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Kim H, Labropoulos N, Cho S, Lee K, Joh JH. Clinical outcomes of nonthermal ablation, thermal ablation, and surgical stripping for varicose veins. J Vasc Surg Venous Lymphat Disord 2024:101902. [PMID: 38754778 DOI: 10.1016/j.jvsv.2024.101902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 04/18/2024] [Accepted: 04/21/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVE The purpose of this study was to compare the clinical outcomes of radiofrequency ablation (RFA), cyanoacrylate closure (CAC), mechanochemical ablation (MOCA), and surgical stripping (SS) for incompetent saphenous veins and to determine a suitable treatment modality for a specific clinical situation. METHODS We retrospectively reviewed the data of patients with varicose veins who underwent RFA, CAC, MOCA, or SS from January 2012 to June 2023. The clinical outcomes, including postoperative complications and the Aberdeen Varicose Vein Questionnaire score, were assessed. RESULTS During the study period, 2866 patients with varicose veins were treated. Among them, 1670 patients (57.9%) were women. The mean age was 55.3 ± 12.9 years. RFA, CAC, MOCA, and SS were performed in 1984 (68.7%), 732 (25.4%), 78 (2.7%), and 88 (3.0%) patients, respectively. The complete target vein closure rate after RFA, CAC, and MOCA was 94.5%, 98%, and 98%, respectively. The absence of a target vein after SS was 98%. Deep vein thrombosis developed in four patients: one in the RFA group and three in CAC group. Surgical or endovenous procedure-induced thrombosis occurred in 2.3%, 4.8%, 6.4%, and 2.3% of the patients after RFA, CAC, MOCA, and SS, respectively. Phlebitis along the target vein occurred in 0.2% and 3.8% of patients after RFA and MOCA, respectively. A hypersensitivity reaction occurred in 3.7% of patients after CAC. Readmission was required for two patients who had undergone SS. Transient nerve symptoms developed in five (0.3%), zero, one (1.3%), and two (2.3%) patients after RFA, CAC, MOCA, and SS, respectively. After treatment, the Aberdeen Varicose Vein Questionnaire score improved significantly in all groups. CONCLUSIONS The clinical outcomes with improvement in quality of life were comparable among the different treatment modalities. The proximity of the nerve or skin to the target vein is the most important factor in selecting a suitable treatment modality.
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Affiliation(s)
- Hyangkyoung Kim
- Department of Surgery, Ewha Womans University Mokdong Hospital, Seoul, Korea
| | - Nicos Labropoulos
- Department of Surgery, Stony Brook University Medical Center, New York, NY
| | - Sungsin Cho
- Department of Surgery, Ewha Womans University Mokdong Hospital, Seoul, Korea
| | - Kwangjin Lee
- Department of Surgery, Ewha Womans University Mokdong Hospital, Seoul, Korea
| | - Jin Hyun Joh
- Department of Surgery, Ewha Womans University Mokdong Hospital, Seoul, Korea; Division of Vascular Surgery, Department of Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea.
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Chervonski E, Muqri F, Jacobowitz GR, Rockman CB, Maldonado TS, Berland TL, Garg K, Cayne NS, Sadek M. Safety and efficacy of endovenous ablation in patients with a history of deep vein thrombosis. J Vasc Surg Venous Lymphat Disord 2024:101898. [PMID: 38677553 DOI: 10.1016/j.jvsv.2024.101898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/08/2024] [Accepted: 04/11/2024] [Indexed: 04/29/2024]
Abstract
OBJECTIVE Endovenous ablation is the standard of care for patients with symptomatic superficial venous insufficiency. For patients with a history of deep vein thrombosis (DVT), concern exists for an increased risk of postprocedural complications, particularly venous thromboembolism. The objective of this study was to evaluate the safety and efficacy of endovenous thermal ablation in patients with a history of DVT. METHODS The national Vascular Quality Initiative Varicose Vein Registry was queried for superficial venous procedures performed from January 2014 to July 2021. Limbs treated with radiofrequency or laser ablation were compared between patients with and without a DVT history. The primary safety end point was incident DVT or endothermal heat-induced thrombosis (EHIT) II-IV in the treated limb at <3 months of follow-up. The secondary safety end points included any proximal thrombus extension (ie, EHIT I-IV), major bleeding, hematoma, pulmonary embolism, and death due to the procedure. The primary efficacy end point was technical failure (ie, recanalization at <1 week of follow-up). Secondary efficacy end points included the risk of recanalization over time and the postprocedural change in quality-of-life measures. Outcomes stratified by preoperative use of anticoagulation (AC) were also compared among those with prior DVT. RESULTS Among 33,892 endovenous thermal ablations performed on 23,572 individual patients aged 13 to 90 years, 1698 patients (7.2%) had a history of DVT. Patients with prior DVT were older (P < .001), had a higher body mass index (P < .001), were more likely to be male at birth (P < .001) and Black/African American (P < .001), and had greater CEAP classifications (P < .001). A history of DVT conferred a higher risk of new DVT (1.4% vs 0.8%; P = .03), proximal thrombus extension (2.3% vs 1.6%; P = .045), and bleeding (0.2% vs 0.04%; P = .03). EHIT II-IV, pulmonary embolism, and hematoma risk did not differ by DVT history (P = NS). No deaths from treatment occurred in either group. Continuing preoperative AC in patients with prior DVT did not change the risk of any complications after endovenous ablation (P = NS) but did confer an increased hematoma risk among all endovenous thermal ablations and surgeries (P = .001). Technical failure was similar between groups (2.0% vs 1.2%; P = .07), although a history of DVT conferred an increased recanalization risk over time (hazard ratio, 1.90; 95% confidence interval, 1.46, 2.46; P < .001). The groups had comparable improvements in postprocedural venous clinical severity scores and Heaviness, Aching, Swelling, Throbbing, and Itching scores (P = NS). CONCLUSIONS Endovenous thermal ablation for patients with a history of DVT was effective. However, appropriate patient counseling regarding a heightened DVT risk, albeit still low, is critical. The decision to continue or withhold AC preoperatively should be tailored on a case-by-case basis.
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Affiliation(s)
| | - Furqan Muqri
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Glenn R Jacobowitz
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Caron B Rockman
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Thomas S Maldonado
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Todd L Berland
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Neal S Cayne
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Mikel Sadek
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY.
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Pinto P, Fukaya E, Rodriguez LE, Obi A, Ting W, Aziz F, Nguyen K, Murphy EH, Ochoa Chaar CI. Variations and inconsistencies in venous ablation coverage policies between single-state and multistate carriers in the United States. J Vasc Surg Venous Lymphat Disord 2024; 12:101685. [PMID: 37703944 DOI: 10.1016/j.jvsv.2023.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/02/2023] [Accepted: 07/05/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Vein ablation is a common and effective treatment for patients with chronic venous insufficiency. The overuse of vein ablation despite the existence of evidence-based guidelines has resulted in insurance companies developing restrictive policies for coverage that create barriers to appropriate care. This study compares the insurance coverage by single-state carriers (SSCs) and multistate carriers (MSCs), highlighting the variations and inconsistencies in the various policies. METHODS The American Venous Forum Venous Policy Navigator was reviewed for the various policies available in the United States. The policies were divided into SSCs and MSCs. The characteristics of the policies, including the anatomic and hemodynamic criteria for specific veins, duration of conservative treatment, disease severity, symptoms, and types of procedures covered, were compared between the two groups. SAS, version 9.4 (SAS Institute Inc) was used for statistical analysis. RESULTS A total of 122 policies were analyzed and divided between SSCs (n = 85; 69.7%) and MSCs (n = 37; 30.3%). A significant variation was found in the size requirement for great saphenous vein ablation. Although 48% of the policies did not specify a size criterion, the remaining policies indicated a minimal size, ranging from 3 to 5.5 mm. However, no significant differences were found between SSCs and MSCs. Similar findings were encountered for the small and anterior accessory saphenous veins. MSCs were more likely to define a saphenous reflux time >500 ms compared with SSCs (81.1% vs 58.8%; P = .04). A significant difference was found between the SSCs and MSCs in the criteria for perforator ablation in terms of size and reflux time. MSCs were significantly more likely to provide coverage for mechanochemical ablation than were SSCs (24.3% vs 8.2%; P = .03). SSCs were more likely to require ≥12 weeks of compression stocking therapy than were MSCs (76.5% vs 48.7%; P = .01). No significant differences were found in the clinical indications between the two groups; however, MSCs were more likely to mention major hemorrhage than were SSCs. CONCLUSIONS The results of this study highlight the variations in policies for venous ablation, in particular, the striking inconsistencies in size criteria. MSCs were more likely to cover mechanochemical ablation and require a shorter duration of conservative therapy before intervention compared with SSCs. Evidence-based guidance is needed to develop more coherent policies for venous ablation coverage.
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Affiliation(s)
- Paula Pinto
- Division of Vascular Surgery and Endovascular Therapy, Yale School of Medicine, Yale University, New Haven, CT.
| | - Eri Fukaya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA
| | | | - Andrea Obi
- Division of Vascular Surgery, University of Michigan, Ann Arbor, MI
| | - Windsor Ting
- Division of Vascular Surgery, The Mount Sinai Hospital, New York, NY
| | - Faisal Aziz
- Division of Vascular Surgery, Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Hershey, PA
| | - Khanh Nguyen
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR
| | - Erin H Murphy
- Division of Vascular Surgery, Sanger Heart & Vascular Institute, Charlotte, NC
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery and Endovascular Therapy, Yale School of Medicine, Yale University, New Haven, CT
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Athavale A, Monahan D, Fukaya E. A systematic review on ablation techniques for larger saphenous veins in patients with symptomatic superficial venous disease. J Vasc Surg Venous Lymphat Disord 2024; 12:101681. [PMID: 37703943 DOI: 10.1016/j.jvsv.2023.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/16/2023] [Accepted: 08/28/2023] [Indexed: 09/15/2023]
Abstract
OBJECTIVE The aim of this study was to summarize the existing evidence for the treatment of saphenous veins >10 mm in diameter, to determine whether there were vein size limits for treatment modalities, and to determine if there are specific technical considerations for treatment of large veins. METHODS We searched the literature for reports of treatment methods and outcomes for patients with large-diameter saphenous veins treated with various ablation methods between 1993 and 2023. These studies were evaluated for the size of the vein determined as "large diameter," type of ablation method, study type, outcomes, adverse events, and any technical considerations noted. A systematic review was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. The COVIDENCE software was used for full-text screening and data extraction. Three reviewers reviewed the data, and the content expert served as the tiebreaker. RESULTS Seventy-one records were identified, of which 24 studies were deemed appropriate for extraction. Most of the studies identified reported outcomes of endovenous thermal ablation modalities. There were fewer studies on non-thermal, non-tumescent techniques, and these studies reported an overall lower occlusion rate compared with endovenous thermal ablation techniques. CONCLUSIONS Large head-to-head trials or randomized controlled that compare all the modalities over a long follow-up duration are yet to be performed. In the existing literature, there is considerable heterogeneity in terms of the study size, design, definition of large veins, site of vein measurement, and follow-up periods, making it challenging to make fair comparisons and draw firm conclusions. Currently available evidence supports the use of endothermal ablation techniques for the treatment of veins >10 mm in diameter as they have a more favorable efficacy and safety profile and have a larger body of evidence available compared with non-thermal, non-tumescent techniques or surgery.
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Affiliation(s)
- Anand Athavale
- Division of Vascular Surgery, Stanford University School of Medicine, Palo Alto, CA
| | | | - Eri Fukaya
- Division of Vascular Surgery, Stanford University School of Medicine, Palo Alto, CA.
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Abstract
OBJECTIVE This study aimed to investigate the efficacy of foam sclerotherapy in the treatment of tortuous Great Saphenous Vein (GSV) insufficiency. METHODS In this prospective non-randomized study 62 patients with tortuous GSV insufficiency were included. All patients were delivered sclerosant agent in the form of foam into the GSV through a cannula above the knee level. Characteristics of patients, diameter of veins, reflux grades, Venous Clinical Severity Score (VCSS) and Clinical, Etiological, Anatomical, Pathological (CEAP) scores, concentration of sclerosant agent, complications and follow-up results were recorded. RESULTS Foam sclerotheraphy was performed with 100% technical success in all patients at operative room. There were no allergic reactions or neurological complications during and after the operations. Ecchymosis was the most common complication with 37.1% frequency. . VCSS scores significantly decreased from 6.43% to 2.53%, during follow-up from initial admission to sixth months, respectively (P<0.05).In the first month parameters, successful occlusion rate was 88.7%, whereas its rate was 82.3% in sixth month. Recanalization rate significantly increased from 11.3% to 17.7% during follow-up from first to sixth months, respectively (P<0.05). CONCLUSIONS Due to its low complication rate, low cost, acceptable total occlusion rate and reproducibility; Foam sclerotherapy can be considered a reliable treatment for patients with tortuous GSV insufficiency.
