018.

RESULTS

A total of 126 saphenous veins of 101 patients were included. TEACAC occurred in 5 of 101 (4.9%) patients, and in 5 of 126 (3.9%) treated saphenous veins. The mean follow-up time was 285±12 days. Based on Kabnick classification of endovenous heat-induced thrombosis (EHIT), the following TEACAC grades were observed: grade I (n=2), grade II (n=1), grade III (n=2), and grade IV (n=0). No patient or procedural predictive factors for TEACAC were identified. In patients with TEACAC-1 or TEACAC-2, the thrombus spontaneously disappeared by the 2-week follow-up. Patients with TEACAC-3 received therapeutic rivaroxaban or dabigatran, which resolved the thrombus within 2-4 weeks. No deep vein thrombosis or symptomatic pulmonary embolism was found.

CONCLUSIONS

TEACAC was found not to be a rare complication after CAC. All patients should be informed of the risk of TEACAC prior to treatment. Treatment of TEACAC class 1-3 following EHIT guideline seems to be both safe and effective.

A Prospective Study Evaluating Patterns of Responses to the Caprini Score to Prevent Venous Thromboembolism After Interventional Treatment for Varicose Veins

Background

Venous thromboembolism (VTE) is a critical complication of varicose vein treatments. The Caprini Score (CS) is an established tool to assess patients’ VTE risks. One disadvantage is the number of questions required, some of them referring to a low incidence of disease, even lower in patients seeking an elective procedure. These elements take time and may result in filling errors if the CS is not filled out by a properly trained health professional.

Objective

To establish a response pattern in CS, with emphasis on questions that usually have a negative answer and propose a simpler adaptative digital version without changing the original structure of the tool.

Methods

two hundred and twenty-seven patients in the pre-surgical treatment of varicose veins were enrolled prospectively and submitted to the CS evaluation.

Results

The pattern of dichotomous responses could be divided arbitrarily into four subgroups considering the percentage of positive responses: none (11 items), less than 3% (13 items), between 3% and 20% (5 items), and more than 20% (8 items). Of the 12 CS questions related to illnesses that occurred in the last month, ten had had no responses, and 2 were less than 3%.

Conclusion

There is a pattern in the CS responses of patients with an indication of surgical treatment of varicose veins. Many of the CS questions are not helpful in this scenario and may result in filling errors performed by untrained providers. An adaptative version of the CS might benefit varicose veins surgery VTE risk stratification

A multicenter randomized controlled trial of cyanoacrylate closure and surgical stripping for incompetent great saphenous veins

OBJECTIVE

The treatment of varicose veins has shifted from conventional surgical stripping (SS) to minimally invasive endovenous modalities. Cyanoacrylate closure (CAC) with the VenaSeal system (Medtronic, Dublin, Ireland) has increased in popularity owing to its nonthermal and nontumescent technique. The purpose of the present study was to compare the clinical outcomes of CAC and SS for the treatment of incompetent great saphenous veins.

METHODS

An open-label, multicenter, prospective, randomized controlled trial was conducted. The subjects were randomized to either the CAC or SS procedure. The primary endpoint of the present study was to evaluate complete closure of the target vein at 3 months. Target vein occlusion was assessed on the third day and 1, 3, 6, and 12 months postoperatively using duplex ultrasound. The pain and ecchymosis grades were also assessed. Additionally, the clinical outcomes, such as the venous clinical severity score and Aberdeen Varicose Vein Questionnaire score, were assessed.

RESULTS

Three-month follow-up data were obtained for all 126 enrolled and randomized subjects (63 with CAC and 63 with SS). At 3 months, complete target vein closure was observed in both groups. The postoperative pain score was significantly better in the CAC group than in the SS group (0.3 ± 0.6 in the CAC group and 1.1 ± 1.5 in the SS group; P < .001). In addition, the mean ecchymosis grade was 0.3 ± 0.5 in the CAC group and 1.1 ± 1.1 in the SS group (P < .001). The venous clinical severity score and quality of life had improved equally in both groups. The adverse events after both procedures were mostly minor complications (9 events in CAC group and 20 events in SS group). Major complications occurred in one patient who had undergone the SS procedure.

CONCLUSIONS

The CAC and SS procedures were both associated with complete occlusion of the target vein at 3 months. The postoperative pain and ecchymosis grades were significantly lower in the CAC group. Other differences between the two groups included the frequency and nature of the complications. The results showed that CAC has high success with few complications.

Changes of stump length depending on starting position of glue injection related to venous diameter during cyanoacrylate closure for incompetent saphenous veins

OBJECTIVES

A common pattern of recurrence after cyanoacrylate treatment of incompetent saphenous veins has been associated with reflux from the residual stump. The purpose of this study was to analyze the starting point of cyanoacrylate glue injection from the junction to decrease stump length.

