Effects of eccentric compression by a crossed-tape technique after endovenous laser ablation of the great saphenous vein: a randomized study

Compression Therapy after Thermal Ablation of Varicose Veins: A Meta-Analysis

OBJECTIVE

To investigate whether compression therapy after thermal ablation of varicose veins can improve the prognosis of patients.

METHODS

Systematic research were applied for Chinese and English electronic databases(PubMed, Web of Science, Cochrane Library, CNKI, Wanfang, VIP Databases). Eligible prospective studies that comparing the efficacy of compression therapy and non-compression therapy on patients after thermal ablation of varicose veins were included. The interest outcome such as pain, quality of life (QOL), venous clinical severity score (VCSS), time to return to work and complications were analyzed.

RESULTS

10 studies were of high quality, and randomized controlled trials involving 1,545 patients met the inclusion criteria for this study. At the same time, the meta-analysis showed that the application of compression therapy improved pain (SMD: -0.51, 95% CI: -0.95, -0.07) but exhibited no statistically significant effect on QOL (SMD: 0.04, 95% CI: -0.08, 0.16), VCSS (MD: -0.05, 95% CI: -1.19, 1.09), time to return to work (MD: -0.43, 95% CI: -0.90, 0.03), total complications (RR: 0.54, 95% CI: 0.27, 1.09), and thrombosis (RR: 0.71, 95% CI: 0.31, 1.62).

CONCLUSION

Compression therapy after thermal ablation of varicose veins can slightly relieve pain, but it has not been found to be associated with improvement in other outcomes.

Black holes in compression therapy: A quest for data

OBJECTIVE

Although compression therapy (CT) is considered a crucial conservative treatment in chronic venous disease, strong evidence is missing for many clinical indications. This literature review aims to point out what strong evidence we have for CT and all the clinical scenarios where strong evidence still needs to be included.

METHODS

The research was conducted on MEDLINE with PubMed, Scopus and Web of Science. The time range was set between January 1980 and October 2022. Only articles in English were included.

RESULTS

The main problem with CT is the low scientific quality of many studies on compression. Consequently, we have robust data on the effectiveness of CT only for advanced venous insufficiency (C3-C6), deep vein thrombosis and lymphedema. We have data on the efficacy of compression for venous symptoms control and in sports recovery, but the low quality of studies cannot result in a strong recommendation. For compression in postvenous procedures, superficial venous thrombosis, thromboprophylaxis, post-thrombotic syndrome prevention and treatment, and sports performance, we have either no data or very debated data not allowing any recommendation.

CONCLUSIONS

We need high-level scientific studies to assess if CT can be effective or definitely ineffective in the clinical indications where we still have a paucity of or contrasting data.

Comparative Efficacy of Postoperative Compression Methods After EVLT for Great Saphenous Vein Insufficiency

Introduction: The preference for endovascular techniques in treating varicose veins, particularly in the great saphenous vein (GSV), has increased due to their minimally invasive nature and reduced complications. Post-operative care, especially involving compression therapy, remains crucial to improve outcomes, prevent varicose vein recurrence, and enhance overall recovery. This study aimed to evaluate the efficacy of eccentric compression therapy compared to alternative post-operative care methods following endovenous laser treatment (EVLT) for GSV insufficiency. Methods: This prospective randomized clinical trial encompassed 88 EVLT procedures for GSV insufficiency. The participants were divided into two groups, each receiving different postoperative compression methods, and were evaluated over a specified period. The primary outcome was the pain scale after EVLT; meanwhile, the secondary outcome measured in the present study was the rate of GSV occlusion after EVLT. Results: Both groups underwent all EVLT procedures successfully without any complications. At the one-month duplex ultrasound (DUS) follow-up, the sapheno-femoral junction occlusion rates were 97% (43 out of 44) for group A (eccentric compression plus gradual compression stocking) and 95% (42 out of 44) for group B (only gradual compression stocking). Ecchymosis was observed in only 12 patients across both groups, accounting for an overall occurrence of 13.6%. Group A patients reported significantly lower analgesic usage (10%) compared to group B (18%), although this difference did not reach statistical significance. Analysis of postoperative pain data utilizing the visual analog scale (VAS) showed a median value of 5.5 in group B patients, which decreased to 3.1 with the application of eccentric compression. Moreover, there was less ecchymosis in group A observed by one week. Conclusion: This study contributes to the ongoing discourse on the efficacy of postoperative compression in varicose vein treatment. It underscores the necessity for more comprehensive, well-designed studies to yield clearer conclusions and provide better guidance for post-procedure care.

Stocking-only versus additional eccentric compression after below-the-knee truncal vein sclerotherapy: A SOVAECS prospective randomized within-person trial

OBJECTIVE

After foam sclerotherapy in the truncal saphenous vein, the clinical effects of additional eccentric compression has not yet been explored.