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Affiliation(s)
- Mehmet Karacalilar
- Department of Cardiovascular Surgery, Batman Region Public Hospital, Batman/Turkey
| | - Huseyin B Kutas
- Department of Cardiovascular Surgery, Batman Region Public Hospital, Batman/Turkey
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Mayrovitz HN, Aoki KC, Colon J. Chronic Venous Insufficiency With Emphasis on the Geriatric Population. Cureus 2023; 15:e40687. [PMID: 37485203 PMCID: PMC10358300 DOI: 10.7759/cureus.40687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 06/13/2023] [Indexed: 07/25/2023] Open
Abstract
The underpinning of Chronic Venous Insufficiency (CVI) is valvular dysfunction, which manifests on a spectrum depending on the severity of insufficiency and duration of the disease. The mainstay of treatment relies on compression therapy of a proper type and intensity. In older adults, special consideration must be taken during the patient encounter to account for age-related factors. This review discusses the clinical presentation, diagnosis, and mimicking of CVI, focusing mainly on older adults. The epidemiology, risk factors, disease burden, and grave complications -- such as thrombosis and ulceration, are reviewed. The physiological impacts of CVI are described, providing the background for treatment strategies, including non-invasive, medical, and surgical therapies. The findings show advanced age to be an important risk factor contributing to CVI and that other age-related factors add to the risk of severe complications. Clinical assessments combined with objective measurements that assess localized skin water using tissue dielectric constant values or whole limb assessments may aid in the differential diagnosis. Furthermore, understanding the mechanism of action of compression therapy, the mainstay of CVI treatment, and its physiological impacts, allows for its informed use in geriatric patients with increased risks of potential compression-related side effects.
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Affiliation(s)
- Harvey N Mayrovitz
- Medical Education and Simulation, Nova Southeastern University's Dr. Kiran C. Patel College of Allopathic Medicine, Davie, USA
| | - Kawaiola C Aoki
- Medicine, Nova Southeastern University's Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, USA
| | - Jessica Colon
- Medicine, Nova Southeastern University's Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, USA
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Gloviczki P, Lawrence PF, Wasan SM, Meissner MH, Almeida J, Brown KR, Bush RL, Di Iorio M, Fish J, Fukaya E, Gloviczki ML, Hingorani A, Jayaraj A, Kolluri R, Murad MH, Obi AT, Ozsvath KJ, Singh MJ, Vayuvegula S, Welch HJ. The 2022 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part I. Duplex Scanning and Treatment of Superficial Truncal Reflux: Endorsed by the Society for Vascular Medicine and the International Union of Phlebology. J Vasc Surg Venous Lymphat Disord 2023; 11:231-261.e6. [PMID: 36326210 DOI: 10.1016/j.jvsv.2022.09.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 09/23/2022] [Indexed: 11/06/2022]
Abstract
The Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society collaborated to update the 2011 Society for Vascular Surgery/American Venous Forum clinical practice guidelines and provide new evidence-based recommendations on critical issues affecting the care of patients with varicose veins. Each recommendation is based on a recent, independent systematic review and meta-analysis of the diagnostic tests and treatments options for patients with lower extremity varicose veins. Part I of the guidelines includes evidence-based recommendations for the evaluation of patients with CEAP (Clinical Class, Etiology, Anatomy, Pathology) class 2 varicose vein using duplex ultrasound scanning and other diagnostic tests, open surgical treatment (ligation and stripping) vs endovenous ablation techniques, thermal vs nonthermal ablation of the superficial truncal veins, and management of incompetent perforating veins in CEAP class 2 disease. We have also made recommendations on the concomitant vs staged treatment of varicose tributaries using phlebectomy or liquid or foam sclerotherapy (with physician-compounded foam or commercially prepared polidocanol endovenous microfoam) for patients undergoing ablation of incompetent superficial truncal veins.
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Affiliation(s)
- Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN.
| | - Peter F Lawrence
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, CA
| | - Suman M Wasan
- Department of Medicine, University of North Carolina, Chapel Hill, and Rex Vascular Specialists, UNC Health, Raleigh, NC
| | | | - Jose Almeida
- Miller School of Medicine, University of Miami, Miami, FL
| | | | - Ruth L Bush
- Central Texas Veterans Affairs Healthcare System and Texas A&M University College of Medicine, Temple, TX
| | | | - John Fish
- Department of Medicine, Jobst Vascular Institute, University of Toledo, Toledo, OH
| | - Eri Fukaya
- Division of Vascular Surgery, Stanford University, Stanford, CA
| | | | | | - Arjun Jayaraj
- RANE Center for Venous and Lymphatic Diseases, Jackson, MS
| | - Raghu Kolluri
- Heart and Vascular Service, OhioHealth Riverside Methodist Hospital, Columbus, OH
| | - M Hassan Murad
- Evidence-Based Practice Research Program, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
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Outcome Measures of In-Office Endovenous Radiofrequency Treatment of Varicose Vein Feasibility. Diagnostics (Basel) 2023; 13:diagnostics13020327. [PMID: 36673138 PMCID: PMC9857463 DOI: 10.3390/diagnostics13020327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/31/2022] [Accepted: 01/09/2023] [Indexed: 01/17/2023] Open
Abstract
RFA is a relatively new treatment, approved by the FDA in 1999 and is a minimally invasive intervention that has become one of the most common alternatives due to its many advantages, including decreased pain, less morbidity, shorter hospital stay and faster return to work. We retrospectively analyzed a total of 503 limbs submitted for surgical interventions for VVs using the RFA, combined or not with surgical phlebectomies and sclerotherapy, in our institution between April 2012 and December 2020. The technical success was 99.8%, as in one case the RFA catheter arrested at the first third of the thigh due to the tortuosity of the vessel. On the first post-operative day, the mean VAS scale was 0.32 ± 0.56 (0-2). Perioperative complications occurred in 77 cases (15.3%): intraoperative pain in 24 cases, in nine cases associated with vagal syndrome, superficial hematoma in 30 cases, EHIT in seven cases, phlebitis in 14 cases and paresthesia in two cases. RFA procedures had been shown to be cost-effective therapeutic options in adult patients requiring treatment due to the incompetence of the GSV. In our study, we highlighted that this technique is feasible as an ambulatory procedure; it improves quality of life and symptoms in the majority of patients with varicose veins, with a rapid return to normal life and work activities.
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Shon S, Kim H, Kim HC, Cho S, Lee SH, Joh JH. National trend of the treatment for chronic venous diseases in Korea between 2010 and 2020. Ann Surg Treat Res 2023; 104:27-33. [PMID: 36685771 PMCID: PMC9830049 DOI: 10.4174/astr.2023.104.1.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 10/12/2022] [Accepted: 10/20/2022] [Indexed: 01/04/2023] Open
Abstract
Purpose Limited data are available on the nationwide trend of treatments for chronic venous disease (CVD). The aim of the present study was to identify the nationwide trends of CVD treatments in Korea. Methods A serial, cross-sectional study was conducted with the use of time trends to analyze patients with CVD between 2010 and 2020. The trends in the number of patients and procedures were analyzed including sclerotherapy, open surgery, and endovenous thermal ablation (ETA). Health Insurance Review and Assessment Service data were used to analyze the trends. For the statistical analysis, MedCalc Statistical software was used. P < 0.05 was considered statistically significant. Results A total of 1,867,307 patients with CVD were managed in Korea between 2010 and 2020. The annual number of patients with CVD increased from 143,108 in 2010 to 219,319 in 2020 (risk ratio [RR], 1.53; P < 0.001). The percentage of patients with CVD who had venous ulcer gradually decreased from 3.1% in 2010 to 1.7% in 2020 (RR, 0.86; P < 0.001). The number of conventional surgeries including stripping and local resection of varicose veins decreased from 32,384 in 2010 to 21,792 in 2020 (RR, 0.67; P < 0.001). The number of ETAs performed increased, from 290 in 2011 to 12,126 procedures in 2020 (RR, 41.81; P < 0.001). Conclusion The total number of patients with CVD increased during the last 11 years. The number of conventional open surgery and sclerotherapy procedures decreased. On the contrary, the number of ETAs significantly increased in Korea.
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Affiliation(s)
- SooBum Shon
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Hyangkyoung Kim
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Hyeong Cheol Kim
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Sungsin Cho
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Seung Hwan Lee
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jin Hyun Joh
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
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10
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Khryshchanovich VY, Shestak NG, Skobeleva NY. [Truncal mechanochemical versus thermal endovenous ablation for varicose vein disease: a systematic review and meta-analysis]. Khirurgiia (Mosk) 2022:116-126. [PMID: 35658143 DOI: 10.17116/hirurgia2022061116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To compare the outcomes of thermal and mechanochemical endovenous ablative techniques in patients with varicose veins. MATERIAL AND METHODS We searched the PubMed, EMBASE and Cochrane Library databases for studies devoted to mechanochemical and thermal endovenous ablative techniques from inception until July 2021. The primary outcome was anatomical success. Secondary endpoints were intraoperative pain syndrome, complications, modification of disease severity and quality of life. RESULTS This meta-analysis enrolled 10 comparative studies and 1.252 participants after truncal ablations. The follow-up period ranged from 4 weeks to 36 months. With regard to overall anatomical success, 245 out of 267 (91.8%) patients after mechanochemical ablation and 249 out of 266 (93.6%) patients after thermal ablation had favorable results after a month (low-quality evidence; odds ratio [OR] 0.79; 95% CI 0.40-1.55). No statistical heterogeneity was identified (χ2=1.48; df=2; p=0.48; I2=0%). Further analysis identified different incidence of total occlusion after 12 months or later (OR 0.36; 95% CI 0.11-1.21; p=0.05; I2=68%). Mechanochemical ablation resulted less intraoperative pain. Mean difference was -1.3 (95% CI -2.53- -0.07; p=0.00001). MOCA was followed by fewer incidence of nerve injury, hematoma, deep vein thrombosis and phlebitis. There were more cases of skin pigmentation compared to thermal ablation (low-quality evidence, p>0.05). Subsequent assessment of disease severity identified significant between-group difference of means (-0.64 (95% CI -1.82-0.53; p=0.004) and -0.16 (95% CI -0.43-0.11; p=0.005) after 6 and 12 months, respectively). Further assessment of quality of life revealed no between-group differences. These data were characterized by moderate methodological quality. CONCLUSION Mechanochemical ablation is as effective as standard TA within the first postoperative month. However, this approach is associated with lesser anatomical success after 12 months. In most studies, pain syndrome was less severe in case of mechanochemical ablation. These data suggest that mechanochemical ablation is a safe alternative for varicose veins. However, further large-scale trials are required to define the role of MOCA.
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Affiliation(s)
| | - N G Shestak
- Belarussian State Medical University, Minsk, Republic of Belarus.,Savchenko Minsk City Clinical Hospital No. 4, Minsk, Republic of Belarus
| | - N Ya Skobeleva
- Belarussian State Medical University, Minsk, Republic of Belarus.,Clinical Maternity Hospital of Minsk Region, Minsk, Republic of Belarus
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Gujja K, Kayiti T, Sanina C, Wiley JM. Chronic Venous Insufficiency. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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A Systematic Review About Outcomes of Percutaneous Treatment Modalities for Pathologic Saphenous And Perforating Veins. J Vasc Surg Venous Lymphat Disord 2022; 10:1172-1183.e5. [DOI: 10.1016/j.jvsv.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 03/14/2022] [Indexed: 11/21/2022]
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Hwang K, Park SW, Hwang JH, Kwon YW, Min J, Jang H, Chang IS, Kim KW. Hydrophilic guidewire usage under ultrasound guidance in facilitating catheter advancement during endovenous treatment of incompetent great saphenous veins. Ann Surg Treat Res 2022; 102:117-124. [PMID: 35198515 PMCID: PMC8831093 DOI: 10.4174/astr.2022.102.2.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 12/22/2021] [Accepted: 01/11/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose This study was performed To investigate the use of hydrophilic guidewires for facilitating catheter advancement during varicose vein treatment using radiofrequency ablation (RFA) or cyanoacrylate closure (CAC). Methods From March 2016 to April 2019, 463 limbs of 285 with incompetent great saphenous veins were subjected to RFA (321 limbs of 197 patients) or CAC (142 limbs of 88 patients). Procedure records were reviewed for the use of a hydrophilic guidewire, reason for the guidewire usage, and diameter of the guidewire. Results A hydrophilic guidewire was used to facilitate catheter advancement to treat 92 of 463 limbs (19.9%). For RFA, a guidewire was used to treat 53 of 321 limbs (16.5%). Among them, 15 limbs (28.3%) had vasospasm, and 38 limbs (71.7%) had venous tortuosity. For CAC, guidewire was used for 39 of 142 limbs (27.5%). Among them, 10 limbs (25.6%) had vasospasm, 23 limbs (59.0%) had venous tortuosity, and 6 limbs (15.4%) had repeated engagement of a J-tip guidewire into the varicose tributaries. In CAC, the frequency of hydrophilic guidewire usage was higher than that in RFA (P = 0.006). All varicose vein treatment sessions were technically successful. Conclusion Hydrophilic guidewire usage could facilitate catheter advancement when hindered by vasospasm, tortuosity of the saphenous vein, or repeated engagement into the varicose tributaries.
