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Wiske C, Chervonski E, Rockman CB, Jacobowitz GR, Sadek M. Venous ablation procedures by provider type, including advanced practice providers. J Vasc Surg Venous Lymphat Disord 2024:101872. [PMID: 38518987 DOI: 10.1016/j.jvsv.2024.101872] [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: 12/14/2023] [Revised: 01/17/2024] [Accepted: 03/07/2024] [Indexed: 03/24/2024]
Abstract
OBJECTIVE The necessary training and certification of providers performing venous ablation has become a topic of debate in recent years. As venous interventions have shifted away from the hospital, the diversity of provider backgrounds has increased. We aimed to characterize superficial venous ablation practice patterns associated with different provider types. METHODS We analyzed Medicare Fee-For-Service data from 2010 through 2018. Procedures were identified by their Current Procedural Terminology code and included radiofrequency ablation, endovenous laser ablation, chemical adhesive ablation (ie, VenaSeal; Medtronic, Inc), and mechanochemical ablation. These procedures were correlated with the practitioner type to identify provider-specific trends. RESULTS Between 2010 and 2018, the number of ablation procedures increased by 107% from 114,197 to 236,558 per year (P < .001). Most procedures were performed by surgeons without vascular board certification (28.7%; 95% confidence interval [CI], 28.7%-28.8%), followed by vascular surgeons (27.1%; 95% CI, 27.0%-27.2%). Traditionally noninterventional specialties, which exclude surgeons, cardiologists, and interventional radiologists, accounted for 14.1% (95% CI, 14.1%-14.2%), and APPs accounted for 3.5% (95% CI, 3.4%-3.5%) of all ablation procedures during the study period. The total number of ablations increased by 9.7% annually (95% CI, 9.7%-9.8%), whereas procedures performed by APPs increased by 62.0% annually (95% CI, 61.6%-62.4%). There were significant differences between specialties in the use of nonthermal ablation modalities: APPs had the highest affinity for nonthermal ablation (odds ratio [OR], 2.60; 95% CI, 2.51-2.69). Cardiologists were also more likely to use nonthermal ablation (OR, 1.62; 95% CI, 1.59-1.66). Similarly, the uptake of new nonthermal technology (ie, chemical adhesives) was greatest among APPs (OR, 3.57; 95% CI, 3.43-3.70) and cardiologists (OR, 1.86; 95% CI, 1.81-1.91). Vascular surgeons were less likely to use nonthermal modalities (OR, 0.95; 95% CI, 0.92-0.97), including new nonthermal technology in the first year of availability (OR, 0.93; 95% CI, 0.90-0.95). CONCLUSIONS The use of venous procedures has increased rapidly during the past decade, particularly as endovenous ablations have been performed by a wider practitioner base, including APPs and noninterventionalists. Practice patterns differ by provider type, with APPs and cardiologists skewing more toward nonthermal modalities, including more rapid uptake of new nonthermal technology. Provider-specific biases for specific ablation modalities might reflect differences in training, skill set, the need for capital equipment, clinical privileges, or reimbursement. These data could help to inform training paradigms, the allocation of resources, and evaluation of appropriateness in a real-world setting.
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Affiliation(s)
- Clay Wiske
- Division of Vascular & Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY; Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA.
| | | | - Caron B Rockman
- Division of Vascular & Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Glenn R Jacobowitz
- Division of Vascular & Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Mikel Sadek
- Division of Vascular & Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
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Yılmaz S, Çakır Peköz B, Dincer N, Deniz S, Oğuzkurt L. Classification of reflux patterns in patients with great saphenous vein insufficiency and correlation with clinical severity. ACTA ACUST UNITED AC 2021; 27:219-224. [PMID: 33517254 DOI: 10.5152/dir.2021.19580] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE This study aims to establish a clinically applicable classification of reflux patterns in patients with great saphenous vein insufficiency and to evaluate the relationship between this classification, the demographics, and severity of clinical findings. METHODS This is a retrospective study from prospectively collected data of 503 patients who had the complaint of varicose vein. All patients had complete physical examination and their medical history was recorded. Lower limbs of all patients were examined with Doppler ultrasonography. A total of 787 limbs with great saphenous vein insufficiency were included in the analysis. The reflux patterns of great saphenous vein insufficiency were classified into 4 types as: type 1, great saphenous vein reflux without involvement of malleolar region and saphenofemoral junction (SFJ); type 2, reflux involving malleolar region with competent SFJ; type 3, reflux involving SFJ with competent malleolar region; and type 4, reflux involving both the SFJ and the malleolar region. We evaluated the association between the classification of great saphenous vein insufficiency and age, sex, body mass index (BMI), disease duration, clinical, etiological, anatomical and pathophysiological elements (CEAP) classification and venous clinical severity score (VCSS). RESULTS The mean age of the patients was 45.3±11.7 years, with a male-to-female ratio of 2:3. The most common reflux pattern in patients with great saphenous vein insufficiency was type 3 (48.9%), while 14.8% of patients had type 1, 10.4% had type 2, and 25.7% had type 4. Patients with type I reflux pattern were younger in age (p = 0.002), had lower BMI (p = 0.002), fewer number of children (p = 0.008), as well as milder clinical severity score (p = 0.002) compared to other reflux types. Duration of disease symptoms was not significantly correlated with the reflux patterns, but VCSS increased with the involvement of malleolar region as in type 2 compared to type 1 (2.82±1.67 vs. 2.74±2.31), and further increased with the involvement of SFJ as in type 3 (4.13±2.92 vs. 2.82±1.67). Patients with diffuse reflux pattern (type 4) had the most severe clinical presentation (4.59±2.9). CONCLUSION We developed a clinically applicable classification of reflux patterns in patients with great saphenous vein insufficiency based on the involvement of malleolar region and/or SFJ. We showed an association between weight, BMI, VCSS, CEAP classification and the extent of insufficiency.
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Affiliation(s)
- Sezen Yılmaz
- School of Medicine,Koç University, Istanbul, Turkey
| | - Burçak Çakır Peköz
- University of Health Sciences, Adana Health Practices and Research Center, Adana, Turkey
| | - Neris Dincer
- School of Medicine,Koç University, Istanbul, Turkey
| | - Sinan Deniz
- Department of Diagnostic and Interventional Radiology, Koç University Hospital, Istanbul, Turkey
| | - Levent Oğuzkurt
- Department of Diagnostic and Interventional Radiology, Koç University Hospital, Istanbul, Turkey
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Barnat N, Grisey A, Lecuelle B, Anquez J, Gerold B, Yon S, Aubry JF. Noninvasive vascular occlusion with HIFU for venous insufficiency treatment: preclinical feasibility experience in rabbits. ACTA ACUST UNITED AC 2019; 64:025003. [DOI: 10.1088/1361-6560/aaf58d] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Arslan Ü, Çalık E, Tort M, Yıldız Z, Tekin Aİ, Limandal HK, Kaygın MA, Dağ Ö, Erkut B. More Successful Results with Less Energy in Endovenous Laser Ablation Treatment: Long-term Comparison of Bare-tip Fiber 980 nm Laser and Radial-tip Fiber 1470 nm Laser Application. Ann Vasc Surg 2017. [PMID: 28647634 DOI: 10.1016/j.avsg.2017.06.042] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Varices and venous insufficiency are common and serious health problems in the general population which affect the quality of life. Endothermal treatment of the great saphenous vein has become the first line of treatment for superficial venous reflux, and the endovenous laser ablation (EVLA) method has been widely accepted all over the world. In this method, ablation is provided by a laser fiber inserted into the lumen of the vein. Initially, the fibers were 810 nm, but today the fibers are usually 940, 980, or 1470 nm. METHODS The study included 400 patients (419 procedures) who were diagnosed with venous insufficiency and underwent 980 and 1470 nm EVLA. Patients were followed up for 48 months. A 980-nm bare-tip laser catheter in Group A and a 1470-nm radial-tip laser catheter in Group B were inserted until they were 2 cm below the saphenofemoral junction. An EVLA catheter was drawn slowly at the rate of 1-3 cm/sec (2.08 ± 0.6). The energy applied to the saphenous vein was 60-120 J/cm (84.65 ± 13.03) and 45-120 J/cm (76.95 ± 15.06) in Group A and Group B, respectively (P < 0.001), with 15 W in the continuous mode. Follow-up visits included a physical examination and Doppler ultrasonography performed at the following time points: day 1, week 1, and months 1, 6, 12, 24, 36, and 48. Saphenous vein occlusion rates and postprocedure saphenous vein diameters were evaluated at each follow-up visit. Pain levels were evaluated using the Wong-Baker FACES® pain scale (0-10). Postoperative complications were recorded. RESULTS Group A (980 nm laser) consisted of 200 patients with a mean age of 37.84 ± 12.2 years. Group B (1470 nm laser) consisted of 200 patients with a mean age of 38.38 ± 12.1 years. The mean duration of the procedure was 32.2 ± 9.7 min in Group A and 31.7 ± 8.8 min in Group B, respectively (P = 0.47). Induration, ecchymosis, and paresthesia rates were significantly higher in the bare-tip laser group. The most important complication, deep vein thrombosis, was observed in 4 patients in Group A. Recanalization rates were found to be increased by prolonged follow-up periods. At the 48-month follow-up, this rate was 15.9% in Group A and 8.3% in Group B (P = 0.017). This rate showed that the 1470-nm wavelength laser treatment was more successful in Group B than in Group A over the long term. CONCLUSIONS Both the 980 and 1470 nm wavelength laser-assisted EVLA procedures appear to be effective in treating saphenous vein insufficiency. The 1470-nm radial-tip fiber is preferred due to lower energy levels, lower complication rates, early return to daily life, and the successful long-term occlusion rate.