METHODS

Between April 2020 and February 2021, we enrolled 42 patients (84 limbs) who underwent bilateral endovenous combined therapy for great saphenous vein (GSV) reflux. Each patient received the same type of endovenous ablation in both above-the-knee GSVs (laser, radiofrequency, cyanoacrylate glue), and combined foam sclerotherapy was performed on both below-the-knee GSVs. Subsequently, we conducted a prospective randomized, single-blind, within-person study in which each patient's bilateral truncal saphenous vein of the calves underwent two different compression therapies: wearing of a regular class II compression stocking on one side (RC group) and additional eccentric compression on the other side (AC group). The primary end point was the occlusion range (score, 0-10) of the below-the-knee truncal GSV after foam sclerotherapy. The secondary outcomes were the pain score (visual analog scale score range, 0-10) of the paired limb, the required number of additional foam sclerotherapy sessions, compliance with compression therapy, and procedure-related complications.

RESULTS

For the above-the-knee GSV, endovenous laser treatment (n = 44), endovenous radiofrequency ablation (n = 14), and endovenous cyanoacrylate glue ablation (n = 26) were performed. The mean subcompression pressure of the medial calf in the supine and standing positions were 16.7 ± 2.34 mm Hg and 24.5 ± 6.6 mm Hg in the RC group and 38.5 ± 5.5 mm Hg and 45.3 ± 8.2 mm Hg in the AC group, respectively (P = .000). The secondary outcomes of pain score, number of additional foam sclerotherapy sessions, and pigmentation were not significantly different statistically between the two groups. The patient-reported satisfaction scores (range, 0-10) on compression at 24 hours postoperatively were 8.03 ± 1.9 for the AC group and 7.98 ± 1.9 for the RC group (P = .317; Wilcoxon signed ranks test). In both groups, the closure rate of the above-the-knee GSV at 1 month postoperatively was 100%. No procedure-related complications were identified within 1 month postoperatively, including no deep vein thrombosis, numbness, or skin necrosis requiring additional medical attention.

CONCLUSIONS

The 24 hours of additional eccentric compression on the truncal GSV compared with the use of a conventional knee-level stocking only did not yield any clinical advantages in terms of the occlusion range, postoperative pain, need for additional sclerotherapy, or skin pigmentation after foam sclerotherapy. The decision on which type of compression therapy to perform after foam sclerotherapy in the truncal vein should be comprehensively determined.

Influence of compression therapy following varicose vein surgery: a prospective randomized study

Background

The use of compression dressings after phlebectomy is based solely on clinical experience due to the lack of a unified set of definitive recommendations, which makes clinical practice extremely heterogeneous.

Objectives

To evaluate compression therapy with elastic stockings for 7 days after phlebectomy.

Methods

We randomly allocated 104 lower limbs with disease classified as C1 and C2 to 1 of 2 groups: an intervention group (64 limbs) - wearing elastic compression stockings for the first 7 days after phlebectomy; or a control group (40 limbs) - given conventional bandaging for 24 hours postoperatively. We compared clinical response by analyzing the evolution of symptoms, hematoma formation, and preoperative vs. postoperative limb volume.

Results

Pain (median 1.0 vs. 1.5, p=0.0320) and limb volume (mean 43.7 vs. 99.8, p=0.0071) were significantly improved in patients wearing elastic compression stockings for 7 days after phlebectomy compared with controls.

Conclusions

Use of elastic compression therapy for 7 days after phlebectomy was effective for improving pain and lower limb volume.

Compression versus no compression after endovenous radiofrequency ablation: A meta-analysis of randomized controlled trials

OBJECTIVES

The aim of this meta-analysis was to compare compression with no-compression, after radiofrequency endothermal ablation of a truncal varicose vein.

METHODS

Databases, such as PubMed, Embase, Cochran Library, and Web of Science, were independently searched by two researchers for relevant literature, preliminary screening was performed, and the full text was read to select studies that met the inclusion criteria. The quality of the included literature was evaluated using the Cochrane Risk of Bias tool, and meta-analysis was performed using Review Manager 5.4.

RESULTS

A total of four randomized controlled trials were included and a total of 552 patients were involved. Among them, 273 patients were in the compression group and 279 in the no-compression group. Meta-analysis results showed that the pain using the 100 mm Visual Analogue Scale was lower in the compression group than the pain in the no-compression group (MD = -4.22, 95% CI = -7.95 - -0.49, p = 0.03). No significant differences in terms of occlusion rate (RR = 0.99, 95% CI = 0.96-1.02, p = 0.55), Aberdeen Varicose Vein Questionnaire (MD = 0.46, 95% CI = -0.80-1.73, p = 0.47), and complications (OR = 1.33, 95% CI = 0.61-2.94, p = 0.47) were observed between groups.

CONCLUSIONS

This meta-analysis suggests that compression therapy reduced post-operative pain compared to the no-compression group. However, no additional advantages were observed in terms of occlusion rates, quality of life scores and complications.