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Affiliation(s)
- Kyosoo Hwang
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Sang Woo Park
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Jin Ho Hwang
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Yong Wonn Kwon
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Jeeyoung Min
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Hyemin Jang
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
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Mo M, Hirokawa M, Satokawa H, Yasugi T, Yamaki T, Ito T, Onozawa S, Kobata T, Shirasugi N, Shokoku S, Sugano N, Sugiyama S, Hoshina K, On Behalf Of Guideline Committee Japanese Society Of Phlebology, Ogawa T, On Behalf Of Japanese Commitee Of Endovenous Treatment For Varicose Veins. Supplement of Clinical Practice Guidelines for Endovenous Thermal Ablation for Varicose Veins: Overuse for the Inappropriate Indication. Ann Vasc Dis 2021; 14:323-327. [PMID: 35082936 PMCID: PMC8752913 DOI: 10.3400/avd.ra.21-00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 10/04/2021] [Indexed: 11/17/2022] Open
Abstract
While endovenous thermal ablation (ETA) become first choice of treatment for varicose veins, overuse of ETA for the inappropriate indication is growing problem. ETA is performed not only on varicose cases without symptom but also non diseased cases with segmental reflux of saphenous veins or no reflux. Indications of ETA was demonstrated in “the Clinical Practice Guidelines for ETA for Varicose Veins 2019” by Japanese Society of Phlebology. Purpose of this supplement is description of basics of correct indication for ETA. We also demonstrate the typical case of overuse of ETA for wrong indication. (This is a translation of Jpn J Phlebol 2020; 31: 39–43.)
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Affiliation(s)
- Makoto Mo
- Department of Cardiovascular Surgery, Yokohama Minami Kyosai Hospital, Yokohama, Kanagawa, Japan
| | | | - Hirono Satokawa
- Department of Cardiovascular Surgery, Fukushima Medical University, School of Medicine, Fukushima, Fukushima, Japan
| | - Takumi Yasugi
- Department of Cardiovascular Surgery, Ehime University, Toon, Ehime, Japan
| | - Takashi Yamaki
- Department of Plastic and Reconstructive Surgery, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Takaaki Ito
- Department of Dermatology, Hyogo College of Medicine, Nisinomiya, Hyogo, Japan
| | - Shiro Onozawa
- Department of Radiology, Teikyo University Mizonokuchi Hospital, Kawasaki, Kanagawa, Japan
| | - Takashi Kobata
- Department of Cardiovascular Surgery, Kanazawa Medical University Himi Municipal Hospital, Himi, Toyama, Japan
| | - Nozomu Shirasugi
- Department of Vascular Surgery, Yokohama Asahi Chuo General Hospital, Yokohama, Kanagawa, Japan
| | | | - Norihide Sugano
- Department of Surgery, Tokyo Metropolitan Health and Medical Treatment Corporation Ohkubo Hospital, Tokyo, Japan
| | - Satoru Sugiyama
- Department of Surgery, Hiroshima Teishin Hospital, Hiroshima, Hiroshima, Japan
| | | | - On Behalf Of Guideline Committee Japanese Society Of Phlebology
- Department of Cardiovascular Surgery, Yokohama Minami Kyosai Hospital, Yokohama, Kanagawa, Japan.,Ochanomizu Vascular and Vein Clinic, Tokyo, Japan.,Department of Cardiovascular Surgery, Fukushima Medical University, School of Medicine, Fukushima, Fukushima, Japan.,Department of Cardiovascular Surgery, Ehime University, Toon, Ehime, Japan.,Department of Plastic and Reconstructive Surgery, Tokyo Women's Medical University Medical Center East, Tokyo, Japan.,Department of Dermatology, Hyogo College of Medicine, Nisinomiya, Hyogo, Japan.,Department of Radiology, Teikyo University Mizonokuchi Hospital, Kawasaki, Kanagawa, Japan.,Department of Cardiovascular Surgery, Kanazawa Medical University Himi Municipal Hospital, Himi, Toyama, Japan.,Department of Vascular Surgery, Yokohama Asahi Chuo General Hospital, Yokohama, Kanagawa, Japan.,Shokoku Shintaro Clinic, Okayama, Okayama, Japan.,Department of Surgery, Tokyo Metropolitan Health and Medical Treatment Corporation Ohkubo Hospital, Tokyo, Japan.,Department of Surgery, Hiroshima Teishin Hospital, Hiroshima, Hiroshima, Japan.,Department of Vascular Surgery, Tokyo University, Tokyo, Japan.,Department of Cardiovascular Surgery, Fukushima Dai-Ichi Hospital, Fukushima, Fukushima, Japan
| | - Tomohiro Ogawa
- Department of Cardiovascular Surgery, Fukushima Dai-Ichi Hospital, Fukushima, Fukushima, Japan
| | - On Behalf Of Japanese Commitee Of Endovenous Treatment For Varicose Veins
- Department of Cardiovascular Surgery, Yokohama Minami Kyosai Hospital, Yokohama, Kanagawa, Japan.,Ochanomizu Vascular and Vein Clinic, Tokyo, Japan.,Department of Cardiovascular Surgery, Fukushima Medical University, School of Medicine, Fukushima, Fukushima, Japan.,Department of Cardiovascular Surgery, Ehime University, Toon, Ehime, Japan.,Department of Plastic and Reconstructive Surgery, Tokyo Women's Medical University Medical Center East, Tokyo, Japan.,Department of Dermatology, Hyogo College of Medicine, Nisinomiya, Hyogo, Japan.,Department of Radiology, Teikyo University Mizonokuchi Hospital, Kawasaki, Kanagawa, Japan.,Department of Cardiovascular Surgery, Kanazawa Medical University Himi Municipal Hospital, Himi, Toyama, Japan.,Department of Vascular Surgery, Yokohama Asahi Chuo General Hospital, Yokohama, Kanagawa, Japan.,Shokoku Shintaro Clinic, Okayama, Okayama, Japan.,Department of Surgery, Tokyo Metropolitan Health and Medical Treatment Corporation Ohkubo Hospital, Tokyo, Japan.,Department of Surgery, Hiroshima Teishin Hospital, Hiroshima, Hiroshima, Japan.,Department of Vascular Surgery, Tokyo University, Tokyo, Japan.,Department of Cardiovascular Surgery, Fukushima Dai-Ichi Hospital, Fukushima, Fukushima, Japan
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Chaitidis N, Kokkinidis DG, Papadopoulou Z, Kyriazopoulou M, Schizas D, Bakoyiannis C. Treatment of chronic venous disorder: A comprehensive review. Dermatol Ther 2021; 35:e15238. [PMID: 34859549 DOI: 10.1111/dth.15238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 11/15/2021] [Accepted: 11/28/2021] [Indexed: 12/16/2022]
Abstract
Chronic venous disorder (CVD) is highly prevalent vascular disorder affecting up to 45% of the general population, with clinical manifestations ranging from teleangiectasias to venous leg ulcers (VLUs). We examined the currently available data in order to provide an updated, comprehensive review on treatment options of CVD. We searched MEDLINE, Cochrane, Scopus, EMBASE, ClinicalTrials, and OpenGrey databases for relevant articles in English published until November 2020. Compression treatment is the mainstay of conservative treatment. Pharmacological treatment can provide significant symptomatic relief and hence it should be considered as part of conservative treatment. Transcutaneous Lacer treatment (TCL) is a safe and effective alternative option to sclerotherapy for treatment of C1 stage. High ligation and stripping (HL/S), ultrasound-guided foam sclerotherapy (UGFS), endovenous thermal ablation (EVTA) systems and non thermal non tumescent ablation (NTNT) systems are safe and efficacious first-line options for treatment of saphenous insufficiency. Interventional treatment of co-existing incompetent perforator veins (IPVs) is not supported by contemporary evidence. Regarding deep venous insufficiency (DVI), treatment of symptomatic femoroiliocaval occlusive venous disease refractory to conservative treatment with percutaneous transluminal venoplasty stenting has produced encouraging results.
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Affiliation(s)
| | - Damianos G Kokkinidis
- Section of Cardiovascular Medicine, Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Zoi Papadopoulou
- 3rd Department of Pediatrics, Ippokrateio General Hospital Of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria Kyriazopoulou
- Department of Dermatology and Venereology, 401 General Military Hospital of Athens, Athens, Greece
| | - Dimitrios Schizas
- 1st Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Christos Bakoyiannis
- 1st Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Yen CC. A Rare Case of Pulmonary Thromboembolism without Deep Vein Thrombosis after Nonthermal Nontumescent Ablative Methods for Varicose Vein Surgery. Ann Vasc Surg 2021; 79:438.e1-438.e3. [PMID: 34644654 DOI: 10.1016/j.avsg.2021.07.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 07/03/2021] [Accepted: 07/06/2021] [Indexed: 11/28/2022]
Abstract
The NTNT ablative method for varicose vein surgery is characterized by low-difficulty, minimally invasive and fast recovery and make surgeon suppose its very low risks of any major complications. We present a case of PTE without DVT confirmed by ultrasonography and CT angiography (CTA) after NTNT ablative methods for varicose vein surgery.
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Affiliation(s)
- Chih-Chien Yen
- Division of Cardiovascular Surgery, Department of Surgery, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan (ROC); Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University Taipei City, Taiwan (ROC).
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17
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Sharmila DN. Surgery for Varicose Veins. Indian J Surg 2021. [DOI: 10.1007/s12262-021-03044-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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18
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Farah MH, Nayfeh T, Urtecho M, Hasan B, Amin M, Sen I, Wang Z, Prokop LJ, Lawrence PF, Gloviczki P, Murad MH. A systematic review supporting the Society for Vascular Surgery, the American Venous Forum, and the American Vein and Lymphatic Society guidelines on the management of varicose veins. J Vasc Surg Venous Lymphat Disord 2021; 10:1155-1171. [PMID: 34450355 DOI: 10.1016/j.jvsv.2021.08.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/13/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Several diagnostic tests and treatment options for patients with lower extremity varicose veins have existed for decades. The purpose of this systematic review was to summarize the latest evidence to support the forthcoming updates of the clinical practice guidelines on the management of varicose veins for the Society for Vascular Surgery (SVS), the American Venous Forum (AVF) and the American Vein and Lymphatic Society. METHODS We searched multiple databases for studies that addressed four clinical questions identified by the AVF and the SVS guideline committee about evaluating and treating patients with varicose veins. Studies were selected and appraised by pairs of independent reviewers. A meta-analysis was conducted when feasible. RESULTS We included 73 original studies (45 were randomized controlled trials) and 1 systematic review from 12,915 candidate references. Moderate certainty of evidence supported the usefulness of duplex ultrasound (DUS) examination as the gold standard test for diagnosing saphenous vein incompetence in patients with varicose veins and chronic venous insufficiency (clinical, etiological, anatomic, pathophysiological classification [CEAP] class C2-C6). High ligation and stripping (HL/S) was associated with higher anatomic closure rates at 30 days and 5 years when compared with radiofrequency ablation and ultrasound-guided foam sclerotherapy (UGFS) (moderate certainty), while no significant difference was seen when compared with endovenous laser ablation (EVLA) at 5 years. UGFS was associated with an increased risk of recurrence compared with HL/S. EVLA was associated with lower anatomic closure rates at 30 days than cyanoacrylate closure (CAC) and higher rates at one and 5 years when compared with UGFS. Thermal interventions were associated with lower generic quality of life scores and an increased risk of adverse events when compared with CAC or n-butyl cyanoacrylate (low certainty). Thermal interventions were associated with a lower risk of recurrent incompetence when compared with UGFS and an increased risk of recurrent incompetence than CAC. The evidence for great saphenous vein ablation alone to manage perforator disease was inconclusive. CONCLUSIONS The current systematic review summarizes the evidence to develop and support forthcoming updated SVS/AVF/American Vein and Lymphatic Society clinical practice guideline recommendations. The evidence supports duplex scanning for evaluating patients with varicose veins and confirms that HL/S resulted in similar long-term saphenous vein closure rates as EVLA and in better rates than radiofrequency ablation and UGFS. Thermal interventions were associated with inferior generic quality of life scores than nonthermal interventions, but had a lower risk of recurrent incompetence than UGFS. The recommendations in the guidelines should consider this information as well as other factors such as patients' values and preferences, anatomic considerations of individual patients, and surgical expertise.
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Affiliation(s)
- Magdoleen H Farah
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn
| | - Tarek Nayfeh
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn
| | - Meritxell Urtecho
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn
| | - Bashar Hasan
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn
| | - Mustapha Amin
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn
| | - Indrani Sen
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Zhen Wang
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn
| | | | - Peter F Lawrence
- Division of Vascular Surgery, Department of Surgery, University of California, Los Angeles, Calif
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - M Hassan Murad
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn.