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Affiliation(s)
- Ümit Arslan
- Cardiovascular Surgery Unit, Erzurum Regional Training and Research Hospital, Erzurum, Turkey.
| | - Eyüpserhat Çalık
- Cardiovascular Surgery Unit, Erzurum Regional Training and Research Hospital, Erzurum, Turkey
| | - Mehmet Tort
- Cardiovascular Surgery Unit, Erzurum Regional Training and Research Hospital, Erzurum, Turkey
| | - Ziya Yıldız
- Cardiovascular Surgery Unit, Erzurum Regional Training and Research Hospital, Erzurum, Turkey
| | - Ali İhsan Tekin
- Cardiovascular Surgery Unit, Kayseri Regional Training and Research Hospital, Erzurum, Turkey
| | - Hüsnü Kamil Limandal
- Cardiovascular Surgery Unit, Erzurum Regional Training and Research Hospital, Erzurum, Turkey
| | - Mehmet Ali Kaygın
- Cardiovascular Surgery Unit, Erzurum Regional Training and Research Hospital, Erzurum, Turkey
| | - Özgür Dağ
- Cardiovascular Surgery Unit, Erzurum Regional Training and Research Hospital, Erzurum, Turkey
| | - Bilgehan Erkut
- Cardiovascular Surgery Unit, Erzurum Regional Training and Research Hospital, Erzurum, Turkey
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Nguyen T, Bergan J, Min R, Morrison N, Zimmet S. Curriculum of the American College of Phlebology. Phlebology 2016. [DOI: 10.1258/026835506779613534] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- T Nguyen
- Dermatology, Mohs Micrographic & Dermatologic surgery, Procedural Dermatology, University of Texas-MD Anderson Cancer Center, Houston, TX, USA
| | - J Bergan
- Department of Surgery, UCSD School of Medicine, San Diego, CA, USA
| | - R Min
- Department of Radiology, Cornell University School of Medicine, New York, NY, USA
| | - N Morrison
- Morrison Vein Institute, Scottsdale AZ, USA
| | - S Zimmet
- Zimmet Vein and Dermatology, Austin, TX, USA
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Salles-Cunha SX, Rajasinghe H, Dosick SM, Gale SS, Seiwert A, Jones L, Beebe HG, Comerota AJ. Fate of Great Saphenous Vein After Radio-Frequency Ablation: Detailed Ultrasound Imaging. Vasc Endovascular Surg 2016; 38:339-44. [PMID: 15306951 DOI: 10.1177/153857440403800405] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Radio-frequency ablation (RFA) of the great saphenous vein (GSV) is an endovascular alternative to stripping. To determine long-term effectiveness, the fate of GSV treated for valvular insufficiency with RFA was evaluated in detail with ultrasound imaging (US). One hundred lower extremities were examined with high-resolution color flow US, an average of 8 months after RFA treatment of an incompetent GSV. For every cm of the RFA-treated segment, the US observation was classified as follows: absent, occluded, or recanalized. Lengths of vein segments in each class were added and percentages of absent, occluded, or recanalized segments were calculated. Five groups were identified. Group I (n=15): segment of treated GSV was absent. Group II (n=4): segment of treated GSV was visualized and occluded (these vein segments had no flow and were shrunk and “fibrotic” or thrombosed without clear evidence of significant shrinkage). Group III (n=1): segment of treated GSV was recanalized. Group IV (n= 27): segment of treated GSV was obstructed (absent or occluded). Group V (n=53): segment of treated GSV was partially recanalized, on average being 53% absent, 32% occluded, and 15% recanalized. Maximum recanalization was 50% of treated segment. RFA was successful in obliterating all of the GSV treated segment in 46% of veins (groups I, 15%, plus II, 4%, plus IV, 27%) and obliterated more than half of the treated vein segment in 53% of the cases (group V). A dynamic process of recanalization and thrombosis warrants further evaluation to determine if and how a collateral network may develop.
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Cicek MC, Cicek OF, Lafci G, Uzun A. Comparison of cutaneous nerve injury and vessel disruption complications following saphenous vein stripping using big or small olive heads. Pak J Med Sci 2016; 32:626-9. [PMID: 27375703 PMCID: PMC4928412 DOI: 10.12669/pjms.323.10017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To compare the nerve injury and vessel disruption complicaitons in patients undergoing saphenous vein stripping using olive heads of different sizes. Methods: Big olive heads were used in group A (n=50) and small olive heads were used in group B (n=50) from the ankle to the groin; in group C (n=50), the vein was stripped in two sections; in an upward fashion by stripping the distal portion from the ankle to the level of the knee using small olive heads and by stripping the proximal portion from the knee to the level of the groin using big olive heads. Results: Six months after the operation, nerve injury symptoms were identified in 26%, 4%, 6% of patients in groups A, B, and C respectively. Vessel disruption occurred 2% in group A, 32% in group B, and 4% in group C. Both vessel disruption and nerve injury complications of group C were significantly lower than group A and B (p<0.001). Conclusion: Saphenous stripping using big olive heads for the proximal portion from the groin down to the level of the knee and using small olive heads for the distal portion from the knee to the level of the ankle is the alternative method which results in minimal nerve injury and vessel disruption.
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Affiliation(s)
- Mustafa Cuneyt Cicek
- Mustafa Cuneyt Cicek, Department of Cardiovascular Surgery, Konya Numune State Hospital, Konya, Turkey
| | - Omer Faruk Cicek
- Omer Faruk Cicek, Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Education and Research Hospital, Ankara, Turkey
| | - Gokhan Lafci
- Gokhan Lafci, Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Education and Research Hospital, Ankara, Turkey
| | - Alper Uzun
- Alper Uzun, Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Education and Research Hospital, Ankara, Turkey
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Zhan HT, Bush RL. A review of the current management and treatment options for superficial venous insufficiency. World J Surg 2015; 38:2580-8. [PMID: 24803347 DOI: 10.1007/s00268-014-2621-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The recognition of lower extremity venous disease as a significant cause of morbidity and lower quality of life, afflicting up to 25 % of Western populations, has led to rapid and drastic improvements in treatment options as well as an increasing awareness of the disease. Superficial venous disease, a frequent medical problem encountered in clinical practices, is now a common reason for referral to providers offering a spectrum of interventions. Venous guidelines have been set forth by the American Venous Forum and Society for Vascular Surgery covering simple spider veins to chronic venous ulcerations. (Gloviczki et al. J Vas Surg 53:2S-48S, 2011) This review provides an overview of the modern management of varicose veins and venous insufficiency.