Compression Therapy Following Endovenous Thermal Ablation of Varicose Veins: A Systematic Review and Meta-Analysis

OBJECTIVE

A systematic review and meta-analysis were performed to evaluate the necessity for compression therapy with elastic stockings following endovenous thermal ablation (EVTA) for chronic venous insufficiency.

METHODS

MedLine, ScienceDirect and the Cochrane Library were searched for the relevant literature according to the inclusion and exclusion criteria. Two researchers independently extracted data and assessed the quality of the literature. Randomized controlled trials comparing the use of elastic stockings for compression therapy versus no compression therapy following RFA or EVLA for varicose veins were included in this study. The primary outcome of postoperative pain was assessed using the visual analogue pain scale. Secondary outcomes included the bruising score, quality of life, venous clinical severity score, time to return to normal activities, complications, and the rate of saphenous vein occlusion. The mixed effect model or random effect model was used to calculate relative risk (RR), mean difference (MD) or standardized mean difference following the heterogeneity test. Sensitivity analysis was performed for outcomes with high heterogeneity (I² >50%). Outcomes were described qualitatively for studies that could not be pooled.

RESULTS

Six RCTs with 1,045 subjects were included. Overall, postoperative compression therapy significantly reduced the mean pain in the first 10 days post-EVTA (MD = - 4.98,95% CI: -8.71 to -1.24), and the time to return to normal activities (MD = -1.01, 95% CI: -1.97 to -0.06). In terms of the bruising score, the venous clinical severity score, complications (RR = 1.05,95% CI: 0.55-2.00), quality of life at 2 weeks (MD = -0.71,95% CI: -2.09 to 0.67) and 6 months (MD = 0.26,95% CI: -1.22 to 1.74), and the saphenous vein occlusion rate (RR=1.00,95% CI: 0.95-1.04), there were no significant differences between the compression and control groups.

CONCLUSION

Our study recommends the routine use of compression therapy with elastic stockings following EVTA of varicose veins to reduce postoperative pain and the time to return to normal activities. However, further multi-center and high-quality randomized clinical trials are needed for the unified treatment for varicose veins, the target population as well as the duration of compression therapy on whether elastic stockings is beneficial following EVTA.

Effect of Compression Stockings after Endovenous Laser Ablation of the Great Saphenous Vein with a 1470 nm Diode Laser Device and a 2ring Fiber

The aim of this study was to demonstrate the effects of compression following the endovenous laser ablation (EVLA) of incompetent great saphenous veins (GSVs) using a 1470 nm diode laser (Ceralas E 1470 nm, biolitec) and a 2ring radial fiber (ELVeS Radial 2ring™, biolitec). In this single-center prospective study, 150 legs of 150 consecutive patients were randomly allocated to one of three groups (A, B, and C). Group A patients did not undergo postoperative compression. Group B patients wore a thigh-length graduated compression stocking (23–32 mmHg) for 7 days, whereas group C patients wore the same stocking for 28 days. No additional phlebectomies or sclerotherapies were performed. Investigations were performed prior to intervention, at the day of intervention (D0), at day 7 (D7), and at day 28 post intervention (D28). The primary endpoint was post-interventional pain measured on a 10-point scale. A significant but small pain decrease was observed in the first week of compression, by comparing group B’s mean pain scores to those of group A (p = 0.009). Wearing a compression stocking after EVLA reduced pain within the first week on a significant, but low level. Taking the very low differences in pain levels into account, the difference may not be clinically relevant and post-treatment compression may not be necessary if no additional phlebectomies or sclerotherapies are performed.

Systematic review on the incidence and management of endovenous heat-induced thrombosis following endovenous thermal ablation of the great saphenous vein

OBJECTIVE

A systematic review and meta-analysis was performed to determine the incidence of endovenous heat-induced thrombosis (EHIT) and evaluate its management after endovenous thermal ablation of the great saphenous vein (GSV).

METHODS

MEDLINE and Embase were searched for studies with at least 100 patients who underwent great saphenous vein endovenous thermal ablation and had duplex ultrasound follow-up within 30 days. Data were gathered on the incidence of thrombotic complications and on the management of cases of EHIT. The primary outcome for the meta-analysis was EHIT types 2 to 4 and secondary outcomes were deep venous thrombotic events (which we defined as types 2-4 EHIT plus deep vein thrombosis [DVT]), DVT, and pulmonary embolism (PE). Pooled proportions were calculated using random effects modelling.

RESULTS

We included 75 studies (23,265 patients). EHIT types 2 to 4 occurred in 1.27% of cases (95% confidence interval [CI], 0.74%-1.93%). Deep venous thrombotic events occurred in 1.59% (95% CI, 0.95%-2.4%). DVT occurred in 0.28% (95% CI, 0.18%-0.4%). Pulmonary embolism occurred in 0.11% (95% CI, 0.06%-0.18%). Of the 75 studies, 24 gave a description of the management strategy and outcomes for EHIT and there was inconsistency regarding its management. Asymmetrical funnel plots of studies that reported incidence of EHIT 2 to 4 and DVT suggest publication bias.