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Cost-effectiveness Analysis of Current Varicose Veins Treatments. J Vasc Surg Venous Lymphat Disord 2021; 10:504-513.e7. [PMID: 34450353 DOI: 10.1016/j.jvsv.2021.05.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 05/02/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To analyze the effectiveness and cost-effectiveness of technologies for treatment of varicose veins over 5 years - conservative care (CONS), surgery (HL/S), ultrasound guided foam sclerotherapy (UGFS), endovenous laser ablation (EVLA), and radiofrequency ablation (RFA), mechanochemical ablation (MOCA) and cyanoacrylate glue occlusion (CAE). METHODS A systematic review was updated and used to construct a Markov decision model. Outcomes were re-intervention on the truncal vein, re-treatment of residual varicosities and quality-adjusted life years (QALY) and costs over five years. RESULTS UGFS has a significantly greater re-intervention rate than other procedures, while there is no significant difference between the other procedures. The cost per QALY of EVLA versus UGFS in our base-case model is £16966 ($23700) per QALY, which is considered cost-effective in the UK. RFA, MOCA and CAE have greater procedure costs than EVLA with no evidence of greater benefit for patients. CONCLUSIONS EVLA is the most cost-effective therapeutic option, with RFA a close second, in adult patients requiring treatment in the upper leg for incompetence of the GSV. MOCA, UGFS, CAE, CONS and HL/S are not cost-effective at current prices in the UK National Health Service. MOCA and CAE appear promising but further evidence on effectiveness, re-interventions and health-related quality of life is needed, as well as how cost-effectiveness may vary across settings and reimbursement systems.
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Abstract
BACKGROUND Great saphenous vein (GSV) incompetence, causing varicose veins and venous insufficiency, makes up the majority of lower-limb superficial venous diseases. Treatment options for GSV incompetence include surgery (also known as high ligation and stripping), laser and radiofrequency ablation, and ultrasound-guided foam sclerotherapy. Newer treatments include cyanoacrylate glue, mechanochemical ablation, and endovenous steam ablation. These techniques avoid the need for a general anaesthetic, and may result in fewer complications and improved quality of life (QoL). These treatments should be compared to inform decisions on treatment for varicosities in the GSV. This is an update of a Cochrane Review first published in 2011. OBJECTIVES To assess the effects of endovenous laser ablation (EVLA), radiofrequency ablation (RFA), endovenous steam ablation (EVSA), ultrasound-guided foam sclerotherapy (UGFS), cyanoacrylate glue, mechanochemical ablation (MOCA) and high ligation and stripping (HL/S) for the treatment of varicosities of the great saphenous vein (GSV). SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, and AMED databases, and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 2 November 2020. We undertook reference checking to identify additional studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) treating participants for varicosities of the GSV using EVLA, RFA, EVSA, UGFS, cyanoacrylate glue, MOCA or HL/S. Key outcomes of interest are technical success, recurrence, complications and QoL. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, applied Cochrane's risk of bias tool, and extracted data. We calculated odds ratios (ORs) with 95% confidence intervals (CIs) and assessed the certainty of evidence using GRADE. MAIN RESULTS We identified 11 new RCTs for this update. Therefore, we included 24 RCTs with 5135 participants. Duration of follow-up ranged from five weeks to eight years. Five comparisons included single trials. For comparisons with more than one trial, we could only pool data for 'technical success' and 'recurrence' due to heterogeneity in outcome definitions and time points reported. All trials had some risk of bias concerns. Here we report the clinically most relevant comparisons. EVLA versus RFA Technical success was comparable up to five years (OR 0.98, 95% CI 0.41 to 2.38; 5 studies, 780 participants; moderate-certainty evidence); over five years, there was no evidence of a difference (OR 0.85, 95% CI 0.30 to 2.41; 1 study, 291 participants; low-certainty evidence). One study reported recurrence, showing no clear difference at three years (OR 1.53, 95% CI 0.78 to 2.99; 291 participants; low-certainty evidence), but a benefit for RFA may be seen at five years (OR 2.77, 95% CI 1.52 to 5.06; 291 participants; low-certainty evidence). EVLA versus UGFS Technical success may be better in EVLA participants up to five years (OR 6.13, 95% CI 0.98 to 38.27; 3 studies, 588 participants; low-certainty evidence), and over five years (OR 6.47, 95% CI 2.60 to 16.10; 3 studies, 534 participants; low-certainty evidence). There was no clear difference in recurrence up to three years and at five years (OR 0.68, 95% CI 0.20 to 2.36; 2 studies, 443 participants; and OR 1.08, 95% CI 0.40 to 2.87; 2 studies, 418 participants; very low-certainty evidence, respectively). EVLA versus HL/S Technical success may be better in EVLA participants up to five years (OR 2.31, 95% CI 1.27 to 4.23; 6 studies, 1051 participants; low-certainty evidence). No clear difference in technical success was seen at five years and beyond (OR 0.93, 95% CI 0.57 to 1.50; 5 studies, 874 participants; low-certainty evidence). Recurrence was comparable within three years and at 5 years (OR 0.78, 95% CI 0.47 to 1.29; 7 studies, 1459 participants; and OR 1.09, 95% CI 0.68 to 1.76; 7 studies, 1267 participants; moderate-certainty evidence, respectively). RFA versus MOCA There was no clear difference in technical success (OR 1.76, 95% CI 0.06 to 54.15; 3 studies, 435 participants; low-certainty evidence), or recurrence (OR 1.00, 95% CI 0.21 to 4.81; 3 studies, 389 participants; low-certainty evidence). Long-term data are not available. RFA versus HL/S No clear difference in technical success was detected up to five years (OR 5.71, 95% CI 0.64 to 50.81; 2 studies, 318 participants; low-certainty evidence); over five years, there was no evidence of a difference (OR 0.88, 95% CI 0.29 to 2.69; 1 study, 289 participants; low-certainty evidence). No clear difference in recurrence was detected up to three years (OR 0.93, 95% CI 0.58 to 1.51; 4 studies, 546 participants; moderate-certainty evidence); but a possible long-term benefit for RFA was seen (OR 0.41, 95% CI 0.22 to 0.75; 1 study, 289 participants; low-certainty evidence). UGFS versus HL/S Meta-analysis showed a possible benefit for HL/S compared with UGFS in technical success up to five years (OR 0.32, 95% CI 0.11 to 0.94; 4 studies, 954 participants; low-certainty evidence), and over five years (OR 0.09, 95% CI 0.03 to 0.30; 3 studies, 525 participants; moderate-certainty evidence). No clear difference was detected in recurrence up to three years (OR 1.81, 95% CI 0.87 to 3.77; 3 studies, 822 participants; low-certainty evidence), and after five years (OR 1.24, 95% CI 0.57 to 2.71; 3 studies, 639 participants; low-certainty evidence). Complications were generally low for all interventions, but due to different definitions and time points, we were unable to draw conclusions (very-low certainty evidence). Similarly, most studies evaluated QoL but used different questionnaires at variable time points. Rates of QoL improvement were comparable between interventions at follow-up (moderate-certainty evidence). AUTHORS' CONCLUSIONS Our conclusions are limited due to the relatively small number of studies for each comparison and differences in outcome definitions and time points reported. Technical success was comparable between most modalities. EVLA may offer improved technical success compared to UGFS or HL/S. HL/S may have improved technical success compared to UGFS. No evidence of a difference was detected in recurrence, except for a possible long-term benefit for RFA compared to EVLA or HL/S. Studies which provide more evidence on the breadth of treatments are needed. Future trials should seek to standardise clinical terminology of outcome measures and the time points at which they are measured.
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Affiliation(s)
- Jade Whing
- Northern Vascular Centre, Freeman Hospital, Newcastle, UK
| | - Sandip Nandhra
- Northern Vascular Centre, Freeman Hospital, Newcastle, UK
| | - Craig Nesbitt
- Northern Vascular Centre, Freeman Hospital, Newcastle, UK
| | - Gerard Stansby
- Northern Vascular Centre, Freeman Hospital, Newcastle, UK
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Siribumrungwong B, Wilasrusmee C, Orrapin S, Srikuea K, Benyakorn T, McKay G, Attia J, Rerkasem K, Thakkinstian A. Interventions for great saphenous vein reflux: network meta-analysis of randomized clinical trials. Br J Surg 2021; 108:244-255. [PMID: 33793723 PMCID: PMC10364879 DOI: 10.1093/bjs/znaa101] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 10/12/2020] [Accepted: 11/01/2020] [Indexed: 11/14/2022]
Abstract
BACKGROUND A variety of endovascular and open surgical interventions exist to treat great saphenous vein reflux. However, comparisons of treatment outcomes have been inconsistent. METHODS A systematic review and network meta-analysis of RCTs was performed to compare rates of incomplete stripping or non-occlusion of the great saphenous vein with or without reflux (anatomical failure) at early, mid- and long-term follow-up; and secondary outcomes (reintervention and clinical recurrence) among intervention groups. The surface under the cumulative ranking curve (SUCRA) method was used to estimate the probability of the intervention with the lowest anatomical failure rates. RESULTS Some 72 RCTs were included. Comparisons of endothermal techniques with open surgery were mostly not significantly different, except for endovenous laser ablation (EVLA), which had higher long-term anatomical failure rates (pooled risk ratio (RR) 1.87, 95 per cent c.i. 1.14 to 3.07). Mechanochemical ablation had higher anatomical failure rates than radiofrequency ablation (RFA) (pooled RR 2.77, 1.38 to 5.53), and cyanoacrylate closure (CAC) had a RR 0.56 (0.34 to 0.93) times lower than either RFA or EVLA at the early term. Ultrasound-guided foam sclerotherapy had a higher risk of anatomical failure and reintervention than open surgery, with the lowest SUCRA value, and CAC was ranked first, third and first for best intervention for anatomical failure at early, mid and long term respectively. However, clinical recurrence rates were not significantly different between all comparisons. CONCLUSION Mechanochemical ablation and ultrasound-guided foam sclerotherapy performed poorly, with higher anatomical failure rates in the long term. The other treatment modalities had similar rates of anatomical failure in the short and mid term.
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Affiliation(s)
- B Siribumrungwong
- Division of Vascular and Endovascular Surgery, Department of Surgery, Thammasat University Hospital, Pathum Thani, Thailand.,Centre of Excellence in Applied Epidemiology, Thammasat University Hospital, Thammasat University, Pathum Thani, Thailand
| | - C Wilasrusmee
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - S Orrapin
- Division of Vascular and Endovascular Surgery, Department of Surgery, Thammasat University Hospital, Pathum Thani, Thailand
| | - K Srikuea
- Division of Vascular and Endovascular Surgery, Department of Surgery, Thammasat University Hospital, Pathum Thani, Thailand
| | - T Benyakorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Thammasat University Hospital, Pathum Thani, Thailand
| | - G McKay
- Centre for Public Health, School of Medicine, Dentistry, and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - J Attia
- Centre for Clinical Epidemiology and Biostatistics, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, and Hunter Medical Research Institute, NSW, Australia
| | - K Rerkasem
- Division of Vascular and Endovascular Surgery, Department of Surgery, Faculty of Medicine; Non-Communicable Disease Centre of Excellence, Research Institute of Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - A Thakkinstian
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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22
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Shmelev K, Gupta R. Choosing the Best Treatment Approach for Axial Vein Reflux: Thermal versus Nonthermal Approaches. Semin Intervent Radiol 2021; 38:209-214. [PMID: 34108808 DOI: 10.1055/s-0041-1729155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Chronic venous insufficiency is a common and treatable medical condition which has a high morbidity if left untreated, progressing to lower extremity edema, skin changes of lipodermatosclerosis, and venous ulceration. Treatment options have significantly expanded over the last several decades, shifting away from the traditional surgical approach to more minimally invasive procedures such as endoluminal venous laser ablation or radiofrequency ablation. Even more recently, several techniques using nonthermal methods to ablate varicose veins have been developed, which offer the advantage of not requiring labor-intensive and painful tumescent anesthesia to protect the surrounding tissues. These techniques include mechanochemical ablation, cyanoacrylate closure, or polidocanol microfoam injection and can be offered to a wider range of patients without the need for sedation while offering similar closure rates and improved postprocedure symptom profile. Furthermore, certain patient characteristics which might preclude or complicate the use of thermal ablation methods might not pose a problem with nonthermal nontumescent methods.