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Affiliation(s)
- Henry T Zhan
- Texas A&M Health Science Center, MS 1359, 8447 State Highway 47, HPEB 3064, Bryan, TX, 77807-3260, USA
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Kutas B, Ozdemir F, Tezcan O, Gunes T, Erkoc K, Altin F, Karahan O. Does the direction of tumescent solution delivery matter in endovenous laser ablation of the great saphenous vein? Ther Adv Cardiovasc Dis 2015; 9:397-402. [DOI: 10.1177/1753944715599729] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: The aim of this study was to compare the two different directions of tumescent solution delivery (from distal to proximal knee to the saphenofemoral junction [SFJ] or proximal to distal SFJ to the knee) in terms of differences in tumescent volume, number of punctures, and pain and comfort scores of patients. Methods: A total of 100 patients were treated with endovenous laser ablation (EVLA) under local anesthesia between August 2013 and October 2013. These 100 patients were divided into two groups. In group 1, tumescent solution was delivered in a proximal to distal direction. In group 2, the tumescent solution was delivered in a distal to proximal direction. In each group, the great saphenous vein (GSV) diameter, delivered total energy, treated GSV length, delivered tumescent volume, number of punctures, and pain and comfort scores were recorded for each patient. Results: All patients were treated unilaterally. EVLA was performed with 100% technical success in all patients. There was no difference statistically between group 1 and group 2 according to GSV diameter, delivered total energy, and treated GSV length. Average tumescent volume, number of punctures, and pain scores in group 2 were lower than in group 1 ( p = 0.0001; p < 0.05). Also, the average comfort score was higher in group 2 than in group 1 ( p = 0.0001; p < 0.05). Conclusions: We believe that delivering the tumescent solution in a distal to proximal direction increases the comfort of both patient and surgeon with lower tumescent volume during the EVLA of the GSV.
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Affiliation(s)
- Baris Kutas
- Department of Cardiovascular Surgery, Diyarbakır Training and Research Hospital, Diyarbakir, Turkey
| | - Ferit Ozdemir
- Department of Cardiovascular Surgery, Diyarbakır Training and Research Hospital, Diyarbakir, Turkey
| | - Orhan Tezcan
- Department of Cardiovascular Surgery, Medical School of Dicle University, Diyarbakir, Turkey
| | - Tevfik Gunes
- Department of Cardiovascular Surgery, Diyarbakır Training and Research Hospital, Diyarbakir, Turkey
| | - Kamuran Erkoc
- Department of Cardiovascular Surgery, Diyarbakır Training and Research Hospital, Diyarbakir, Turkey
| | - Fırat Altin
- Department of Cardiovascular Surgery, Mehmet Akif Ersoy Training and Research Hospital, Istanbul, Turkey
| | - Oguz Karahan
- Department of Cardiovascular Surgery, Medical School of Dicle University, Diyarbakir 21080, Turkey
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Kayssi A, Pope M, Vucemilo I, Werneck C. Endovenous radiofrequency ablation for the treatment of varicose veins. Can J Surg 2015; 58:85-6. [PMID: 25799244 DOI: 10.1503/cjs.014914] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Varicose veins are a common condition that can be treated surgically. Available operative modalities include saphenous venous ligation and stripping, phlebectomy, endovenous laser therapy and radiofrequency ablation. Radiofrequency ablation is the newest of these technologies, and to our knowledge our group was the first to use it in Canada. Our experience suggests that it is a safe and effective treatment for varicose veins, with high levels of patient satisfaction reported at short-term follow-up. More studies are needed to assess long-term effectiveness and compare the various available treatment options for varicose veins.
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Affiliation(s)
- Ahmed Kayssi
- The Division of Vascular Surgery, Trillium Health Partners, University of Toronto, Mississauga, Ont
| | - Marc Pope
- The Division of Vascular Surgery, Trillium Health Partners, University of Toronto, Mississauga, Ont
| | - Ivica Vucemilo
- The Division of Vascular Surgery, Trillium Health Partners, University of Toronto, Mississauga, Ont
| | - Christiane Werneck
- The Division of Vascular Surgery, Trillium Health Partners, University of Toronto, Mississauga, Ont
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Nesbitt C, Bedenis R, Bhattacharya V, Stansby G. Endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus open surgery for great saphenous vein varices. Cochrane Database Syst Rev 2014:CD005624. [PMID: 25075589 DOI: 10.1002/14651858.cd005624.pub3] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Minimally invasive techniques to treat great saphenous varicose veins include ultrasound-guided foam sclerotherapy (UGFS), radiofrequency ablation (RFA) and endovenous laser therapy (EVLT). Compared with flush saphenofemoral ligation with stripping, also referred to as open surgery or high ligation and stripping (HL/S), proposed benefits include fewer complications, quicker return to work, improved quality of life (QoL) scores, reduced need for general anaesthesia and equivalent recurrence rates. This is an update of a review first published in 2011. OBJECTIVES To determine whether endovenous ablation (radiofrequency and laser) and foam sclerotherapy have any advantages or disadvantages in comparison with open surgical saphenofemoral ligation and stripping of great saphenous vein varices. SEARCH METHODS For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched January 2014) and CENTRAL (2013, Issue 12). Clinical trials databases were also searched for details of ongoing or unpublished studies. SELECTION CRITERIA All randomised controlled trials (RCTs) of UGFS, EVLT, RFA and HL/S were considered for inclusion. Primary outcomes were recurrent varicosities, recanalisation, neovascularisation, technical procedure failure, patient QoL scores and associated complications. DATA COLLECTION AND ANALYSIS CN and RB independently reviewed, assessed and selected trials which met the inclusion criteria. CN and RB extracted data and used the Cochrane Collaboration's tool for assessing risk of bias. CN and RB contacted trial authors to clarify details as needed. MAIN RESULTS For this update, eight additional studies were included making a total of 13 included studies with a combined total of 3081 randomised patients. Three studies compared UGFS with surgery, eight compared EVLT with surgery and five compared RFA with surgery (two studies had two or more comparisons with surgery). Study quality, evaluated through the six domains of risk of bias, was generally moderate for all included studies, however no study blinded participants, researchers and clinicians or outcome assessors. Also, nearly all included studies had other sources of bias. The overall quality of the evidence was moderate due to the variations in the reporting of results, which limited meaningful meta-analyses for the majority of proposed outcome measures. For the comparison UGFS versus surgery, the findings may have indicated no difference in the rate of recurrences in the surgical group when measured by clinicians, and no difference between the groups for symptomatic recurrence (odds ratio (OR) 1.74, 95% confidence interval (CI) 0.97 to 3.12; P = 0.06 and OR 1.28, 95% CI 0.66 to 2.49, respectively). Recanalisation and neovascularisation were only evaluated in a single study. Recanalisation at < 4 months had an OR of 0.66 (95% CI 0.20 to 2.12), recanalisation > 4 months an OR of 5.05 (95% CI 1.67 to 15.28) and for neovascularisation an OR of 0.05 (95% CI 0.00 to 0.94). There was no difference in the rate of technical failure between the two groups (OR 0.44, 95% CI 0.12 to 1.57). For EVLT versus surgery, there were no differences between the treatment groups for either clinician noted or symptomatic recurrence (OR 0.72, 95% CI 0.43 to 1.22; P = 0.22 and OR 0.87, 95% CI 0.47 to 1.62; P = 0.67, respectively). Both early and late recanalisation were no different between the two treatment groups (OR 1.05, 95% CI 0.09 to 12.77; P = 0.97 and OR 4.14, 95% CI 0.76 to 22.65; P = 0.10). Neovascularisation and technical failure were both statistically reduced in the laser treatment group (OR 0.05, 95% CI 0.01 to 0.22; P < 0.0001 and OR 0.29, 95% CI 0.14 to 0.60; P = 0.0009, respectively). Long-term (five-year) outcomes were evaluated in one study so no association could be derived,but it appeared that EVLT and surgery maintained similar findings. Comparing RFA versus surgery, there were no differences in clinician noted recurrence (OR 0.82, 95% CI 0.49 to 1.39; P = 0.47); symptomatic noted recurrence was only evaluated in a single study. There were also no differences between the treatment groups for recanalisation (early or late) (OR 0.68, 95% CI 0.01 to 81.18; P = 0.87 and OR 1.09, 95% CI 0.39 to 3.04; P = 0.87, respectively), neovascularisation (OR 0.31, 95% CI 0.06 to 1.65; P = 0.17) or technical failure (OR 0.82, 95% CI 0.07 to 10.10; P = 0.88).QoL scores, operative complications and pain were not amenable to meta-analysis, however quality of life generally increased similarly in all treatment groups and complications were generally low, especially major complications. Pain reporting varied greatly between the studies but in general pain was similar between the treatment groups. AUTHORS' CONCLUSIONS Currently available clinical trial evidence suggests that UGFS, EVLT and RFA are at least as effective as surgery in the treatment of great saphenous varicose veins. Due to large incompatibilities between trials and different time point measurements for outcomes, the evidence is lacking in robustness. Further randomised trials are needed, which should aim to report and analyse results in a congruent manner to facilitate future meta-analysis.