CONCLUSIONS

The recently published guidelines on EHIT from the Society for Vascular Surgery/American Venous Forum provide a framework to direct clinical decision-making. EHIT and other thrombotic complications occur infrequently and have a benign course.

Ultrasound Use in Diagnosis and Management of Venous Leg Ulcer

Leg ulcers caused by venous diseases are effectively assessed by Doppler ultrasonography. The examination provides clear anatomical and physiological information for the diagnosis, treatment planning, and real-time guiding during the surgical treatment. Diagnostic Doppler ultrasonography assesses deep, superficial, and perforator veins, starting from patency assessment by direct visualization and simply compression test. The internal flow can be assessed by pulse wave analysis, which is used for rule out downstream flow obstruction and valvular incompetence. The venous valve function of deep, superficial, and perforator systems can be evaluated by measuring the time of the retrograde flow after flow augmentation performing in the upright position. At the end of the study, the venous map will be obtained and this map will guide clinicians to target treatment where the culprit is. The ultrasound technology has made a big shift in the treatment in the venous disease. In recent years, after the evolution and wide availability of ultrasound, newer treatment modalities have emerged for venous treatment. These include endovenous thermal ablation, endovenous adhesive closure, and ultrasound-guided foam sclerotherapy. Patients no longer require general anesthesia or hospitalization. Therefore utilization of duplex ultrasound has also surged and played an essential role in both diagnosis and therapy in venous ulcer. This article has dedicated to reviewing basic anatomy, the technique in diagnosis, and treatment.

Optimal duration of compression stocking therapy following endovenous thermal ablation for great saphenous vein insufficiency: A meta-analysis

BACKGROUND

The need for patients to wear compression stockings after varicose vein surgery and the duration of compressions tocking therapy has been debated. This study isa meta-analysis of randomized controlled trials (RCTs) to determine the optimal duration of compression stocking therapy after endovenous thermal ablation (ETA) of the great saphenous vein.

METHODS

The PubMed, Embase, and Cochrane Library databases were searched before January 2019. Individual effect sizes were standardized, and a meta-analysis was conducted to calculate the pooled effect size by using a random effects model. The primary outcome was the severity of pain in the postoperative period. Secondary outcomes were quality of life (QoL), leg volume, bruising scores, consumptionof analgesic agents, recovery time off work, satisfaction, and the incidence rates of postoperative complications including paresthesia and phlebitis.

RESULTS

Five RCTsinvolving775 patients were reviewed. The long-duration (1-2 weeks) group significantly reduced postoperative pain at 1 week (mean difference [MD] 1.19; 95% confidence interval [CI]: 0.58-1.80) and recovery time off work (MD: 1.01 day, 95% CI: 0.06-1.96)when compared with the short-duration (24-48 h) group. However, the mean pain scores at 2 (0.1; 95% CI: 0-0.2) and 6 weeks postoperatively (-0.3; 95% CI: -1.09-0.49) did not differ significantly between the two groups. Moreover, the incidence rates of complication, paresthesia, and phlebitis did not differ significantly between the short-duration and long-duration groups.

CONCLUSION

The use of compression therapy for a long time (1-2 weeks) is better than short-term (24-48 h) use in terms of postoperative pain at 1 week and recovery off work. Hence, we recommend the prescription of 1-week compression stocking therapy after ETA in routine clinical practice. However, the available evidence is of variable quality, further well-structured RCTs with improved standardization of compression treatment, types of stockings, and target populations are warranted.

Compression with 23 mmHg or 35 mmHg stockings after saphenous catheter foam sclerotherapy and phlebectomy of varicose veins: A randomized controlled study

Objectives

To compare two different medical compression stockings after varicose vein treatment.

Patients and methods

A randomized single-blind controlled study on two compression regimes after saphenous catheter foam sclerotherapy + phlebectomy was performed. After pads and 5 mmHg contention sock, 23 mmHg (group A, Struva 23®) or 35 mmHg (group B, Struva 35®) medical compression stocking was applied 24 h/day for seven days; subsequently 21–23 mmHg medical compression stocking in daytime. Symptoms, compliance, skin findings, and bioimpedance spectroscopy parameters were assessed.

Results

A total of 94 patients (48 and 49 limbs in groups A and B, respectively) were enrolled. Three (T3) and seven (T7) days post-operatively, most symptoms were significantly milder in group B, especially pain and heaviness at T7 and at day 40 (T40). Ambulation, medical compression stocking stability/tolerability and skin healing were significantly better in group B, with p = 0.046, 0.021/0.060, and 0.010, respectively, at T7. Bioimpedance parameters increased at T7 and decreased at T40 in both groups; leg reactance and limb L-Dex improved in group B at T7 and T40, respectively (p = 0.039 and 0.012).