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Affiliation(s)
- Karen Shmelev
- Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Ramona Gupta
- Northwestern University, Feinberg School of Medicine, Chicago, Illinois
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Outcomes of Saphenous Vein Intervention in the Management of Superficial Venous Incompetence: A Systematic Review and Network Meta-Analysis. Ann Surg 2021; 275:e324-e333. [PMID: 33843795 DOI: 10.1097/sla.0000000000004914] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine the most effective modality of intervention to treat saphenous vein insufficiency. SUMMARY BACKGROUND DATA Endovenous therapies have instigated a paradigm shift in the management of superficial venous incompetence (SVI). When compared with open surgery, endovenous interventions (foam sclerotherapy (FS), radiofrequency ablation (RFA), endovenous laser ablation (EVLA), mechanochemical ablation (MOCA), and cyanoacrylate glue (CAE) closure) potentially offer reduced morbidity with similar procedural efficacy. METHODS A systematic review and series of network meta-analyses of randomized controlled trials (RCTs) were performed assessing risks of procedural failure (within 6-weeks) and recurrence (6-weeks to 5-years), defined by ultrasound, between the different SVI modalities. Treatment comparisons addressing risks of common adverse events, Venous Clinical Severity Score (VCSS) and pain were also performed. RESULTS A systematic search identified 51 articles, describing 36 RCTs, incorporating 7,576 limbs. Outcome data on ten modalities of intervention were analyzed up to five-year follow-up. CAE resulted in the lowest risk of procedural failure within six-weeks. Foam sclerotherapy had the highest risk of recurrence while high ligation with stripping (HLS) and CHIVA were ranked best to reduce long-term recurrence. No intervention increased risks of venous thromboembolism and there was minimal difference in morbidity between treatments. All interventions improved VCSS (Range -1.02 to -4.95), however RFA demonstrated the greatest improvement, followed by EVLA and HLS between two to five-years. EVLA was associated with the highest risk of pain, while MOCA offered the least. CONCLUSION While CAE offered the lowest risk of initial procedural failure, HLS resulted in lower rates of long-term recurrence without considerably increasing morbidity when compared with other endovenous options.
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Borghese O, Pisani A, Di Centa I. Endovenous radiofrequency for chronic superficial venous insufficiency: Clinical outcomes and impact in quality of life. JOURNAL DE MÉDECINE VASCULAIRE 2021; 46:3-8. [PMID: 33546819 DOI: 10.1016/j.jdmv.2020.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 11/22/2020] [Indexed: 01/27/2023]
Abstract
BACKGROUND Endovenous treatment of lower limb varicose veins is progressively replacing conventional surgery. The authors are investigating radiofrequency (RFA) results in terms of vein occlusion, complications, patient's satisfaction and quality of life in a single centre. METHODS AND MATERIALS A retrospective analysis of medical charts with a prospective follow-up was performed on data about patients undergoing RFA for insufficiency of great saphenous vein (GSV). RESULTS A total number of 135 patients (164 limbs) (63% n 85 female; 37% n 50 male; mean age of 53.9 years, range 24-85 years; mean VCSS score (Venous Clinical Severity Score) 6, range 4-22) were included. Complete obliteration of GSV was obtained in 98.2% of the cases. No device- or procedure-related adverse events occurred. No deep venous thromboses, pulmonary embolism, phlebitis, major bleeding, paraesthesia nor skin burn were detected. Patients returned to normal activities in a mean of 8 days (range 5-10). One-month postoperatively, the mean quality of life scores 6 (range 5-9) and mean satisfaction score was 6 (range 4-8) in a scale from 0 to 8. At a median follow-up of 11 months (range 2-18), mean VCSS was 3.9 (range 2-8). CONCLUSIONS Radiofrequency guarantees good functional outcomes and low rate of complications. It is associated with high satisfaction rate and quality of life score.
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Affiliation(s)
- O Borghese
- Department of Vascular Surgery, Foch Hospital, 40, rue Worth, 92150 Suresnes, France.
| | - A Pisani
- Department of Cardiothoracic Surgery Bichat-Claude-Bernard Hospital, Paris, France
| | - I Di Centa
- Department of Vascular Surgery, Foch Hospital, 40, rue Worth, 92150 Suresnes, France
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25
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Tiwari K, Kamerkar D, Shinde B. Endovenous laser therapy in varicose veins-recanalization rate and quality of life. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2021. [DOI: 10.4103/ijves.ijves_169_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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26
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Au‐Yeung CLK, Tse OHR, Pang YCS, Tang CN. Review of thermal and non‐thermal based endovenous treatment: Our local experience. SURGICAL PRACTICE 2020. [DOI: 10.1111/1744-1633.12456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | - On Ho Ronald Tse
- Department of Surgery Pamela Youde Nethersole Eastern Hospital Hong Kong
| | - Yin Chun Skyi Pang
- Department of Surgery Pamela Youde Nethersole Eastern Hospital Hong Kong
| | - Chung Ngai Tang
- Department of Surgery Pamela Youde Nethersole Eastern Hospital Hong Kong
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27
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Classification and treatment of endothermal heat-induced thrombosis: Recommendations from the American Venous Forum and the Society for Vascular Surgery. J Vasc Surg Venous Lymphat Disord 2020; 9:6-22. [PMID: 33012690 DOI: 10.1016/j.jvsv.2020.06.008] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 06/09/2020] [Indexed: 12/12/2022]
Abstract
The American Venous Forum (AVF) and the Society for Vascular Surgery set forth these guidelines for the management of endothermal heat-induced thrombosis (EHIT). The guidelines serve to compile the body of literature on EHIT and to put forth evidence-based recommendations. The guidelines are divided into the following categories: classification of EHIT, risk factors and prevention, and treatment of EHIT. One major feature is to standardize the reporting under one classification system. The Kabnick and Lawrence classification systems are now combined into the AVF EHIT classification system. The novel classification system affords standardization in reporting but also allows continued combined evaluation with the current body of literature. Recommendations codify the use of duplex ultrasound for the diagnosis of EHIT. Risk factor assessments and methods of prevention including mechanical prophylaxis, chemical prophylaxis, and ablation distance are discussed. Treatment guidelines are tailored to the AVF EHIT class (ie, I, II, III, IV). Reference is made to the use of surveillance, antiplatelet therapy, and anticoagulants as deemed indicated, and the recommendations incorporate the use of the novel direct oral anticoagulants. Last, EHIT management as it relates to the great and small saphenous veins is discussed.
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Kabnick LS, Sadek M, Bjarnason H, Coleman DM, Dillavou ED, Hingorani AP, Lal BK, Lawrence PF, Malgor R, Puggioni A. Classification and treatment of endothermal heat-induced thrombosis: Recommendations from the American Venous Forum and the Society for Vascular Surgery This Practice Guidelines document has been co-published in Phlebology [DOI: 10.1177/0268355520953759] and Journal of Vascular Surgery: Venous and Lymphatic Disorders [DOI: 10.1016/j.jvsv.2020.06.008]. The publications are identical except for minor stylistic and spelling differences in keeping with each journal's style. The contribution has been published under a Attribution-Non Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0), (https://creativecommons.org/licenses/by-nc-nd/4.0/). Phlebology 2020; 36:8-25. [PMID: 32998622 PMCID: PMC7820569 DOI: 10.1177/0268355520953759] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The American Venous Forum (AVF) and the Society for Vascular Surgery set forth these guidelines for the management of endothermal heat-induced thrombosis (EHIT). The guidelines serve to compile the body of literature on EHIT and to put forth evidence-based recommendations. The guidelines are divided into the following categories: classification of EHIT, risk factors and prevention, and treatment of EHIT. One major feature is to standardize the reporting under one classification system. The Kabnick and Lawrence classification systems are now combined into the AVF EHIT classification system. The novel classification system affords standardization in reporting but also allows continued combined evaluation with the current body of literature. Recommendations codify the use of duplex ultrasound for the diagnosis of EHIT. Risk factor assessments and methods of prevention including mechanical prophylaxis, chemical prophylaxis, and ablation distance are discussed. Treatment guidelines are tailored to the AVF EHIT class (ie, I, II, III, IV). Reference is made to the use of surveillance, antiplatelet therapy, and anticoagulants as deemed indicated, and the recommendations incorporate the use of the novel direct oral anticoagulants. Last, EHIT management as it relates to the great and small saphenous veins is discussed.
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Affiliation(s)
- Lowell S Kabnick
- Atlantic Health System, Morristown Medical Center, Kabnick Vein Center, Morristown, NJ, USA
| | - Mikel Sadek
- Division of Vascular Surgery, NYU Langone Health, New York, NY, USA
| | - Haraldur Bjarnason
- Division of Vascular and Interventional Radiology, Mayo Clinic, Rochester, MN, USA
| | - Dawn M Coleman
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Ellen D Dillavou
- Division of Vascular Surgery, Duke University Medical Center, Durham, NC, USA
| | - Anil P Hingorani
- Division of Vascular Surgery, NYU Langone Hospital-Brooklyn, Brooklyn, NY, USA
| | - Brajesh K Lal
- Center for Vascular Research and Department of Vascular Surgery, University of Maryland, and the Vascular Service, Baltimore VA Medical Center, Baltimore, MD, USA
| | - Peter F Lawrence
- Department of Surgery, Division of Vascular Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Rafael Malgor
- Division of Vascular Surgery and Endovascular Therapy, The University of Colorado, Anschutz Medical Center, Aurora, CO, USA
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SANRI US, ÖZSİN KK, ATLI F, TOKTAŞ F, YAVUZ S. Kronik venöz yetmezlik olgularında Endovenöz Radyofrekans Ablasyonun Klinik Sonuçları: İki Yıllık Takip Sonuçları. ACTA MEDICA ALANYA 2020. [DOI: 10.30565/medalanya.752398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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The clinical outcomes of endovenous microwave and laser ablation for varicose veins: A prospective study. Surgery 2020; 168:909-914. [PMID: 32792099 DOI: 10.1016/j.surg.2020.06.035] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND This study investigates the clinical outcomes of endovenous microwave ablation and endovenous laser ablation for varicose veins. METHODS A total of 139 patients who underwent endovenous microwave ablation and 145 patients who underwent endovenous laser ablation were included in this multicenter study. The clinical outcomes and complications were assessed at 1, 6, and 12 months after the procedure. The effect on quality of life was assessed by the Aberdeen Varicose Vein Questionnaire and the EuroQol Group 5-Dimension Self-Report Questionnaire. RESULTS The endovenous microwave ablation group had a shorter procedure time than the endovenous laser ablation group (42.58 ± 15.62 minutes vs 65.46 ± 24.38 minutes, P < .01), and no significant differences were observed in the other procedure parameters. The incidences of induration (20.26% vs 31.06%) and ecchymosis (13.07% vs 22.98%, P < .05) were lower in the endovenous microwave ablation group. The rates of temporary paresthesia (9.80% vs 18.01%) and residual varicosities (8.61% vs 16.77%, P < .05) were lower in the endovenous microwave ablation group at 1 month. There were no significant differences in paresthesia or saphenous vein closure rates between the groups at 6 and 12 months. Both groups had significant improvements in their Aberdeen Varicose Vein Questionnaire and EuroQol Group 5-Dimension Self-Report Questionnaire scores post-procedure, and no significant differences in Aberdeen Varicose Vein Questionnaire and EuroQol Group 5-Dimension Self-Report Questionnaire scores were confirmed. However, local recurrence below the knee was lower in the endovenous microwave ablation group (2.34% vs 8.46%, P < .05) after 12 months. CONCLUSION Our results confirmed that the endovenous microwave ablation procedure demonstrated a shorter procedure time, lower complication, and local recurrence than the endovenous laser ablation procedure.
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Pappas P, Gunnarsson C, David G. Evaluating patient preferences for thermal ablation versus nonthermal, nontumescent varicose vein treatments. J Vasc Surg Venous Lymphat Disord 2020; 9:383-392. [PMID: 32791306 DOI: 10.1016/j.jvsv.2020.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/02/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To measure patient preferences for attributes associated with thermal ablation and nonthermal, nontumescent varicose vein treatments. METHODS Data were collected from an electronic patient preference survey taken by 70 adult participants (aged 20 years or older) at three Center for Vein Restoration clinics in New Jersey from July 19, 2019, through August 13, 2019. Survey participation was voluntary and anonymous (participation rate of 80.5% [70/87]). Patients were shown 10 consecutive screens that displayed three hypothetical treatment scenarios with different combinations of six attributes of interest and a none option. Choice-based conjoint analysis estimated the relative importance of different aspects of care, trade-offs between these aspects, and total satisfaction that respondents derived from different healthcare procedures. Market simulation analysis compared clusters of attributes mimicking thermal ablation and nonthermal, nontumescent treatments. RESULTS Of the six attributes studied, out-of-pocket (OOP) expenditures were the most important to patients (37.2%), followed by postoperative discomfort (17.1%), risk of adverse events (16.3%), time to return to normal activity (11.0%), number of injections (10.0%), and number of visits (8.4%). Patients were willing to pay the most to avoid postoperative discomfort ($68.9) and risk of adverse events ($65.8). The market simulation analysis found that, regardless of the level of OOP spending, 60% to 80% of respondents favored attribute combinations corresponding with nonthermal, nontumescent procedures over thermal ablation, and that less than 1% of participants would forgo either treatment under no cost sharing. CONCLUSIONS Patients are highly sensitive to OOP costs for minimally invasive varicose vein treatments. Market simulation analysis favored nonthermal, nontumescent procedures over thermal ablation.
