Incidence, Risk Factors, Progression, and Treatment of Endovenous Heat-Induced Thrombosis Class 2 or Greater After Endovenous Radiofrequency Ablation

Ultrasound-guided femoral block in patients undergoing radiofrequency ablation of incompetent saphenous veins: A randomized controlled trial

OBJECTIVE

To evaluate the benefit of ultrasound-guided femoral nerve block (UGFN) for reducing pain in patients undergoing radiofrequency ablation (RFA).

METHODS

Patients age 18-70 years scheduled for RFA were prospectively enrolled. Patients were randomly assigned to the UGFN or control group at a 1:1 ratio, and stratified according to concomitant phlebectomy procedure. The pain score and amount of fentanyl use during the operation were recorded. Pain severity and quadriceps muscle strength were recorded at 2-, 6-, and 12-hours postoperation.

RESULTS

Twenty-four patients in each group were included. Moderate to severe pain during surgery was found in 16 (66.7%) patients in the control group, and in 2 (8.3%) patients in the UGFN group (p < 0.001). Fentanyl use during surgery was significantly higher in controls than in UGFN patients (107.29 ± 40.70 μg vs. 42.71 ± 26.04 μg, respectively; p < 0.0001). The postoperative pain score was not significantly different between groups. In the UGFN group, quadriceps femoris weakness was found in 19 (79.2%) patients, and in 1 (4.2%) patient at 2-hours and 6-hours postoperation, respectively. No patient in the control group had quadriceps femoris weakness.

CONCLUSION

UGFN decreased intraoperative pain during RFA. However, patients undergoing UGFN should be observed in the hospital for at least 6 hours, and quadriceps muscle power should be tested before hospital discharge.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Thrombus extension after cyanoacrylate closure of incompetent saphenous veins

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A systematic review and meta-analysis of treatment modalities for anterior accessory saphenous vein insufficiency

OBJECTIVE

To investigate and compare the outcomes of the available treatment modalities for anterior accessory saphenous vein (AASV) incompetence.

METHODS

A systematic literature search was performed in MEDLINE, Embase, and the Cochrane Library. Studies reporting the outcomes of patients who were treated for primary AASV incompetence were included. The methodologic quality of the articles was assessed using the Methodological Index for Non-Randomized Studies (MINORS). A random-effects model was used to estimate anatomic success, defined as AASV occlusion. The secondary outcomes were pain during and after treatment, venous clinical severity score, quality of life, esthetic result, time to return to daily activities, and complications.

RESULTS

The search identified 860 articles, of which 16 met the inclusion criteria. A total of 609 AASVs were reported. The included studies were of poor or moderate quality according to MINORS score. The pooled anatomic success rates were 91.8% after endovenous laser ablation and radiofrequency ablation (EVLA, RFA, 11 studies), 93.6% after cyanoacrylate closure (3 studies), and 79.8% after sclerotherapy (2 studies). The non-pooled anatomic success rate was 97.9% after phlebectomy and 82% after CHIVA. Paresthesia was seen after EVLA in 0.7% of patients (6 studies). Phlebitis was seen in 2.6% of patients after RFA (2 studies), 27% after sclerotherapy (1 study), and 12% after the phlebectomy (1 study). Deep venous thrombosis and skin burn did not occur.

CONCLUSION

Treatment of AASV incompetence is safe and effective. Despite limited evidence, occlusion of the AASV can be achieved with endovenous thermal ablation and cyanoacrylate. There does not appear to be a benefit of EVLA compared to RFA regarding treatment efficacy. Phlebectomy shows promising results if the saphenofemoral junction is competent. Lower results are seen after sclerotherapy and CHIVA. However, studies with sufficient sample sizes of solely treatment of AASV incompetence are needed to draw firm conclusions.

Current status of endothermal heat induced thrombosis

BACKGROUND

There remain many questions regarding the pathophysiology and risk factors for endothermal heat induced thrombosis formation. Moreover, there are a paucity of data on the timing of its occurrence, and there has been no consensus regarding for its treatment. The purpose of this review is to summarize the current knowledge on the pathophysiology, risk factors and treatment strategies for endothermal heat induced thrombosis.

METHODS

The PubMed database was searched from 2001 to present for endothermal heat induced thrombosis, EHIT, deep vein thrombosis, chronic venous insufficiency, varicose veins, endovenous laser and radiofrequency ablation (treatment). All relevant articles identified by the authors mentioning endothermal heat induced thrombosis were included in this review.

RESULTS

A multitude of risk factors, several pathophysiological hypotheses and different treatment strategies are described in the literature.

CONCLUSIONS

Endothermal heat induced thrombosis is marginally understood. There remains a theoretical risk for significant venous thromboembolic complications. With the new uniform classification of EHIT (American Venous Forum), healthcare providers should continue to investigate the nature of this event.

Determining Risk Factors for Endovenous Heat-induced Thrombosis after Radiofrequency Ablation

BACKGROUND

The objective of this study was to evaluate risk factors, incidence, management, and outcome of endovenous heat-induced thrombosis (EHIT) related to radiofrequency ablation (RFA).

METHODS

This was a single-center retrospective analysis of patients over the age of 18 who underwent RFA between 2016 and 2019. Demographics, comorbidities, medications, severity scores, vascular anatomy, procedural details, and outcome data were collected. EHIT-related data included occurrence, grade, laterality, management, and outcome.

RESULTS

During the study period, 672 RFA procedures were performed at our institution. Of these, 642 (median age 57 (21-93), 62.3% female) met study inclusion criteria. EHIT was observed in 43 (6.6%) cases. Concurrent left common femoral vein (CFV) or right femoral vein (FV) incompetence was found to be more prevalent in the EHIT group (P = 0.024 and P = 0.011, respectively). Compared with performing RFA alone, concurrent performance of stab phlebectomy and sclerotherapy with RFA on the left side was found to be associated with possible increased risk for EHIT (P = 0.021). Furthermore, patients with diabetes mellitus (DM) (P = 0.05) and those with median diameter of the treated left vein of 1.2 cm (P = 0.02) were more likely to have a higher EHIT grade (III and IV) than those without DM and those with smaller vein diameter, respectively. Management included aspirin (44%), anticoagulant (28%), both (10%), or neither (18%). EHIT either resolved or regressed (64%), did not change (5%), or propagated (8%) at follow-up.

CONCLUSIONS

Left CFV or right FV incompetence was found to be more prevalent in the total EHIT group. Furthermore, DM and the median size of the treated vein on the left (1.2 cm) were more prevalent in the high (III-IV) versus low grade (I-II) EHIT group. More than 50% of EHIT improved (regressed or resolved) at follow-up regardless of the management option. Further analysis with larger patient samples are needed to confirm the association between these variables and the development of EHIT.