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Affiliation(s)
- Craig Nesbitt
- Sunderland Royal Hospital, Kayll Road, Sunderland, UK
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Golbasi I, Turkay C, Erbasan O, Kemaloğlu C, Sanli S, Turkay M, Bayezid Ö. Endovenous laser with miniphlebectomy for treatment of varicose veins and effect of different levels of laser energy on recanalization. A single center experience. Lasers Med Sci 2014; 30:103-8. [PMID: 24993399 DOI: 10.1007/s10103-014-1626-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 06/25/2014] [Indexed: 10/25/2022]
Abstract
Varicose veins, associated with great saphenous vein (GSV) incompetence, are traditionally treated with conventional surgery. In recent years, minimally invasive alternatives to surgical treatment such as the endovenous laser ablation (EVLA) and radiofrequency (RF) ablation have been developed with promising results. Residual varicose veins following EVLA, regress untouched, or phlebectomy or foam sclerotherapy can be concomitantly performed. The aim of the present study was to investigate the safety and efficacy of EVLA with different levels of laser energy in patients with varicose veins secondary to saphenous vein reflux. From February 2006 to August 2011, 740 EVLA, usually with concomitant miniphlebectomies, were performed in 552 patients. A total of 665 GSV, 53 small saphenous veins (SSV), and 22 both GSV and SSV were treated with EVLA under duplex USG. At 84 patients, bilateral intervention is made. In addition, miniphlebectomy was performed in 540 patients. A duplex ultrasound (US) is performed to patients preoccupying chronic venous insufficiency (with visible varicose veins, ankle edema, skin changes, or ulcer). Saphenous vein incompetence was diagnosed with saphenofemoral, saphenopopliteal, or truncal vein reflux in response to manual compression and release with patient standing. The procedures were performed under local anesthesia with light sedation or spinal anesthesia. Endovenous 980-nm diode laser source was used at a continuous mode. The mean energy applied per length of GSV during the treatment was 77.5 ± 17.0 J (range 60-100 J/cm). An US evaluation was performed at first week of the procedure. Follow-up evaluation and duplex US scanning were performed at 1 and 6 months, and at 1 and 2 years to assess treatment efficacy and adverse reactions. Average follow-up period was 32 ± 4 months (3-55 months). There were one patient with infection and two patients with thrombus extension into the femoral vein after EVLA. Overall occlusion rate was 95%. No post-procedural deep venous thrombosis or pulmonary embolism occurred. Laser energy, less than 80 J/cm, was significantly associated with increased recanalization of saphenous vein, among the other energy levels. EVLA seems a good alternative to surgery by the application of energy of not less than 80 J/cm. It is both safe and effective. It is a well-tolerated procedure with rare and relatively minor complications.
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Affiliation(s)
- Ilhan Golbasi
- Cardiovascular Surgery, Akdeniz University, Antalya, Turkey,
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Sadek M, Kabnick LS, Rockman CB, Berland TL, Zhou D, Chasin C, Jacobowitz GR, Adelman MA. Increasing ablation distance peripheral to the saphenofemoral junction may result in a diminished rate of endothermal heat-induced thrombosis. J Vasc Surg Venous Lymphat Disord 2013; 1:257-62. [DOI: 10.1016/j.jvsv.2013.01.002] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Revised: 12/21/2012] [Accepted: 01/08/2013] [Indexed: 11/17/2022]
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Dumantepe M, Tarhan A, Yurdakul I, Özler A. Endovenous Laser Ablation of Incompetent Perforating Veins with 1470 nm, 400 μm Radial Fiber. Photomed Laser Surg 2012; 30:672-7. [DOI: 10.1089/pho.2012.3351] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Mert Dumantepe
- Department of Cardiovascular Surgery, Memorial Atasehir Hospital Istanbul, Turkey
| | - Arif Tarhan
- Department of Cardiovascular Surgery, Memorial Atasehir Hospital Istanbul, Turkey
| | - Ilhan Yurdakul
- Department of Cardiovascular Surgery, Memorial Atasehir Hospital Istanbul, Turkey
| | - Azmi Özler
- Department of Cardiovascular Surgery, Memorial Atasehir Hospital Istanbul, Turkey
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Nesbitt C, Eifell RK, Coyne P, Badri H, Bhattacharya V, Stansby G. Endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus conventional surgery for great saphenous vein varices. Cochrane Database Syst Rev 2011:CD005624. [PMID: 21975750 DOI: 10.1002/14651858.cd005624.pub2] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Minimally invasive techniques to treat great saphenous varicose veins include ultrasound-guided foam sclerotherapy (USGFS), radiofrequency ablation (RFA) and endovenous laser therapy (EVLT). Compared with conventional surgery (high ligation and stripping (HL/S)), proposed benefits include fewer complications, quicker return to work, improved quality of life (QoL) scores, reduced need for general anaesthesia and equivalent recurrence rates. OBJECTIVES To review available randomised controlled clinical trials (RCT) data comparing USGFS, RFA, EVLT to HL/S for the treatment of great saphenous varicose veins. SEARCH STRATEGY The Cochrane Peripheral Vascular Diseases (PVD) Group searched their Specialised Register (July 2010) and CENTRAL (The Cochrane Library 2010, Issue 3). In addition the authors performed a search of EMBASE (July 2010). Manufacturers of EVLT, RFA and sclerosant equipment were contacted for trial data. SELECTION CRITERIA All RCTs of EVLT, RFA, USGFS and HL/S were considered for inclusion. Primary outcomes were recurrent varicosities, recanalisation, neovascularisation, technical procedure failure or need for re-intervention, patient quality of life (QoL) scores and associated complications. Secondary outcomes were type of anaesthetic, procedure duration, hospital stay and cost. DATA COLLECTION AND ANALYSIS CN, RE, VB, PC, HB and GS independently reviewed, assessed and selected trials which met the inclusion criteria. CN and RE extracted data. The Cochrane Collaboration's tool for assessing risk of bias was used. CN contacted trial authors to clarify details. MAIN RESULTS Thirteen reports from five studies with a combined total of 450 patients were included. Rates of recanalisation were higher following EVLT compared with HL/S, both early (within four months) (5/149 versus 0/100; odds ratio (OR) 3.83, 95% confidence interval (CI) 0.45 to 32.64) and late recanalisation (after four months) (9/118 versus 1/80; OR 2.97 95% CI 0.52 to 16.98), although these results were not statistically significant. Technical failure rates favoured EVLT over HL/S (1/149 versus 6/100; OR 0.12, 95% CI 0.02 to 0.75). Recurrence following RFA showed no difference when compared with surgery. Recanalisation within four months was observed more frequently following RFA compared with HL/S although not statistically significant (4/105 versus 0/88; OR 7.86, 95% CI 0.41 to 151.28); after four months no difference was observed. Neovascularisation was observed more frequently following HL/S compared with RFA, but again this was not statistically significant (3/42 versus 8/51; OR 0.39, 95% CI 0.09 to 1.63). Technical failure was observed less frequently following RFA compared with HL/S although this was not statistically significant (2/106 versus 7/96; OR 0.48, 95% CI 0.01 to 34.25). No randomised clinical trials comparing HL/S versus USGFS met our study inclusion criteria. QoL scores and operative complications were not amenable to meta-analysis. AUTHORS' CONCLUSIONS Currently available clinical trial evidence suggests RFA and EVLT are at least as effective as surgery in the treatment of great saphenous varicose veins. There are insufficient data to comment on USGFS. Further randomised trials are needed. We should aim to report and analyse results in a congruent manner to facilitate future meta-analysis.