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Affiliation(s)
| | | | - Guy David
- University of Pennsylvania Wharton School, Philadelphia, Pa
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32
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A successful surgical treatment of pulmonary thromboembolism after endovenous radiofrequency ablation with extracorporeal membrane oxygenation bridging. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 28:369-371. [PMID: 32551169 DOI: 10.5606/tgkdc.dergisi.2020.17565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 12/23/2019] [Indexed: 11/21/2022]
Abstract
Pulmonary embolism after endovenous radiofrequency ablation is very rare, but a clinically severe complication. Herein, we report a case of pulmonary embolism after endovenous radiofrequency ablation. Early after radiofrequency ablation pulmonary embolism developed and extracorporeal membrane oxygenation implantation was performed. Under extracorporeal membrane oxygenation support, surgical pulmonary embolectomy was performed successfully using the same cannulas and the patient was discharged without any neurological sequelae. In conclusion, although rare after radiofrequency ablation, early recognition of pulmonary embolism and prompt treatment can be life-saving.
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Sandhya PA, Mohil RS, Sricharan R. Randomised controlled study to compare radiofrequency ablation with minimally invasive ultrasound-guided non-flush ligation and stripping of great saphenous vein in the treatment of varicose veins. Ann R Coll Surg Engl 2020; 102:525-531. [PMID: 32538106 DOI: 10.1308/rcsann.2020.0116] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Flush ligation at the saphenofemoral junction and stripping of the great saphenous vein is being increasingly replaced by endovenous methods such as radiofrequency or endovenous laser ablation for the treatment of varicose veins. These modalities are expensive and not widely available. A minimally invasive ultrasound-guided surgery with non-flush ligation and stripping under local anaesthesia is a cost-effective alternative with similar postoperative outcomes. MATERIALS AND METHODS A total of 62 limbs (58 patients) with saphenofemoral junction incompetence underwent clinical evaluation including the CEAP clinical score, the venous clinical severity score, the venous disability score and venous doppler. Patients were randomly assigned to either group A (radiofrequency ablation) or group B (ultrasound-guided non-flush ligation and stripping of the great saphenous vein) for procedures under tumescent anaesthesia and ultrasound guidance. Patients were followed-up on days 7, 30 and 90 to assess primary (obliteration rates) and secondary (venous clinical severity score and venous disability score) outcomes. RESULTS Both the groups showed 100% obliteration of the great saphenous vein at day 90. The venous clinical severity and venous disability scores significantly improved from day 0 to day 90 in both groups (p = 0.0001). There were no major complications. Group A showed significantly lower minor complications (p = 0.001). None required conversation to general anaesthesia. CONCLUSIONS The ultrasound-guided non-flush ligation and stripping of the great saphenous vein are as efficacious as radio frequency ablation, with similar obliteration rates, improvement in disability scores and complication profile at a lower cost. It has the potential for wider availability in the community as most surgeons are conversant with the surgical procedure.
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Affiliation(s)
- P A Sandhya
- Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - R S Mohil
- Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - R Sricharan
- RajaRajeswari Medical College and Hospital, Bangalore, India
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Kahraman N, Özsin KK. Ultrasound-guided catheter-directed foam sclerotherapy can be safely applied for the treatment of great saphenous varicose veins in elderly patients. Vascular 2020; 28:597-603. [PMID: 32281494 DOI: 10.1177/1708538120915102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Although many published series have shown the results of ultrasound-guided catheter-directed foam sclerotherapy, little is known about the outcomes and complications in older patients. METHODS A total of 152 patients older than 65 years (group 1: 61.8% male, mean age 69.0 ± 4.5 years) and 244 patients younger than 65 years (group 2: 48.8% male, mean age 45.7 ± 11.2 years) were included in the study. Ultrasound-guided catheter-directed foam sclerotherapy was performed in patients with great saphenous vein valvular incompetence and saphenofemoral junction incompetence. Occlusion status was recorded by ultrasonography. Venous clinical severity score and visual analog score were calculated pre- and post-intervention. RESULTS Complete occlusion rate of the great saphenous vein at 12 months post-procedure for the groups 1 and 2 was 86.4% and 86.3%, respectively. Venous clinical severity score and visual analog score were significantly different before ultrasound-guided catheter-directed foam sclerotherapy and four weeks after ultrasound-guided catheter-directed foam sclerotherapy (p < 0.001) in both the groups. There were no observed major complications in both the groups. CONCLUSIONS With low complication rate and acceptable total occlusion rate, ultrasound-guided catheter-directed foam sclerotherapy can be considered a reliable treatment for older patients.
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Affiliation(s)
- Nail Kahraman
- Bursa Yüksek İhtisas Training and Research Hospital Cardiovasculary Surgery Department, Bursa, Turkey
| | - Kadir K Özsin
- Bursa Yüksek İhtisas Training and Research Hospital Cardiovasculary Surgery Department, Bursa, Turkey
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Ashpitel HF, Dabbs EB, Salguero FJ, Nemchand JL, La Ragione RM, Whiteley MS. Histopathologic differences in the endovenous laser ablation between jacketed and radial fibers, in an ex vivo dominant extrafascial tributary of the great saphenous vein in an in vitro model, using histology and immunohistochemistry. J Vasc Surg Venous Lymphat Disord 2020; 7:234-245. [PMID: 30771831 DOI: 10.1016/j.jvsv.2018.09.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 09/20/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The study aimed to investigate the biologic effects of the 1470-nm endovenous laser (EVL), with a jacketed fiber and a radial fiber, during EVL ablation of an ex vivo dominant extrafascial tributary of the great saphenous vein in our in vitro model by histology and immunohistochemistry. METHODS Ten segments of the dominant extrafascial tributary of the great saphenous vein were harvested by a consultant vascular surgeon from patients during routine varicose vein surgery. Six segments were treated using an ex vivo model of our design by a 1470-nm EVL with a jacketed fiber. The other four segments were also treated by a 1470-nm EVL but with a radial-firing fiber. Each segment was split into five sections and treated at five different linear endovenous energy densities (LEEDs) at 10 W: 0, 20, 40, 60, and 80 J/cm. The veins were incubated and subsections collected at 6 and 24 hours after treatment. Subsections were immersed in buffered formalin and taken for histologic and immunohistochemical analysis. Histopathologic analysis was then performed. RESULTS Treatment with the radial fiber led to a pattern of damage that was more homogeneous than with the jacketed fiber, with no carbonization of tissue present. Significant transmural damage and necrosis were observed at LEEDs of 60 and 80 J/cm in both treatment groups. At the same LEEDs, p53 and caspase 3 analysis showed that transmural cell wall vein death (necrosis or apoptosis) occurred by 6 hours after treatment with both fibers. CONCLUSIONS There was a significant difference in the effects of treatment with a jacketed fiber and a radial fiber in EVL ablation in vitro. Although both fibers caused transmural vein wall cell death at similar LEEDs, the pattern of damage with the radial fiber was more homogeneous. There was no overtreatment of tissue in terms of carbonization after treatment with the radial fiber. Treatment with the jacketed fiber showed carbonization of tissue at the same LEEDs.
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Affiliation(s)
- Henry F Ashpitel
- Research Department, The Whiteley Clinic, Guildford, Surrey, United Kingdom; Department of Pathology and Infectious Diseases, School of Veterinary Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, United Kingdom
| | - Emma B Dabbs
- Research Department, The Whiteley Clinic, Guildford, Surrey, United Kingdom
| | - Francisco J Salguero
- Department of Pathology and Infectious Diseases, School of Veterinary Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, United Kingdom
| | - Jaya L Nemchand
- Research Department, The Whiteley Clinic, Guildford, Surrey, United Kingdom; Department of Pathology and Infectious Diseases, School of Veterinary Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, United Kingdom
| | - Roberto M La Ragione
- Department of Pathology and Infectious Diseases, School of Veterinary Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, United Kingdom
| | - Mark S Whiteley
- Research Department, The Whiteley Clinic, Guildford, Surrey, United Kingdom; Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, United Kingdom.
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Lurie F. Advanced Stages of Chronic Venous Disease: Evolution of Surgical Techniques and Advantages of Associated Medical Treatment. Adv Ther 2020; 37:6-12. [PMID: 31981107 PMCID: PMC7004425 DOI: 10.1007/s12325-019-01216-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Indexed: 11/23/2022]
Abstract
Contemporary interventional treatment of primary chronic venous disease (CVD) is mainly focused on the treatment of venous reflux. The long-term results of endovenous ablation (EVA) and high ligation and stripping are not different with respect to varicose vein recurrence, and this recurrence appears to be a manifestation of disease progression. Since inflammation is one of the key mechanisms of CVD development and progression, efforts to minimize inflammation and angiogenic potential in endovenous and surgical procedures are worthwhile. As techniques continue to be refined, surgery remains a valid option; in particular, the techniques that minimize trauma can be beneficial regarding recurrence. Medical treatment with venoactive drug therapy such as micronized purified flavonoid fraction (MPFF; Daflon®), which has proven clinical benefits in patients with CVD, can be used before and after EVA or surgery to minimize inflammation, pain, hemorrhage, and reduce CVD symptoms.
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Hassanin A, Aherne TM, Greene G, Boyle E, Egan B, Tierney S, Walsh SR, McHugh S, Aly S. A systematic review and meta-analysis of comparative studies comparing nonthermal versus thermal endovenous ablation in superficial venous incompetence. J Vasc Surg Venous Lymphat Disord 2019; 7:902-913.e3. [DOI: 10.1016/j.jvsv.2019.06.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 06/18/2019] [Indexed: 12/29/2022]
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Somasundaram SK, Weerasekera A, Worku D, Balasubramanian RK, Lister D, Valenti D, Rashid H, Singh Gambhir RP. Office Based Endovenous Radiofrequency Ablation of Truncal Veins: A Case for Moving Varicose Vein Treatment out of Operating Theatres. Eur J Vasc Endovasc Surg 2019; 58:410-414. [PMID: 31351830 DOI: 10.1016/j.ejvs.2019.05.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 05/11/2019] [Accepted: 05/23/2019] [Indexed: 01/27/2023]
Abstract
OBJECTIVES This study aims to assess the efficacy and outcomes at one year after office based endovenous radiofrequency ablation (OBEVRFA) as a standalone procedure for varicose veins under local anaesthesia. METHODS A retrospective study of prospectively collected data of all OBEVRFAs done in the vascular unit from April 2014 to June 2016 was performed. The demographics, clinical findings, initial venous duplex ultrasound (DUS) findings, the vein ablated, and immediate complications were recorded. Patients were reviewed at six weeks and again if necessary with or without a repeat DUS. The follow up period ranged from 12 to 38 months. Patients undergoing further procedures for symptomatic residual veins within the follow up period were recorded. Average cost and income were obtained from the hospital Patient Level Information and Costing Systems data. RESULTS A total of 523 limbs were listed for OBEVRFA during the study period. Ninety-four (18%) were cancelled on the day of surgery for various reasons. A total of 429 procedures in 394 patients were performed. There were 35 bilateral cases; each limb performed on separate occasions. The female to male ratio was 1.2:1. The median age was 54 years (range 17-88 years). The CEAP (Clinical, Etiologic, Anatomic and Pathophysiologic) classification was C2 to C3, 291 (68%); C4 to C5, 11 (26%), and C6, 26 (6%). Forty-seven (11%) recurrent varicose veins were treated. There were three recorded cases of endovenous heat induced thrombosis (EHIT). Sixty (14%) patients were lost to follow up. One hundred and five (29%) patients underwent repeat DUS for persistent symptoms. In the follow up period, only 86 patients (23%) needed further multiple avulsions. CONCLUSIONS OBEVRFAs of the truncal veins for the treatment of varicose veins is safe and effective and could be performed in all suitable patients to free up theatre capacity.