Conclusions

Compression with 23 and 35 mmHg medical compression stocking after catheter foam sclerotherapy + phlebectomy was effective and well tolerated at immediate/short term. Compression with 35 mmHg medical compression stocking provided less adverse post-operative symptoms and better tissue healing. Bioimpedance results confirmed a slightly better edema improvement with 35 mmHg medical compression stocking.

Indications for medical compression stockings in venous and lymphatic disorders: An evidence-based consensus statement

Objective Medical compression stockings are a standard, non-invasive treatment option for all venous and lymphatic diseases. The aim of this consensus document is to provide up-to-date recommendations and evidence grading on the indications for treatment, based on evidence accumulated during the past decade, under the auspices of the International Compression Club. Methods A systematic literature review was conducted and, using PRISMA guidelines, 51 relevant publications were selected for an evidence-based analysis of an initial 2407 unrefined results. Key search terms included: 'acute', CEAP', 'chronic', 'compression stockings', 'compression therapy', 'lymph', 'lymphatic disease', 'vein' and 'venous disease'. Evidence extracted from the publications was graded initially by the panel members individually and then refined at the consensus meeting. Results Based on the current evidence, 25 recommendations for chronic and acute venous disorders were made. Of these, 24 recommendations were graded as: Grade 1A (n = 4), 1B (n = 13), 1C (n = 2), 2B (n = 4) and 2C (n = 1). The panel members found moderately robust evidence for medical compression stockings in patients with venous symptoms and prevention and treatment of venous oedema. Robust evidence was found for prevention and treatment of venous leg ulcers. Recommendations for stocking-use after great saphenous vein interventions were limited to the first post-interventional week. No randomised clinical trials are available that document a prophylactic effect of medical compression stockings on the progression of chronic venous disease (CVD). In acute deep vein thrombosis, immediate compression is recommended to reduce pain and swelling. Despite conflicting results from a recent study to prevent post-thrombotic syndrome, medical compression stockings are still recommended. In thromboprophylaxis, the role of stockings in addition to anticoagulation is limited. For the maintenance phase of lymphoedema management, compression stockings are the most important intervention. Conclusion The beneficial value of applying compression stockings in the treatment of venous and lymphatic disease is supported by this document, with 19/25 recommendations rated as Grade 1 evidence. For recommendations rated with Grade 2 level of evidence, further studies are needed.

Eccentric compression of large varicose veins after foam sclerotherapy using a novel silicone gel pad

Ziel: Wir evaluierten eine neuartige exzentrische Kompression, die ultraschalltransparentes Silikon-Gel zwischen selbstklebenden Fo-lien als individuelles Druckpolster verwendet.

Methodik: Es wurden 120 Patienten mit 148 oberflächlichen Varizen (Ø 5,1–13,7 mm; MW: 7,6) nach Schaumverödung einbezogen: A) segmental randomisiert mit fokaler Kompression durch Silikon-Gel-Polster (Venartis® SGP) für 14 Tage plus Kompressionsstrumpf KKl. 2 (KS) tagsüber für 28 Tage, oder B) nur KS. Das SGP-System besteht aus einer selbstklebenden Basisfolie, auf die Silikon dem Venenverlauf folgend aufgetragen wird. Eine zweite Folie bedeckt Gel und Basisfolie. Den Patienten war Duschen erlaubt. Ermittelt wurden Querschnittsreduktion (QR, Ultra-schallscans) sowie klinische Parameter nach 2, 4 und 8 Wochen.

Ergebnisse: Segmente mit SGP zeigten gegenüber KS eine höhere QR, im Mittel 52,5 vs. 23,1 % (2 Wo), 48,4 vs. 28,9 % (4 Wo) und 66,7 vs. 39,2 % (8 Wo). Entzündungsreaktionen waren unter SGP mit 12,4 vs. 39,9 % signifikant seltener, ebenso Verfärbungen mit 10,8 vs. 35,1 %. Minithrombektomien (8,1 vs. 29,7 %) und orale Analgetika (6,8 vs. 19,6 %) wurden seltener benötigt. Unerwünschte Wirkungen: Diskrete Hautirritationen (10,1 %).

Schlussfolgerung: Indikationsspezifische Silikonhärten, Dosierungen, Tragezeiten und die Höhe externer Drücke bedürfen weiterer Untersuchungen, wobei die Ultraschalltransparenz neue Wege eröffnet.

Compression therapy for venous disease

For centuries, compression therapy has been utilized to treat venous disease. To date it remains the mainstay of therapy, particularly in more severe forms such as venous ulceration. In addition to mechanisms of benefit, we discuss the evidence behind compression therapy, particularly hosiery, in various forms of venous disease of the lower extremities. We review compression data for stand-alone therapy, post-intervention, as DVT prevention, post-thrombotic syndrome and venous ulcer disease. We also review the data comparing compression modalities as well as the use of compression in mixed arteriovenous disease.