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Affiliation(s)
- Craig Nesbitt
- Department of Vascular Surgery, Queen Elizabeth Hospital, Queen Elizabeth Avenue, Sheriff Hill, Gateshead, Tyne and Wear, UK, NE9 6SX
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Corcos L, Pontello D, DE Anna D, Dini S, Spina T, Barucchello V, Carrer F, Elezi B, DI Benedetto F. Endovenous 808-nm diode laser occlusion of perforating veins and varicose collaterals: a prospective study of 482 limbs. Dermatol Surg 2011; 37:1486-98. [PMID: 21883649 DOI: 10.1111/j.1524-4725.2011.02133.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Endovenous laser ablation (EVLA) was performed in the treatment of great and small saphenous veins (GSVs, SSVs), perforating veins (PVs), and varicose collaterals (VCs). OBJECTIVE To verify the outcome in PVs and VCs. MATERIALS AND METHODS Four hundred eighty-two limbs of 306 patients were studied. EVLA was performed on 167 GSVs, 52 SSVs, and 534 PVs of 303 limbs and on VCs of 467 limbs; 133 GSVs were stripped, 300 of saphenofemoral junctions (SFJs) and 45 saphenopopliteal junctions (SPJs) were interrupted. Limbs were selected using duplex ultrasound examination and photographs; PVs-VCs diameter (<4 mm) and VC length were measured. EVLA was performed using a 808-nm diode laser, 0.6-mm fibers, continuous emission, 4 to 10 W, and 10 to 20 J/cm. Follow-up on 467 limbs occurred over a mean 27.5 months (range 3 months to 6 years); 98 limbs were followed up for longer than 4 years. RESULTS Operating time range from 10 to 30 minutes per limb. Blood vaporization, thrombosis, fibrosis, and atrophy prevailed in PVs and in the large VCs (>4 mm) and massive coagulation in the smaller (<4 mm). High rate of occlusion was seen, with different rates of patent PV-VC mainly in diameter >6 mm. Thirty-nine out of 511 patent PVs (7.6%) and 96 out of 778 VCs (12-13%) were re-treated using EVLA or foam sclerotherapy. Minor complications occurred in 88 of the 778 (11%). CONCLUSIONS EVLA of PVs and VCs is effective and faster than surgery in 2- to 6-mm PVs and VCs using an 808-nm diode laser.
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Affiliation(s)
- Leonardo Corcos
- Department of Surgical Sciences, Postgraduate School of Vascular Surgery, University of Udine, Udine, Italy.
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Ergenoglu MU, Sayin MM, Kucukaksu DS. Endovenous laser ablation with 980-nm diode laser: early and midterm results. Photomed Laser Surg 2011; 29:691-7. [PMID: 21668376 DOI: 10.1089/pho.2010.2972] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE Endovenous laser ablation (EVLA) is an efficient method to treat incompetent great saphenous veins (GSV) with high occlusion rates. The aim of this prospective study is to demonstrate the treatment outcomes of EVLA of incompetent GSV with a 980-nm diode laser in an ambulatory setting. BACKGROUND DATA EVLA of the incompetent GSV with a 980-nm diode laser appears to be an extremely safe technique. There are several treatment alternatives available. Among the emerging techniques, EVLA is one of the most promising. METHODS Ninety eight patients (103 limbs) with symptomatic varicose veins secondary to GSV insufficiency treated with 980-nm EVLA were prospectively studied. In all patients, laser energy was administered with constant pullback of fiberoptic laser catheter under tumescent anesthesia. The patients were assessed and followed by clinical examination and venous duplex ultrasonography. Pain scores of the patients from discharge to their first follow-up visit (7 days) were recorded by using visual analog scale (VAS). Patient satisfaction was assessed and recorded at 6 month follow-up. RESULTS All patients tolerated EVLA procedure well, and were discharged from hospital on the same day with ablation procedure. The overall success rate was 97.5% in 98 patients. Mean length of measured treated vein segment was 29.93±6.36 cm. Mean applied total energy was 2006.24±480.16 J. Major complications such as deep vein thrombosis and skin burns were not seen. Most of the complications were minor and improved quickly. All patients returned to daily activities within 2 days. CONCLUSIONS EVLA of the GSV insufficiency using 980-nm diode laser is an effective and safe technique with a high patient satisfaction rate. The advantages of the procedure are that it is performed as an outpatient procedure, provides early mobilization, causes minimal cessation of daily activities, and avoids classic surgical complications.
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Affiliation(s)
- Mehmet Umit Ergenoglu
- Faculty of Medicine, Department of Cardiovascular Surgery, Yeditepe University, Devlet Yolu Ankara Cad. No: 102/104, Kadikoy, Istanbul, Turkey.
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Hingorani AP, Ascher E, Marks N, Shiferson A, Patel N, Gopal K, Jacob T. Predictive factors of success following radio-frequency stylet (RFS) ablation of incompetent perforating veins (IPV). J Vasc Surg 2009; 50:844-8. [DOI: 10.1016/j.jvs.2009.04.046] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2008] [Revised: 04/09/2009] [Accepted: 04/18/2009] [Indexed: 11/24/2022]
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Lakhwani MN, Dadlani NI, Wong YC. 980-nm laser therapy versus varicose vein surgery in racially diverse Penang, Malaysia. ANZ J Surg 2009; 79:352-7. [DOI: 10.1111/j.1445-2197.2009.04888.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Leopardi D, Hoggan BL, Fitridge RA, Woodruff PW, Maddern GJ. Systematic Review of Treatments for Varicose Veins. Ann Vasc Surg 2009; 23:264-76. [PMID: 19059756 DOI: 10.1016/j.avsg.2008.10.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2008] [Revised: 10/20/2008] [Accepted: 10/24/2008] [Indexed: 10/21/2022]
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Zafarghandi MR, Akhlaghpour S, Mohammadi H, Abbasi A. Endovenous Laser Ablation (EVLA) in Patients With Varicose Great Saphenous Vein (GSV) and Incompetent Saphenofemoral Junction (SFJ): An Ambulatory Single Center Experience. Vasc Endovascular Surg 2009; 43:178-84. [DOI: 10.1177/1538574408326182] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives: To evaluate treatment results for varicose great saphenous vein (GSV) using endovenous laser ablation (EVLA) in an ambulatory single center. Material and methods: We prospectively studied 77 limbs with varicose GSV in 74 patients who were treated using 980-nm EVL with a 600-mm laser fiber and the power settings of 10-25 Watts. The patients were followed using color Doppler ultrasound. Results: Continued closure of treated GSV was found in 98.3% of the legs evaluated at 3-week follow-up (n = 60). At 3- and 6-month intervals, 94.1% and 97% successful occlusion was achieved, respectively. The main complications of the procedure included prolonged leg pain (2 cases), hyperestheasia (one case) and lidocaine sensitivity (one case). Conclusion: EVLA treatment of the GSV is a safe and highly effective method accompanied with few complications in midterm follow-up. It is feasible in ambulatory settings and the patients return to their daily activities early after intervention.