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Affiliation(s)
| | | | - Dawit Worku
- Department of Vascular Surgery, King's College Hospital, London, UK
| | | | - David Lister
- Department of Vascular Surgery, King's College Hospital, London, UK
| | - Domenico Valenti
- Department of Vascular Surgery, King's College Hospital, London, UK
| | - Hisham Rashid
- Department of Vascular Surgery, King's College Hospital, London, UK
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Sincos IR, Baptista APW, Coelho Neto F, Labropoulos N, Alledi LB, Marins EMD, Puggina J, Belczak SQ, Cardoso MG, Aun R. Prospective randomized trial comparing radiofrequency ablation and complete saphenous vein stripping in patients with mild to moderate chronic venous disease with a 3-year follow-up. EINSTEIN-SAO PAULO 2019; 17:eAO4526. [PMID: 31066792 PMCID: PMC6497181 DOI: 10.31744/einstein_journal/2019ao4526] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 12/04/2018] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To compare the use of the radiofrequency thermoablation of the saphenous vein with the ligation technique, and complete removal of the saphenous vein, from the saphenofemoral junction to the ankle. METHODS A total of 49 patients with chronic venous disease in the Comprehensive Classification System for Chronic Venous Disorders (CEAP) classes 2 to 4 for clinical signs, etiology, anatomic distribution and pathophysiology, were assessed at baseline, after 4 weeks, and after 1 year. The parameters assessed were complications, period of absence from activities, Venous Clinical Severity Score (VCSS) and quality of life scores according to Aberdeen Varicose Veins Questionnaire (AVVQ). They were re-examined 1 and 3 years after treatment to evaluate recurrence rates. RESULTS The success rate per limb (p=0.540), VCSS (p=0.636), AVVQ (p=0.163), and clinical complications were similar in the two treatment groups. Nevertheless, the radiofrequency thermoablation group had significant shorter length of hospital stay (0.69±0.47) and absence from activities (8.62±4.53), p<000.1. CONCLUSION Patients submitted to radiofrequency thermoablation had an occlusion rate, clinical recurrence and improvement in quality of life comparable to removal of the saphenous vein. However, these patients spent less time hospitalized and away from their daily activities during recovering.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Ricardo Aun
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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Woo HY, Kim SM, Kim D, Chung JK, Jung IM. Outcome of ClosureFAST radiofrequency ablation for large-diameter incompetent great saphenous vein. Ann Surg Treat Res 2019; 96:313-318. [PMID: 31183336 PMCID: PMC6543052 DOI: 10.4174/astr.2019.96.6.313] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/15/2019] [Accepted: 04/01/2019] [Indexed: 12/12/2022] Open
Abstract
Purpose There is limited data on the outcomes of radiofrequency ablation (RFA) for large diameter saphenous veins. This study aimed to determine whether the large-diameter great saphenous vein (GSV) affected closure rate, complications, and clinical and quality of life (QoL) improvement. Methods From January 2012 to September 2016, a total of 722 limbs were treated with ClosureFAST RFA in a single center. Patients were divided into 2 groups according to the vein diameter measured 3 cm below the saphenofemoral junction (group A ≤ 12 mm, group B > 12 mm). Vein closure was evaluated with duplex scan at 3–5 days, 1, 3, 6, and 12 months postoperatively. The incidence of complications, improvements in symptoms (measured by the Venous Clinical Severity Score [VCSS]) and QoL (measured by the Aberdeen Varicose Vein Symptom Severity Score [AVSS]) were evaluated. Results Groups consisted of 663 GSVs in group A (mean diameter, 6.00 ± 1.74 mm) and 59 in group B (mean diameter, 13.17 ± 1.28 mm). Vein closure rates at 12 months were 98.9% in group A and 100% in group B (P = 0.428). There was no significant difference in the incidence of complications. Both groups showed marked improvements in the VCSS and the AVSS with no significant differences. Conclusion For large-diameter veins, RFA showed comparable outcomes in terms of closure rate, complications, clinical and QoL improvements.
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Affiliation(s)
- Hye Young Woo
- Department of Surgery, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, Seoul, Korea
| | - Suh Min Kim
- Department of Surgery, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Daehwan Kim
- Department of Surgery, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, Seoul, Korea
| | - Jung Kee Chung
- Department of Surgery, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, Seoul, Korea
| | - In Mok Jung
- Department of Surgery, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, Seoul, Korea
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Mousa A, El Azzazi M, Elkalla MA. Different management options for primary varicose veins in females: A prospective study. Surg Open Sci 2019; 1:25-33. [PMID: 32754689 PMCID: PMC7391904 DOI: 10.1016/j.sopen.2019.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 03/26/2019] [Accepted: 05/02/2019] [Indexed: 02/08/2023] Open
Abstract
Background The aim of this study was to evaluate the long-term follow-up results of different management modalities in treating primary uncomplicated lower limb female varicosities. Methods A prospective study took place within a 3-year period from June 2010 until May 2012. Patients were divided into 3 groups: group I (n = 35) included those who underwent open surgical treatment. Group II (n = 25) included those who subjected to ultrasound-guided foam sclerotherapy (USGFS). While group III (n = 20) included those who treated with endovenous laser therapy (EVLT). The patients were followed up for 6 years. Results All selected patients were female aged from 35-62 years with a mean of 47 ± 7.6 years. Thirty-five patients (43.75%) were treated surgically by saphenofemoral junction disconnection (SFJD), and great saphenous vein (GSV) stripping; 25 patients (31.25%) with ultrasound-guided foam sclerotherapy and the remaining 20 patients (25%) were treated with endovenous laser therapy. A significant success rate of GSV ablation was obtained for the endovenous laser therapy treated group over the ultrasound-guided foam sclerotherapy treated patients (P = .023). There was no significant difference between the surgically treated group and those group treated with endovenous laser therapy (P = .85). Recurrence was observed following long-term follow-up after 6 years in 8.5% in group I, 36% in group II, and 10% in group III, respectively. Venous clinical severity score (VCSS) and health-related quality of life score (HRQOLS) improved significantly in all treated groups. Conclusions Long-term follow-up of patients with primary superficial varicosities among females is mandatory to elucidate the postoperative recurrence, especially those who underwent ultrasound-guided foam sclerotherapy. In addition to the observation of the development of newly formed varicosities in susceptible individuals which might develop later following long-term follow-up.
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Affiliation(s)
- Ahmed Mousa
- Department of Vascular & Endovascular Surgery, Al-Hussain University Hospital, Faculty of Medicine for Males, Al-Azhar University, Cairo, Egypt.,Division of Vascular & Endovascular Surgery, Department of Surgery, College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Mohamed El Azzazi
- Department of Diagnostic and Interventional Radiology, Al-Hussain University Hospital, Faculty of Medicine for Males, Al-Azhar University, Cairo, Egypt
| | - Mai A Elkalla
- Medical Student, Faculty of Medicine, Helwan University, Cairo, Egypt
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Wright TF, Brunetti GF, Kennedy P. Lidocaine safety after saphenous vein tumescent anesthesia. Phlebology 2019; 34:683-689. [PMID: 30871437 DOI: 10.1177/0268355519836834] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives For endovenous thermal ablation of the saphenous veins, tumescent lidocaine anesthesia is often used. Unfortunately, information is sparse on the pharmacokinetics of lidocaine absorption and its maximum safe dose. The aim of this study was to evaluate plasma concentration of lidocaine on 12 lead electrocardiograms (ECGs) and symptoms over time after the administration of tumescent lidocaine during endovenous thermal ablation procedures in healthy volunteers. Methods An observational study of symptoms, 12 lead ECGs, and serum lidocaine levels were obtained following the administration of either 15 mg/kg lidocaine or 35 mg/kg lidocaine in the perivenous saphenous space under ultrasound guidance. Blood was drawn at regular intervals in heparinized tubes and spun at 3000 r/min for 10 min. The plasma lidocaine levels were plotted vs. time for statistical comparisons. Results With the 35 mg/kg dose, four of 11 participants developed symptoms of lidocaine toxicity at 40 min, which resolved by 180 min. The 35 mg/kg dose resulted in a mean serum lidocaine peak of 2.55 µg/ml at 60 min. The 15 mg/kg dose did not result in any symptoms of lidocaine toxicity, and it resulted in a serum lidocaine plateau of 0.85 µg/ml at 180 min. No significant changes were seen on the 12-lead ECG after the administration of lidocaine at either dose. Conclusions The 15 mg/kg total lidocaine dose did not cause symptoms and appears to be a safe lidocaine dosage for tumescent anesthesia for saphenous endovenous thermal ablations. The 35 mg/kg lidocaine dose is associated with lidocaine toxicity. More study on the maximal safe dose of lidocaine for endovenous thermal ablations is needed.
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Affiliation(s)
| | - Giulietta F Brunetti
- College of Arts and Sciences and the Department of Mathematics, University of Missouri, Columbia, USA
| | - Patrick Kennedy
- Department of Otolaryngology - Head & Neck Surgery, University of Cincinnati, Cincinnati, USA
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Lin ZC, Loveland PM, Johnston RV, Bruce M, Weller CD. Subfascial endoscopic perforator surgery (SEPS) for treating venous leg ulcers. Cochrane Database Syst Rev 2019; 3:CD012164. [PMID: 30827037 PMCID: PMC6397791 DOI: 10.1002/14651858.cd012164.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Venous leg ulcers are complex, costly, and their prevalence is expected to increase as populations age. Venous congestion is a possible cause of venous leg ulcers, which subfascial endoscopic perforator surgery (SEPS) attempts to address by removing the connection between deep and superficial veins (perforator veins). The effectiveness of SEPS in the treatment of venous leg ulcers, however, is unclear. OBJECTIVES To assess the benefits and harms of subfascial endoscopic perforator surgery (SEPS) for the treatment of venous leg ulcers. SEARCH METHODS In March 2018 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. SELECTION CRITERIA We included randomised controlled trials (RCTs) of interventions that examined the use of SEPS independently or in combination with another intervention for the treatment of venous leg ulcers. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, extracted data, assessed risk of bias, and assessed the certainty of evidence using the GRADE approach. MAIN RESULTS We included four RCTs with a total of 322 participants. There were three different comparators: SEPS plus compression therapy versus compression therapy (two trials); SEPS versus the Linton procedure (a type of open surgery) (one trial); and SEPS plus saphenous surgery versus saphenous surgery (one trial). The age range of participants was 30 to 82, with an equal spread of male and female participants. All trials were conducted in hospital settings with varying durations of follow-up, from 18 months to 6 years. One trial included participants who had both healed and active ulcers, with the rest including only participants with active ulcers.There was the potential for reporting bias in all trials and performance bias and detection bias in three trials. Participants in the fourth trial received one of two surgical procedures, and this study was at low risk of performance bias and detection bias.SEPS + compression therapy versus compression therapy (2 studies; 208 participants)There may be an increase in the proportion of healed ulcers at 24 months in people treated with SEPS and compression therapy compared with compression therapy alone (risk ratio (RR) 1.17, 95% confidence interval (CI) 1.03 to 1.33; 1 study; 196 participants); low-certainty evidence (downgraded twice, once for risk of bias and once for imprecision).It is uncertain whether SEPS reduces the risk of ulcer recurrence at 24 months (RR 0.85, 95% CI 0.26 to 2.76; 2 studies; 208 participants); very low-certainty evidence (downgraded three times, twice for very serious imprecision and once for risk of bias).The included trials did not measure or report the following outcomes; time to complete healing, health-related quality of life (HRQOL), adverse events, pain, duration of hospitalisation, and district nursing care requirements.SEPS versus Linton approach (1 study; 39 participants)It is uncertain whether there is a difference in ulcer healing at 24 months between participants treated with SEPS and those treated with the Linton procedure (RR 0.95, 95% CI 0.83 to 1.09; 1 study; 39 participants); very low-certainty evidence (downgraded three times, twice for very serious imprecision and once for risk of bias).It is also uncertain whether there is a difference in risk of recurrence at 60 months: (RR 0.47, 95% CI 0.10 to 2.30; 1 study; 39 participants); very low-certainty evidence (downgraded three times, twice for very serious imprecision and once for risk of bias).The Linton procedure is possibly associated with more adverse events than SEPS (RR 0.04, 95% CI 0.00 to 0.60; 1 study; 39 participants); very low-certainty evidence (downgraded three times, twice for very serious imprecision and once for risk of bias).The outcomes time to complete healing, HRQOL, pain, duration of hospitalisation and district nursing care requirements were either not measured, reported or data were not available for analysis.SEPS + saphenous surgery versus saphenous surgery (1 study; 75 participants)It is uncertain whether there is a difference in ulcer healing at 12 months between participants treated with SEPS and saphenous surgery versus those treated with saphenous surgery alone (RR 0.96, 95% CI 0.64 to 1.43; 1 study; 22 participants); very low certainty evidence (downgraded three times, twice for very serious imprecision and once for high risk of reporting bias).It is also uncertain whether there is a difference in the risk of recurrence at 12 months: (RR 1.03, 95% CI 0.15 to 6.91; 1 study; 75 participants); very low certainty evidence (downgraded three times, twice for very serious imprecision and once for high risk of reporting bias).Finally, we are uncertain whether there is an increase in adverse events in the SEPS group (RR 2.05, 95% CI 0.86 to 4.90; 1 study; 75 participants); very low certainty evidence (downgraded three times, twice for very serious imprecision and once for high risk of reporting bias).The outcomes time to complete healing, HRQOL, serious adverse events, pain, duration of hospitalisation, and district nursing care requirements were either not measured, reported or data were not available for analysis. AUTHORS' CONCLUSIONS The role of SEPS for the treatment of venous leg ulcers remains uncertain. Only low or very low-certainty evidence was available for inclusion. Due to small sample sizes and risk of bias in the included studies, we were unable to determine the potential benefits and harms of SEPS for this purpose. Only four studies met our inclusion criteria, three were very small, and one was poorly reported. Further high-quality studies addressing the use of SEPS in venous leg ulcer management are likely to change the conclusions of this review.