A systematic review of the compression regimes used in randomised clinical trials following endovenous ablation

Objectives

There is insufficient evidence to inform guidelines on the optimal compression strategy following ablation for varicose veins. This study aimed to identify the practice of key opinion leaders performing randomised clinical trials involving endovenous ablation.

Method

A systematic review of MEDLINE/EMBASE/CENTRAL was performed identifying the compression strategies used in randomised clinical trials where at least one comparator arm underwent endovenous ablation.

Results

Thirty-four randomised clinical trials were identified. At least 14 different compression products were used, with at least 6 different pressures in 7 different regimes with durations from 2 to 84 days. There was no evidence of any convergence of practice over time.

Conclusions

A lack of evidence as to the optimal strategy for compression has resulted in a marked variation in clinical practice. There is no suggestion that this variation is becoming less over time indicating that experience is not helping to form a consensus and, therefore, further research is required.

Compression regimes after endovenous ablation for superficial venous insufficiency – A survey of members of the Vascular Society of Great Britain and Ireland

Introduction

The optimal compression regime following ultrasound guided foam sclerotherapy (UGFS), radiofrequency ablation (RFA) and endovenous laser ablation (EVLA) for varicose veins is not known. The aim of this study was to document current practice.

Methods

Postal questionnaire sent to 348 consultant members of the Vascular Society of Great Britain and Ireland.

Results

Valid replies were received from 41% ( n = 141) surgeons representing at least 68 (61%) vascular units. UGFS was used by 74% surgeons, RFA by 70% and EVLA by 32%, but fewer patients received UGFS (median 30) annually, than endothermal treatment (median 50) – P = 0.019. All surgeons prescribed compression: following UGFS for median seven days (range two days to three months) and after endothermal ablation for 10 days (range two days to six weeks) – P = 0.298. Seven different combinations of bandages, pads and compression stockings were reported following UGFS and four after endothermal ablation. Some surgeons advised changing from bandages to stockings from five days (range 1–14) after UGFS. Following endothermal ablation, 71% used bandages only, followed by compression stockings after two days (range 1–14). The majority of surgeons (87%) also treated varicose tributaries: 65% used phlebectomy, the majority (65%) synchronously with endothermal ablation. Concordance of compression regimes between surgeons within vascular units was uncommon. Only seven units using UGFS and six units using endothermal ablation had consistent compression regimes.

Conclusion

Compression regimes after treatments for varicose veins vary significantly: more evidence is needed to guide practice.

Consensus for the Treatment of Varicose Vein with Radiofrequency Ablation

The objective of this paper is to introduce the schematic protocol of radiofrequency (RF) ablation for the treatment of varicose veins. Indication: anatomic or pathophysiologic indication includes venous diameter within 2–20 mm, reflux time ≥0.5 seconds and distance from the skin ≥5 mm or subfascial location. Access: it is recommended to access at or above the knee joint for great saphenous vein and above the mid-calf for small saphenous vein. Catheter placement: the catheter tip should be placed 2.0 cm inferior to the saphenofemoral or saphenopopliteal junction. Endovenous heat-induced thrombosis ≥class III should be treated with low-molecular weight heparin. Tumescent solution: the composition of solution can be variable (e.g., 2% lidocaine 20 mL+500 mL normal saline+bicarbonate 2.5 mL with/without epinephrine). Infiltration can be done from each direction. Ablation: two cycles’ ablation for the first proximal segment of saphenous vein and the segment with the incompetent perforators is recommended. The other segments should be ablated one time. During RF energy delivery, it is recommended to apply external compression. Concomitant procedure: It is recommended to do simultaneously ambulatory phlebectomy. For sclerotherapy, it is recommended to defer at least 2 weeks. Post-procedural management: post-procedural ambulation is encouraged to reduce the thrombotic complications. Compression stocking should be applied for at least 7 days. Minor daily activity is not limited, but strenuous activities should be avoided for 2 weeks. It is suggested to take showers after 24 hours and tub baths, swimming, or soaking in water after 2 weeks.

Therapeutic effect of compression stockings versus no compression on isolated superficial vein thrombosis of the legs: a randomized clinical trial

OBJECTIVE/BACKGROUND

Leg compression is considered basic treatment for superficial vein thrombosis (SVT), although scientific proof for its efficacy is lacking. The aim of the study was to evaluate the therapeutic effect of compression stockings on isolated SVT of the legs.