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Affiliation(s)
- Mohammad Reza Zafarghandi
- Department of Cardiovascular Surgery, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran,
| | - Shahram Akhlaghpour
- Departments of Interventional Radiology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Halimeh Mohammadi
- Department of Surgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Abbasi
- Department of Basic and Clinical Research, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
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Minimally invasive vein therapy and treatment options for endovenous heat-induced thrombus. JOURNAL OF VASCULAR NURSING 2008; 26:53-7. [PMID: 18492558 DOI: 10.1016/j.jvn.2008.03.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Radiofrequency ablation and endovenous laser therapy are types of minimally invasive techniques that have been used in the treatment of chronic venous insufficiency. In both procedures, high-intensity heat via thermal energy is produced and delivered via an endovenous catheter placed in the saphenous vein. This results in changes that therapeutically induce closure of the vein by denaturing the vessel wall with subsequent thrombus formation. Patients undergo ultrasound 48 to 72 hours postprocedure to confirm vessel occlusion and assess for possible extension of thrombus into the deep venous system. Thrombus is frequently visualized with the procedure in the tributaries, the venous dilations, and at times the saphenofemoral junction. In any other setting, thrombus at the saphenofemoral junction would warrant anticoagulation. However, the characteristics, composition, and behavior of endovenous heat-induced thrombus are different than de novo thrombosis. This postprocedure endovenous heat-induced thrombus is considered a normal consequence of the procedure and does not require traditional anticoagulation in most cases, depending on the location.
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Vuylsteke M, Liekens K, Moons P, Mordon S. Endovenous Laser Treatment of Saphenous Vein Reflux: How Much Energy Do We Need to Prevent Recanalizations? Vasc Endovascular Surg 2008; 42:141-9. [DOI: 10.1177/1538574407311107] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The aim of this study was to report the results of high-energy endovenous laser treatment to measure the relationship between the fluence and the outcome in terms of recanalization. In 97 patients, 129 great saphenous veins were treated with endovenous laser treatment, using a 980-nm diode laser. Follow-up visits were done at 3 days, 1 month, and 6 months. The best results were noted 1 month postoperative, but at 6 months, control late recanalizations occured decreasing occlusion rate to 90.6%. Patients were divided into 2 groups according to the outcome (occlusion or recanalization) at 6 months, and statistical analysis was done. The authors found 52 J/cm2 mean fluence in the occlusion group and 43.7 J/cm2 in the nonocclusion group. This was a statistical significant difference ( P < .01). The occlusion rate on long term is fluence dependent. But recanalizations might occur even in these higher fluence treatment groups. A fluence of 52J/cm2 is advised.
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Affiliation(s)
| | - Koen Liekens
- Department of Vascular Surgery, Sint-Andries Hospital
| | - Peter Moons
- Department of Radiology Sint-Andries Hospital, Tielt, Belgium
| | - Serge Mordon
- INSERM-IFR 114, Lille University Hospital 59037 Lille, France
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Baik HW, Kwak BK, Shim HJ, Kim YS, Lee JB, Kim KS. A New Ischemic Model Using a Radiofrequency Wire Electrode in a Rabbit Hindlimb. Cardiovasc Intervent Radiol 2008; 31:790-8. [DOI: 10.1007/s00270-008-9302-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2007] [Revised: 11/29/2007] [Accepted: 01/09/2008] [Indexed: 11/30/2022]
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Timperman PE. Endovenous Laser Treatment of Incompetent Below-Knee Great Saphenous Veins. J Vasc Interv Radiol 2007; 18:1495-9. [DOI: 10.1016/j.jvir.2007.07.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Demirtas Y, Ayhan S, Findikcioglu K, Yavuzer R, Atabay K. Selective Percutaneous Desiccation of the Perforators with Radiofrequency for Strategic Transfer of Angiosomes in a Sequential Four-Territory Cutaneous Island Flap Model. Plast Reconstr Surg 2007; 119:1695-1706. [PMID: 17440343 DOI: 10.1097/01.prs.0000258839.78758.35] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Research in prevention of partial flap necrosis has recently concentrated on extending the safe length of a flap by ligating vessels of known territories. To advance this approach one step further, the authors decided to reveal the least invasive surgical strategy for transfer of angiosomes. METHODS The study was arranged into three experiments. In the first experiment (n = 17 rabbits), a cutaneous island flap model spanning four adjacent vascular territories was developed. In the second experiment (n = 15 rabbits), the flap model was used to test the possibility of desiccating those vessels supplying the angiosomes to be captured percutaneously with radiofrequency. The delay procedures were performed by means of minimal skin incisions, and the flaps were elevated after a 2-week delay period. In the third experiment, the effectiveness of selective interference of these pedicles was compared to minimize the number of target vessels for successful transfer of angiosomes. RESULTS The mean surviving area of the new flap model was 63 +/- 2 percent. The mean surviving flap area was 97 +/- 3 percent for the endoscopy equivalent technique and 94 +/- 4 percent for radiofrequency delay. The results were statistically insignificant between these two groups. In experiment 3, comparison of the results yielded a statistically insignificant difference for flap survival area among all four of the groups. CONCLUSIONS An alternative flap model is introduced for future investigation of the vascular delay process. Percutaneous desiccation of the perforators with radiofrequency was found to be a reliable method, and selective desiccation of the perforator(s) was as efficient as destruction of all vascular sources other than the pedicle.
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Affiliation(s)
- Yener Demirtas
- Ankara, Turkey From the Department of Plastic, Reconstructive, and Aesthetic Surgery, Gazi University, Faculty of Medicine
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Medeiros CAFD. Comparação entre o laser endovenoso e a fleboextração total da veia safena interna: resultados em médio prazo. J Vasc Bras 2006. [DOI: 10.1590/s1677-54492006000400007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Comparar a fotocoagulação endovenosa com laser diodo e a fleboextração total da veia safena interna. MÉTODOS: Trata-se de um estudo prospectivo, controlado e cego de 20 pacientes com varizes sintomáticas e insuficiência bilateral da veia safena interna que foram operados entre março de 2002 e fevereiro de 2004. Para cada caso, foram realizadas aleatoriamente (sorteio) as duas técnicas, sendo uma em cada lado. A avaliação pós-operatória consistiu na aplicação de questionários, exame físico e fotografia digital em todos os pacientes desde o 7º dia de pós-operatório. Também foi realizado controle ultra-sonográfico no 30º dia de pós-operatório e pletismografia a ar no 60º dia após a cirurgia. Este projeto foi aprovado pela comissão de ética, e os pacientes foram incluídos ao assinarem o consentimento pós-informação. Os dados foram submetidos a análise estatística com os programas SPSS e SAS. RESULTADOS: A técnica que utilizou o laser endovenoso apresentou dor semelhante, mas menos edema e menos hematoma durante o pós-operatório. O índice de melhora estética e de satisfação com a cirurgia foi de 100% para as duas técnicas, mas a maioria dos pacientes respondeu que o membro operado com o laser foi o mais beneficiado. Houve melhora do tempo de enchimento venoso nos dois grupos, mas sem diferença significativa entre eles. Durante o seguimento (média de 26 meses), houve um caso de parestesia leve e transitória do lado convencional e somente uma recanalização do lado laser. CONCLUSÃO: A fotocoagulação endovenosa para o tratamento da veia safena interna em pacientes com varizes de membros inferiores é segura e apresenta resultados comparáveis aos da fleboextração convencional.