METHODS

A retrospective review was performed using prospectively collected data of patients with cyanoacrylate closure (CAC). Preoperatively, the diameter of the saphenous vein was measured. CAC was performed according to the manufacturer's instructions. After the procedure, clinical outcomes including pain, venous clinical severity score (VCSS), and quality of life (QoL) using the Aberdeen Varicose Vein Questionnaire (AVVQ) were evaluated. Postoperative duplex scanning was performed to evaluate the occlusion rate of the target vein, stump length, and presence of endovenous glue-induced thrombosis (EGIT). The stump length was analyzed according to the preoperative venous diameter to determine the proper point of glue injection to decrease the stump length.

RESULTS

During the study period, CAC was performed in 408 patients. Mean age was 56.2±11.5 years (range, 19 to 84 years). A total of 279 patients (68.4%) were women. Occlusion of the target vein was achieved in all patients. After the procedure, pain, VCSS, and QoL were improved (P<.001). EGIT developed in 5.8% of patients. There was a 1.53-fold linear increase in the stump length by for every 1-mm increment of the preoperative venous diameter. In 20 patients with a venous diameter ≥5 mm, glue injection was performed safely 4 cm distal to the junction to decrease the stump length.

CONCLUSION

The stump length linearly increased with an increase in the saphenous vein diameter. If the diameter of the saphenous vein is more than 5 mm, cyanoacrylate glue may be injected 4 cm distal to the junction to decrease stump length.

Symptom improvement after cyanoacrylate glue adhesion and endovenous laser ablation in low-grade CEAP clinical classes

OBJECTIVE

Low-grade primary superficial venous reflux (C₀ - C₃EpAsPr) is a common feature of chronic venous disease. However, the procedural efficacy focusing on symptom characteristics and improvement patterns in this population has not been fully explored.

METHODS

From 2018 to 2019, 325 limbs from 279 patients with C₀ - C₃EpAsPr (including 66.1% with C0-1) who underwent cyanoacrylate ablation (CA) with ultrasonography-guided foam sclerotherapy (UGFS) or endovenous laser ablation (EVLA) with UGFS were included in this study. Venous symptoms were classified into five categories: leg heaviness, calf cramping, itching sensation, pain, and numbness. A retrospective propensity score-matched analysis of a prospectively designed case report form (CRF) was performed to identify the improvement magnitude of each symptom. As secondary outcomes, postoperative changes in symptom severity (0 - 5 points), the Venous Reflux Originated Severity Score (VROSS), the Venous Clinical Severity Score (VCSS), and the ChronIc Venous Insufficiency Quality of Life Questionnaire (CIVIQ-14) were evaluated by performing a three-month postoperative data analysis.

RESULTS

After adjusting the data, 174 limbs (87 CA with UGFS and 87 EVLA with UGFS) were matched. Symptoms that showed the greatest improvement after treatment were night cramping (94.7%) and itching (93.8%), followed by heaviness (85.2%), numbness (77.8%), and pain (60.9%). All symptom improvement scores after each endovenous procedure showed similar patterns in both groups. Advantages of CA with UGFS over EVLA with UGFS were observed in procedure time (20.1± 10.6 min vs. 28.4± 10.9 min, p = .001) and perioperative visual analogue pain scores (2.99± 2.34 vs. 3.74 ± 2.49, p = .03). Compared to preoperative values, VROSS, VCSS, CIVIQ-14, and symptom severity scores were significantly improved in both groups (all p < .001). Improvements in all five symptoms (p = .085 to 1.0), VCSS (p = .435), CIVIQ-14 (p = .788) and satisfaction scores (p = .392) three months postoperatively were comparable between the two groups. There were two cases of endovenous glue-induced thrombosis and 24 (27.6%) cases of type IV hypersensitivity reactions in the CA group.

CONCLUSIONS

Minimally invasive endovenous surgery with CA and EVLA provides significant symptom improvement for patients with low-grade CEAP classes.

Thrombotic complications of superficial endovenous ablation: a contemporary review of thermal and non-thermal techniques

Endovenous ablation has become the preferred means to treat superficial venous insufficiency. Ablative technologies have evolved to include a variety of both thermal and nonthermal techniques. The reported thrombotic complications of endovenous heat induced thrombosis (EHIT) and deep venous thrombosis (DVT) associated with thermal techniques are low (<2% overall). However, the limited data on newer non-thermal technologies suggest these modalities may have thrombotic complication rates upwards of 6%. Additionally, the pathophysiology of thrombotic events related to mechanochemical ablative techniques may differ from EHIT, and thus, may have different implications for management. Described is a case report of a stroke after cyanoacrylate ablation of the great saphenous vein, and a review of the current literature reporting the thrombotic complications associated with current thermal and non-thermal techniques. There exists a need for high volume studies on newer ablative techniques to fully understand their associated thrombotic complications. This review highlights the need for a comprehensive classification system and standard treatment algorithm encompassing of thrombotic complications associated with both thermal and non-thermal ablative techniques.

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.