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Affiliation(s)
- Zhiliang Caleb Lin
- The Alfred HospitalSurgical Services55 Commercial RoadMelbourneVictoriaAustralia3004
| | - Paula M Loveland
- Royal Melbourne HospitalDepartment of Medicine300 Grattan StreetParkvilleVictoriaAustralia3050
| | - Renea V Johnston
- Cabrini Institute and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash UniversityMonash Department of Clinical Epidemiology4 Drysdale StreetMelbourneVictoriaAustralia3144
| | - Michael Bruce
- Monash UniversityDepartment of Surgery, Cabrini HospitalCabrini Hospital177 Wattletree RoadMalvernVictoriaAustralia3144
| | - Carolina D Weller
- Monash UniversitySchool of Nursing and MidwiferyLevel 3, 35 Rainforest Walk, Clayton CampusWellington Road, ClaytonMelbourneVICAustralia3800
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Endovenous Photocoagulation Using a Diode Laser for Complicated Varicose Veins Related to Stasis Ulcers. Ann Plast Surg 2018; 82:S103-S107. [PMID: 30461460 DOI: 10.1097/sap.0000000000001726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The objective of this study was to assess the efficacy and safety of endovenous laser photocoagulation (EVLP) at a wavelength of 810 nm for treating complicated venous insufficiency associated with venous ulcers. MATERIALS AND METHODS A retrospective review of 110 patients with 180 legs having chronic venous insufficiencies associated with varicose veins treated over an 8-year period was conducted. Patients ranged from 16 to 80 years of age and included 85 women and 25 men. Of the 110 patients, 32 (29.10%) patients with 40 legs having varicose veins were defined as having complicated varicose veins associated with venous ulcers. All 32 patients received EVLP treatment using a diode laser. Complications were evaluated at 3 weeks (early), 6 weeks (late), and 6 months (final) after EVLP treatment. The primary efficacy and final outcome measurement were determined through quantitative assessment using Hach's and clinical, etiological, anatomical, and pathophysiological classification. Safety was evaluated for each treatment group by monitoring adverse effects. RESULTS Early complications were swelling, local paresthesia, pigmentation, minor superficial thermal injury, superficial phlebitis, and localized hematomas. All complications and ulcerations resolved completely within 2 weeks. No recurrence occurred after the study's 6-month follow-up period. Based on paired t test analysis, clinically significant differences in severity scores were discovered, which were based on Hach's classification before and after EVLP treatment at a wavelength of 810 nm. All patients achieved improvement from clinical, etiological, anatomical, and pathophysiological class C6 to C5. Permanent adverse effects were not observed. CONCLUSIONS Endovenous laser photocoagulation at the wavelength of 810 nm permitted the use of appropriate light doses for treating complicated varicose veins associated with venous ulcers and resulted in significant improvement in lesions.
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Inderhaug E, Schelp CH, Glambek I, Kristiansen IS. Cost-effectiveness analysis of five procedures for great saphenous vein reflux in a Norwegian healthcare setting or societal setting. SAGE Open Med 2018; 6:2050312118801709. [PMID: 30263121 PMCID: PMC6153534 DOI: 10.1177/2050312118801709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 08/27/2018] [Indexed: 01/22/2023] Open
Abstract
Objective The aim of this work was to estimate cost-effectiveness of five common procedures for varicose vein surgery (high ligation and stripping, radiofrequency ablation, endovenous laser ablation, steam vein sclerosis and cyanoacrylate glue) in a Norwegian setting from both a societal and a healthcare payer perspective. Design Cost-effectiveness analysis using decision tree modelling. Methods A structured literature search was conducted to estimate the clinical effectiveness and the rate of complications in the five methods. Data on costs and health-related quality of life associated with varicose vein disease were also collected. With the aid of an expert panel, a structured decision tree was developed. A 1-year perspective was modelled, and a variety of common complications were included. Monte Carlo simulation was used for probabilistic sensitivity analyses. Results The laser ablation strategy was the most cost-effective option from a societal perspective, with an incremental cost-effectiveness ratio of €8448 compared to a no-treatment alternative, and had a 42% probability of being cost-effective using the Norwegian willingness-to-pay threshold of €59,880. From a healthcare payer perspective, however, the steam vein sclerosis strategy was the most cost-effective with an incremental cost-effectiveness ratio of €4072 compared to a no-treatment alternative, and this strategy had a 50% probability of being cost-effective. Conclusion Results from this study did depend upon the perspective chosen for analyses. Although recent endovenous surgical procedures (including laser ablation and steam vein sclerosis) provide clinically effective treatment for advanced, symptomatic varicose vein disease, availability of high-level data is currently limiting the cost-effectiveness analyses.
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Affiliation(s)
- Eivind Inderhaug
- Surgical Department, Haraldsplass Deaconess University Hospital, Bergen, Norway
| | | | - Inge Glambek
- Surgical Department, Haraldsplass Deaconess University Hospital, Bergen, Norway
| | - Ivar S Kristiansen
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
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Porciunculla MDM, Leiderman DBD, Altenfeder R, Pereira CSB, Fioranelli A, Wolosker N, Castelli Junior V. Clinical, ultrasonographic and histological findings in varicose vein surgery. Rev Assoc Med Bras (1992) 2018; 64:729-735. [DOI: 10.1590/1806-9282.64.08.729] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 12/24/2017] [Indexed: 12/17/2022] Open
Abstract
SUMMARY OBJECTIVE This study aims to correlate the demographic data, different clinical degrees of chronic venous insufficiency (CEAP), ultrasound findings of saphenofemoral junction (SFJ) reflux, and anatomopathological findings of the proximal segment of the great saphenous vein (GSV) extracted from patients with primary chronic venous insufficiency (CVI) submitted to stripping of the great saphenous vein for the treatment of lower limb varicose. METHOD This is a prospective study of 84 patients (110 limbs) who were submitted to the stripping of the great saphenous vein for the treatment of varicose veins of the lower limbs, who were evaluated for CEAP clinical classification, the presence of reflux at the SFJ with Doppler ultrasonography, and histopathological changes. We study the relationship between the histopathological findings of the proximal GSV withdrawal of patients with CVI with a normal GSV control group from cadavers. RESULTS The mean age of the patients was higher in the advanced CEAPS categories when comparing C2 (46,1 years) with C4 (55,7 years) and C5-6(66 years), as well as C3 patients (50,6 years) with C5-6 patients. The normal GSV wall thickness (mean 839,7 micrometers) was significantly lower than in the saphenous varicose vein (mean 1609,7 micrometers). The correlational analysis of reflux in SFJ with clinical classification or histopathological finding did not show statistically significant findings. CONCLUSIONS The greater the age, the greater the clinical severity of the patients. The GSV wall is thicker in patients with lower limb varicose veins, but those histopathological changes are not correlated with the disease’s clinical severity or reflux in the SFJ on a Doppler ultrasound.
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Affiliation(s)
| | | | | | | | | | - Nelson Wolosker
- Hospital Israelita Albert Einstein, Brasil; University of São Paulo, Brasil
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Epstein D, Onida S, Bootun R, Ortega-Ortega M, Davies AH. Cost-Effectiveness of Current and Emerging Treatments of Varicose Veins. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2018; 21:911-920. [PMID: 30098668 DOI: 10.1016/j.jval.2018.01.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 01/16/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES To analyze the cost-effectiveness of current technologies (conservative care [CONS], high-ligation surgery [HL/S], ultrasound-guided foam sclerotherapy [UGFS], endovenous laser ablation [EVLA], and radiofrequency ablation [RFA]) and emerging technologies (mechanochemical ablation [MOCA] and cyanoacrylate glue occlusion [CAE]) for treatment of varicose veins over 5 years. METHODS A Markov decision model was constructed. Effectiveness was measured by re-intervention on the truncal vein, re-treatment of residual varicosities, and quality-adjusted life-years (QALYs) over 5 years. Model inputs were estimated from systematic review, the UK National Health Service unit costs, and manufacturers' list prices. Univariate and probabilistic sensitivity analyses were undertaken. RESULTS CONS has the lowest overall cost and quality of life per person over 5 years; HL/S, EVLA, RFA, and MOCA have on average similar costs and effectiveness; and CAE has the highest overall cost but is no more effective than other therapies. The incremental cost per QALY of RFA versus CONS was £5,148/QALY. Time to return to work or normal activities was significantly longer after HL/S than after other procedures. CONCLUSIONS At a threshold of £20,000/QALY, RFA was the treatment with highest median rank for net benefit, with MOCA second, EVLA third, HL/S fourth, CAE fifth, and CONS and UGFS sixth. Further evidence on effectiveness and health-related quality of life for MOCA and CAE is needed. At current prices, CAE is not a cost-effective option because it is costlier but has not been shown to be more effective than other options.
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Affiliation(s)
- David Epstein
- Department of Applied Economics, School of Economics and Business Studies, University of Granada, Granada, Spain
| | - Sarah Onida
- Academic Section of Vascular Surgery, Division of Surgery, Department of Surgery and Cancer, Imperial College London, London, UK; Charing Cross Hospital, London, UK
| | - Roshan Bootun
- Academic Section of Vascular Surgery, Division of Surgery, Department of Surgery and Cancer, Imperial College London, London, UK; Charing Cross Hospital, London, UK
| | - Marta Ortega-Ortega
- Department of Applied Economics, Public Economics and Political Economy, School of Economics and Business, Complutense University of Madrid, Madrid, Spain.
| | - Alun H Davies
- Academic Section of Vascular Surgery, Division of Surgery, Department of Surgery and Cancer, Imperial College London, London, UK; Charing Cross Hospital, London, UK
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de-Abreu GCG, Camargo OD, de-Abreu MFM, de-Aquino JLB. Ultrasound-guided foam sclerotherapy for severe chronic venous insufficiency. ACTA ACUST UNITED AC 2018; 44:511-520. [PMID: 29019582 DOI: 10.1590/0100-69912017005014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 06/22/2017] [Indexed: 11/21/2022]
Abstract
Chronic venous insufficiency is characterized by cutaneous alterations caused by venous hypertension; in severe forms, it progresses to lower limb ulcers. Lower limb varicose veins are the main cause of chronic venous insufficiency, and the classic treatment includes surgery and compressive therapy. Minimally invasive alternative treatments for varicose veins include new techniques such as venous thermal ablation using laser or radiofrequency. The use of different methods depends on clinical and anatomical factors. Ultrasound-guided foam sclerotherapy is the venous injection of sclerosing foam controlled by Doppler ultrasound. Sclerotherapy is very useful to treat varicose veins, and probably, is cheaper than other methods. However, until the present, it is the less studied method.
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de Mik SM, Stubenrouch FE, Legemate DA, Balm R, Ubbink DT. Treatment of varicose veins, international consensus on which major complications to discuss with the patient: A Delphi study. Phlebology 2018; 34:201-207. [PMID: 30012048 PMCID: PMC6431782 DOI: 10.1177/0268355518785482] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Objective To reach consensus on which complications of varicose vein treatments
physicians consider major or minor, in order to standardize the informed
consent procedure and improve shared decision-making. Methods Using the e-Delphi method, expert physicians from 10 countries were asked to
rate complications as “major” or “minor” on a 5-point Likert scale.
Reference articles from a Cochrane review on varicose veins were used to
compose the list of complications. Results Participating experts reached consensus on 12 major complications: allergic
reaction, cellulitis requiring intravenous antibiotics/intensive care, wound
infection requiring debridement, hemorrhage requiring blood
transfusion/surgical intervention, pulmonary embolism, skin necrosis
requiring surgery, arteriovenous fistula requiring repair, deep venous
thrombosis, lymphocele, thermal injury, transient ischemic attack/stroke,
and permanent discoloration. Conclusion An international consensus was reached about what physicians consider to be
major complications of varicose vein treatments. This consensus may assist
in standardizing the information physicians discuss with patients prior to
varicose vein treatment.
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Affiliation(s)
- Sylvana Ml de Mik
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | | | - Dink A Legemate
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - Ron Balm
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - Dirk T Ubbink
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
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Gloviczki P, Dalsing MC, Henke P, Lal BK, O'Donnell TF, Shortell CK, Huang Y, Markovic J, Wakefield TW. Report of the Society for Vascular Surgery and the American Venous Forum on the July 20, 2016 meeting of the Medicare Evidence Development and Coverage Advisory Committee panel on lower extremity chronic venous disease. J Vasc Surg Venous Lymphat Disord 2018; 5:378-398. [PMID: 28411706 DOI: 10.1016/j.jvsv.2017.02.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 02/04/2017] [Indexed: 12/21/2022]
Abstract
On July 20, 2016, a Medicare Evidence Development and Coverage Advisory Committee panel assessed the benefits and risks of currently used lower extremity chronic venous disease (CVD) treatments and their effects on health outcome of the American adult population. The main purpose of the meeting was to advise the Centers for Medicare & Medicaid Services on coverage determination for interventions used for treatment of CVD. A systematic review of the Agency for Healthcare Research and Quality was presented, followed by lectures of invited experts and a public hearing of representatives of professional societies and the industry. After discussing critical issues, the panel voted for key questions. This report summarizes the presented evidence to support recommendations of the Society for Vascular Surgery/American Venous Forum coalition and the presentations on selected discussion topics. These included important venous disease evidence gaps that have not been sufficiently addressed, venous disease treatment disparities and how they may affect the health outcomes of Medicare beneficiaries, and mechanisms that might be supported by the Centers for Medicare & Medicaid Services to improve the evidence base to optimize the care of patients with lower extremity CVD.
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Affiliation(s)
- Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.
| | - Michael C Dalsing
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Peter Henke
- Section of Vascular Surgery, University of Michigan, Ann Arbor, Mich
| | - Brajesh K Lal
- Department of Vascular Surgery, University of Maryland, Baltimore, Md
| | | | - Cynthia K Shortell
- Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Ying Huang
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Jovan Markovic
- Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
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