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Dunn CW, Kabnick LS, Merchant RF, Owens R, Weiss RA. Endovascular Radiofrequency Obliteration Using 90°C for Treatment of Great Saphenous Vein. Ann Vasc Surg 2006; 20:625-9. [PMID: 16865607 DOI: 10.1007/s10016-006-9099-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2005] [Revised: 06/22/2005] [Accepted: 02/27/2006] [Indexed: 11/30/2022]
Abstract
The recommended treatment temperature for endovascular radiofrequency obliteration (RFO) of the great saphenous vein (GSV) is 85 degrees C. Faster catheter pullback rates are possible when the operating catheter tip temperature is increased. We studied the safety and effectiveness of RFO of the GSV using a temperature of 90 degrees C, tumescent infiltration, and catheter pullback rates double the current standard. Sixty-eight patients (85 limbs) with ultrasound-documented saphenofemoral valve reflux underwent Closure procedure. Treatment temperature was increased to 90 degrees C, and pullback times were increased to 5-6 cm/min. Outcome measures were occlusion of treated vein segments at 3 days and 6 months postoperatively and clinical evaluation of complications at 3 days and 6 months postoperatively. At 3 days, 96% (80/83) of GSVs were occluded and at 6 months 90% (66/73) were occluded. At 3 days and 6 months, no limbs had evidence of deep venous thrombosis or skin burns. Pullback times were shortened from 15-18 min to 8 min. Closure procedure of the GSV using 90 degrees C and faster catheter pullback rates occluded a refluxing GSV with similar 3-day and 6-month occlusion rates as 85 degrees C.
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Affiliation(s)
- Charles W Dunn
- Ferrell Duncan Clinic Vein and Laser Center, Springfield, MO, USA.
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de Medeiros CAF, Luccas GC. Comparison of endovenous treatment with an 810 nm laser versus conventional stripping of the great saphenous vein in patients with primary varicose veins. Dermatol Surg 2006; 31:1685-94; discussion 1694. [PMID: 16336888 DOI: 10.2310/6350.2005.31309] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Patients with varicose veins seek medical assistance for many reasons, including esthetic ones. The development of suitable and more flexible instruments, along with less invasive techniques, enables the establishment of new therapeutic procedures. OBJECTIVE To compare endovenous great saphenous vein photocoagulation with an 810 nm diode laser and the conventional stripping operation in the same patient. METHODS Twenty patients selected for operative treatment of primary great saphenous vein insufficiency on duplex scanning were assigned to a bilateral random comparison. In all cases, both techniques were performed, one on each lower limb. Clinically, evaluation was assessed on the seventh, thirtieth, and sixtieth postoperative days. Patients underwent examination with duplex ultrasonography and air plethysmography during the follow-up. RESULTS Patients who received endovenous photocoagulation presented with the same pain but fewer swellings and less bruising than the stripping side. Most patients indicated that the limb operated on by laser received more benefits than the other. There was only one recanalization and no adverse effects. The venous filling time showed better hemodynamics in both techniques. CONCLUSION The endovenous great saphenous vein photocoagulation is safe and well tolerated and presents results comparable to those of conventional stripping.
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Eifell RKG, Bhattacharya V, Stansby GP. Endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus conventional surgery for long saphenous vein varices. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2006. [DOI: 10.1002/14651858.cd005624] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Abstract
Sclerosant microfoam is composed of microbubbles of room or air carbon dioxide (CO(2)). When air is mixed into the surfactant liquid sclerosant, microbubbles of reduced diameter can be obtained of sufficient stability to be injected into the vessels. The area of liquid on the surface is enormously increased in inverse proportion to the diameter of the bubble. Polidocanol in microfoam form displaces the blood from the vessel, permitting homogeneous contact between the sclerosant and the endothelium and facilitating endothelial destruction, and is visible in real time by ultrasonography. The concentration and volume of microfoam can be adjusted according to the disease treated. In the case of home-made foams, however, the volume of gas that can be injected is limited by the low solubility of nitrogen, and only the concentration can be modified. CO(2) is a nontoxic and highly soluble physiological gas, and large amounts can be administered. Here, we report the technique and long-term outcomes of ultrasound-guided injection of polidocanol microfoam in the treatment of large varicose long saphenous veins, postsurgical recurrence varicose veins, varicose ulcers, and venous vascular malformations.
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Affiliation(s)
- Pedro Redondo
- Department of Dermatology, Hemangiomas and Vascular Malformation Area, University Clinic of Navarra, School of Medicine, Pamplona, Spain.
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Furtado de Medeiros CA, Luccas GC. Comparison of Endovenous Treatment with an 810 nm Laser versus Conventional Stripping of the Great Saphenous Vein in Patients with Primary Varicose Veins. Dermatol Surg 2005. [DOI: 10.1097/00042728-200512000-00009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Corcos L, Dini S, De Anna D, Marangoni O, Ferlaino E, Procacci T, Spina T, Dini M. The immediate effects of endovenous diode 808-nm laser in the greater saphenous vein: Morphologic study and clinical implications. J Vasc Surg 2005; 41:1018-24; discussion 1025. [PMID: 15944603 DOI: 10.1016/j.jvs.2005.03.002] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND We conducted this study to evaluate the immediate venous morphologic alterations produced in the great saphenous veins by the endovenous diode 808-nm laser used for the treatment of superficial venous insufficiency and varicose veins of the lower limbs and to clarify the clinical implications of the histologic findings. METHODS Chosen for the study were 24 limbs of 16 patients with CEAP classification 3 to 6, ultrasound-documented greater saphenous insufficiency, and venous diameters between 3.9 mm and 17 mm (mean, 8.04 mm) without phlebitis, saphenous aneurysms, congenital malformations, or deep venous insufficiency. All limbs underwent surgical saphenofemoral disconnection, and the greater saphenous vein was treated with an endovenous diode 808-nm laser by continuous emission at 8 to 12 W and variable retraction speed (</>1 mm/s). Spinal or local, but not tumescent, anesthesia was used. Twenty-nine specimens (3 to 5 cm long) of 24 proximal greater saphenous and five anterior accessory saphenous veins were excised and studied by light microscopy for diameter and thickness of the venous wall, extent of injury into the intima, media, and adventitia, as well as penetration of thermal damage. RESULTS The histologic evaluation showed thermal injury to the intima in all specimens and full-thickness intimal injury in 22 specimens (75%); the average penetration of thermal injury in 29 specimens was 194.40 microm (range, 10 to 900 microm; 14.61% of the mean wall thickness); complete intimal circumference injury occurred in 8 specimen veins <10 mm in diameter (27.5%), full thickness damage in 6 (20.7%), and perforation in 2 (6.9%). CONCLUSIONS Saphenous ablation using 808-nm laser by variable retraction speed, combined with saphenofemoral interruption, leads to sufficient vein wall injury to assure venous occlusion. Full thickness thermal injury or perforation is infrequent. Optimal results can be obtained in veins <10 mm in diameter.
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Affiliation(s)
- Leonardo Corcos
- Postgraduate School of Vascular Surgery, University of Udine, Italy.