METHODS

This was a single-center randomized controlled trial. Eighty patients with isolated SVT of the legs were instructed to wear compression stockings (23-32 mmHg) (CG) or no compression (NCG) for 3 weeks. All patients received low molecular weight heparin (LMWH) at prophylactic dosage. Non-steroidal anti-inflammatory drugs (NSAIDs) were allowed. The primary outcome variable was the reduction of pain as assessed by a visual analog scale (VAS) and the Lowenberg test. Secondary outcomes were the consumption of analgesics, thrombus length, skin erythema, D-dimer, and quality of life (QoL).

RESULTS

Seventy-three patients completed the study. Clinical symptoms and QoL significantly improved from baseline to day 21 in both groups (p < .001 for VAS, Lowenberg test, thrombus length, and erythema; p < .006 for QoL), and consumption of analgesics and D-dimer significantly decreased (p < .001). There was no significant difference between the groups for all tested variables. At day 7, patients in the CG revealed a significantly faster thrombus regression (p = .02).

CONCLUSION

Adding compression stockings for 3 weeks to LMWH and NSAIDs does not bring significant additional benefit in the treatment of isolated SVT. When worn for 1 week, compression stockings stimulate significantly faster thrombus regression.

Endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus open surgery for great saphenous vein varices

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.

Guidelines of the First International Consensus Conference on Endovenous Thermal Ablation for Varicose Vein Disease--ETAV Consensus Meeting 2012

AIM

Endovenous thermal ablation (ETA) procedures are catheter-directed, ultrasound (US)-guided thermal methods for treatment in varicose veins disease. Radiofrequency, laser or steam energy thermally denatures vein wall collagen, leading first to vein wall inflammation, then fibrosis and finally to occlusion. The aim of this guideline is to give evidence-based recommendations for ETA procedures.

METHODS

These guidelines were drafted during a consensus meeting of a group of experts in the field of ETA in June 2012 (Hvar, Croatia) under the auspices of the International Union of Phlebology (IUP). These guidelines review the present state of knowledge as reflected in peer-reviewed published medical literature. The recommendations of these guidelines are graded according to the American College of Chest Physicians Task Force recommendations on Grading Strength of Recommendations and Quality of Evidence in Clinical Guidelines.

RESULTS

Recommendations on the use of ETA procedures were made based on the quality of evidence for efficacy, safety, tolerability, cosmetic outcome, patient satisfaction/preference and, where appropriate, on the experts' opinion. Health economics were not considered, since differences in national health systems and pricing make it difficult to form general conclusions that are relevant at an international level.

Compression stockings after endovenous laser ablation of the great saphenous vein: a prospective randomized controlled trial

OBJECTIVES

To determine if the duration of wearing compression stockings after endovenous laser ablation (EVLA) of the great saphenous vein (GSV) has influence on pain and quality of life.

METHODS

This was a prospective randomized controlled trial. Between December 2006 and February 2008, 109 consecutive patients with EVLA of the GSV were analyzed. Deep vein insufficiency, ulceration, more than one insufficient vein in one leg, and use of anticoagulants were exclusion criteria. Group A used compression stocking for 48 hours after therapy, group B for 7 days. Pain (visual analogue scale [VAS]) and quality of life (SF-36) were analyzed 48 hours, 1 week, and 6 weeks after therapy. Three months after treatment, duplex ultrasound imaging was performed to assess occlusion rates.

RESULTS

Both groups (group A, n = 37; group B, n = 32) where comparable at baseline. After 1 week, there was a significant difference in pain (VAS score 3.7 [± 2.1] vs. 2.0 [± 1.1], p ≤ .001), and physical dysfunction (group A, 85.1 [± 11.2] vs. group B, 95.7 [± 10.1]; p < .001) as well as vitality (group A, 75 [± 13.0] vs. group B, 83.7 [± 13.4]; p = .03), all in favor of group B, which disappeared after 6 weeks. After 6 weeks, no significant differences in all endpoints were present. Duplex ultrasound imaging revealed complete GSV occlusion in all patients, while no cases of deep venous thrombosis had developed.

CONCLUSIONS

Prescribing compression stockings for longer than 2 days after endovenous GSV ablation (without simultaneous phlebectomies) leads to reduced pain and improved physical function during the first week after treatment.

Value of postoperative compression after mini-invasive surgical treatment of varicose veins

OBJECTIVE

It is customary to recommend wearing elastic band compression or compression stockings after treatment of varicose veins. Our aim was to evaluate the benefit from wearing elastic compression stockings after surgical treatment of varicose veins.

METHODS

Prospective nonrandomized study with inclusion of consecutive patients operated on for unilateral varicose veins during a 6-month period with distribution in two groups: group 1, in which the patients were wearing an 18-mm Hg thigh compression stocking from the day of the operation until the postoperative consultation and group 2, in which the patients were wearing an 18-mm Hg thigh compression stocking for only 36 hours after surgery. The evaluation of outcomes was made at the postoperative consultation and concerned pain (self-evaluation by visual analog scale) and analgesic consumption, ecchymosis (self evaluation by visual analog scale), edema (circumference of the ankle), deep or superficial venous thrombosis (ultrasound duplex), quality of life by Chronic Venous Insufficiency Quality-of-Life questionnaire, and duration of postoperative sick leave.