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Caggiati A, Mendoza E. Segmental hypoplasia of the great saphenous vein and varicose disease. Eur J Vasc Endovasc Surg 2004; 28:257-61. [PMID: 15288628 DOI: 10.1016/j.ejvs.2004.06.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2004] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Primitive narrowing of great saphenous vein segments (saphenous hypoplasia) has been described in healthy limbs. The aim of the present study was to detect great saphenous vein segmental hypoplasia in limbs with varicose veins and to evaluate the local anatomical and haemodynamic patterns. MATERIALS AND METHODS The incidence of saphenous hypoplasia and the local haemodynamic rearrangement were evaluated by duplex ultrasonography in 676 normal limbs and in 320 limbs with varicose veins. RESULTS Segmental hypoplasia was demonstrated in 84 normal limbs and in 79 limbs with saphenous reflux. In the latter, the retrograde flow leaves the GSV at the proximal end of the hypoplastic segment to feed tributary veins. CONCLUSIONS Saphenous hypoplasia occurs in varicose limbs more frequently than in healthy ones (p= >0.001). It greatly influences the path of the reflux and the anatomy of the varicose veins. GSV segmental hypoplasia can be detected preoperatively by duplex ultrasonography. Its occurrence may influence surgical management for two main reasons: in about 68% of varicose limbs with segmental hypoplasia, the distal GSV is competent. If the distal GSV is varicose, its size and flow direction is normalised by treating the accessory vein that bypasses the hypoplastic segment.
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Affiliation(s)
- A Caggiati
- Department of Anatomy, University La Sapienza, Rome, Italy.
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Perkowski P, Ravi R, Gowda RCN, Olsen D, Ramaiah V, Rodriguez-Lopez JA, Diethrich EB. Endovenous Laser Ablation of the Saphenous Vein for Treatment of Venous Insufficiency and Varicose Veins:Early Results From a Large Single-Center Experience. J Endovasc Ther 2004; 11:132-8. [PMID: 15056020 DOI: 10.1583/03-1126.1] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE To report early results of a single-center experience with endovenous laser ablation of the saphenous vein (ELAS). METHODS From February 2002 to January 2003, 165 eligible patients (116 women; mean age 59.1 years, range 27-90) were treated with ELAS for venous insufficiency in 203 lower limbs. All patients were symptomatic, and the majority (62%) had class 4 or higher clinical disease (CEAP classification). Eighteen (8.9%) patients had ulcers. A 940-nm diode laser was used in an office setting under local tumescent anesthesia to deliver 100 to 140 laser applications along the course of the vein. Two weeks of compression bandages and a 1-week course of ibuprofen were prescribed postoperatively. All patients underwent a duplex scan of the target vein at 2 weeks. RESULTS The great (154, 76%), short 37 (18%), and accessory 12 (6%) saphenous veins were ablated, achieving a 97% clinical success rate. Postoperative complications were few (mild induration and ecchymosis) and well tolerated (no DVT or nerve injury). Of the 6 (3.0%) recanalized target veins, 4 were only partially open and successfully treated with sclerosis. Of the 18 patients with active ulceration, 15 (83%) demonstrated healing after ELAS. In a satisfaction survey of patients more than 1 year after ELAS treatment, 84% of the 31 responders claimed their symptoms had diminished to none or minimal; 97% were mostly or very satisfied with their treatment results. CONCLUSIONS ELAS for symptomatic saphenous vein incompetence and varicose veins has excellent short-term subjective and objective outcomes. This technique appears to be very successful in reducing symptoms, resolving varicose veins, and healing ulcers.
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Affiliation(s)
- Paul Perkowski
- Department of Cardiovascular and Endovascular Surgery, Arizona Heart Institute and Hospital, 1632 North 20th Street, Phoenix, AZ 85006, USA
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Morrison C, Dalsing MC. Signs and symptoms of saphenous nerve injury after greater saphenous vein stripping: prevalence, severity, and relevance for modern practice. J Vasc Surg 2003; 38:886-90. [PMID: 14603189 DOI: 10.1016/s0741-5214(03)00790-0] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE Saphenous nerve injury has long been recognized as a risk of greater saphenous vein stripping, and it has been suggested by some authors as a reason to avoid stripping below the knee. The rate of injury reported in the literature is extremely variable, with no study adequately addressing the effect of these injuries on patient quality of life. We undertook this study to measure the prevalence of these injuries and quantify their impact on quality of life. METHODS A cross-sectional study of patients who had undergone primary greater saphenous vein stripping to the ankle was performed. Patients who had undergone this procedure, performed in a downward manner by a single surgeon over a 12-year period, were contacted and asked to return for a follow-up examination. Subjects completed the Aberdeen Varicose Vein Symptom Severity Score as well as a questionnaire designed to identify symptoms of saphenous nerve injury and any effects on quality of life. They were then evaluated for saphenous nerve deficits with simple neurologic tests. Charts were reviewed to determine preoperative CEAP classification. Results were analyzed for statistically significant differences between groups. RESULTS Out of 111 patients (127 legs) who had undergone the procedure, 38 (34%) agreed to participate in the study. Three of these patients were ultimately excluded because of an inability to obtain a reliable neurologic examination of the legs, leaving 35 patients with a total of 45 legs operated. Participants did not differ from the potential study population in demographic data, follow-up interval, or preoperative CEAP classification. Median time since operation was 4.5 years (range, 8 months to 10.75 years). Overall, 40% of patients reported symptoms consistent with saphenous nerve injury at some time after operation, but these symptoms affected quality of life in only 6.7%. Symptoms persisted at evaluation in 17.8%, and only one patient (2.3%) reported any negative effect on quality of life at the time of examination. Saphenous nerve deficits were identified in 58% of patients. Patients with deficits had no statistically significant differences from those without deficits in terms of demographic data, follow-up interval, preoperative CEAP class, or Aberdeen score. CONCLUSIONS Signs and symptoms of saphenous nerve injury are common at long-term follow-up after greater saphenous vein stripping to the ankle. However, there appears to be little, if any, significant resultant morbidity. The risk of saphenous nerve injury should therefore not be considered a reason to avoid stripping of the greater saphenous vein to the ankle.
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Affiliation(s)
- Charles Morrison
- Department of Surgery, Section of Vascualr Surgery, Wishard Hospital, Indianapolis, IN 46202, USA
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Venous Ablation: Results with RF, Laser and Sclerotherapy. J Vasc Interv Radiol 2003. [DOI: 10.1016/s1051-0443(03)70130-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Langer HE, Birth U. [Patient education in chronic polyarthritis. 3. Intermediate results of a prospective, controlled study of the effectiveness and side effects of patient seminars for polyarthritis patients]. Z Rheumatol 1988; 49:185-97. [PMID: 3369246 DOI: 10.1159/000335123] [Citation(s) in RCA: 285] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Accepted: 11/11/2011] [Indexed: 01/13/2023]
Abstract
Efficacy and possible negative side effects of a patient education program for rheumatoid arthritis were evaluated in a controlled, prospective study over 3 months. 34 outpatients were educated over a total of 8 h in three groups within a patient-centred design. Before the program the knowledge of the disease depended only on the formal grade of education but not on disease-related variables such as disease duration or disability. Probably due to its individualizing method, the program improved the knowledge of all patients to the same extent, regardless of their intellectual and social prerequisites. The increased cognitive knowledge did not result in negative side effects like increased pain or depression. The pain score remained unchanged. Depression decreased after the education. The group sessions made us suppose that the participants may have represented a selected group of active, psychologically stable patients, who cope well with rheumatoid arthritis. In contrast, we felt that non-participation was the response of the inactive, fatalistic patients with rheumatoid arthritis, who live in social isolation and especially need our care. Therefore, future efforts must particularly focus on the problem of motivation and on an increase in the rate of participation.
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Affiliation(s)
- H E Langer
- Abteilung Krankheiten der Bewegungsorgane und des Stoffwechsels, Medizinischen Hochschule Hannover
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