RESULTS

Fifty patients were included in each group for a total of 100. There was no significant difference between the two groups with regard to demographics, to clinical and hemodynamic characteristics, and to the type of surgery performed (phlebectomy, 32% vs 32%; ambulatory selective varices ablation under local anesthesia, 46% vs 48%; stripping, 10% vs 12%; redo surgery for recurrence, 12% vs 8%). All the surgical procedures were carried out under tumescent local anesthesia. At the postoperative consultation, we did not observe any significant difference between group 1 and group 2 for pain score (0.6 vs 0.8; P = .35), analgesic consumption frequency (8% vs 12%; P = .50), ecchymosis score (1.3 vs 1.2; P = .49), and quality-of-life score (7.00 vs 8.64; P = .43). The circumference of the ankle was not significantly different for the side operated on before and after surgery, for group 1 (25.6 cm vs 26.2 cm; P = .30) and for group 2 (25.5 cm vs 26.2 cm; P = .28). No superficial or deep vein thrombosis was found. There was no difference in sick leave frequency (26.7% vs 32.3%; P = .57) and duration (2.6 vs 2.3 days; P = .83).

CONCLUSIONS

We found no benefit from wearing the compression stocking beyond the first postoperative day for pain, ecchymosis, quality of life, and thrombosis after a mini-invasive surgical treatment for varicose veins carried out under tumescent local anesthesia with immediate ambulation.

Post-treatment compression: duration and techniques

BACKGROUND

Compression treatments used the following intervention for varicose veins range from no compression, to elastic stockings and compression bandaging. There is no consensus on the strength or duration of compression which should be applied following a particular treatment. The author reviews the evidence that has led him to reach his own viewpoint on this subject.

SUMMARY

Compression stockings are often prescribed after treatment of varicose veins, but these in general exert a much lower pressure in the thigh compared with firm inelastic compression bandages. It has been shown by objective investigation that it takes a pressure of 10-15 mmHg in the supine position and 40-50 mmHg in the standing position to occlude a superficial vein in the thigh. The author has published a study in which three groups of patients were studied following varicose vein surgery. One group received a strong medical compression stocking, the second group an inelastic bandaging system which achieved 63 mmHg compression in the standing position and an eccentric compression system which achieved 98 mmHg in the standing position. Adverse events after surgery were most frequent in the stocking group with fewer in the inelastic compression bandage group and fewest in the eccentric compression group. A further study has been published by another author in which elastic compression has been compared with eccentric compression following endovenous laser ablation of the saphenous vein. Eccentric compression reduced postoperative pain. Unfortunately, very little data are available to indicate the period for which compression should be applied following varicose vein treatment.

CONCLUSIONS

In comparison to compression treatments following varicose vein surgery where the actual level of compression has been measured, higher levels of compression are more effective than lower levels in moderating postoperative pain and complications. Strong compression can be achieved by inelastic bandaging or by eccentric compression systems. Far fewer data are available to indicate the duration for which postoperative compression is required.

Endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus conventional surgery for great saphenous vein varices

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.

Randomized clinical trial of different bandage regimens after foam sclerotherapy for varicose veins

BACKGROUND

This trial compared outcomes after foam sclerotherapy in patients wearing compression bandaging for 24 h or 5 days after treatment.

METHODS

Consecutive patients with primary uncomplicated varicose veins were randomized after foam sclerotherapy treatment. The primary endpoint was 6-week Aberdeen Varicose Vein Severity Score (AVVSS) and Burford pain score.

RESULTS

Some 124 legs were randomized, 61 to 24 h and 63 to 5 days of bandaging. Target vein occlusion rates at 6-week duplex imaging were 90 and 89 per cent respectively (P = 0.842). There was no significant difference in phlebitis after 2 weeks (P = 0.445) or skin discoloration after 6 weeks (46 versus 40 per cent; P = 0.546). There was no significant difference in the change in AVVSS from baseline to 2 weeks (-0.29 versus -0.80; P = 0.717) or to 6 weeks (-5.89 versus -5.14; 95 per cent confidence interval (c.i.) for the difference -3.29 to 1.80; P = 0.563), or in change in Burford pain score from baseline to 2 weeks (-9.04 versus -2.80; P = 0.248) or to 6 weeks (-17.32 versus -8.46; 95 per cent c.i. for the difference -19.06 to 1.33; P = 0.088), or in change in Short Form 36 score from baseline to 6 weeks (2.02 versus 1.74; P = 0.903).

CONCLUSION

There was no advantage to compression bandaging for more than 24 h when thromboembolus deterrent stockings were worn for the remainder of 14 days.

REGISTRATION NUMBER

NCT00991497 (http://www.clinicaltrials.gov).