Twelve-Month Follow-up of the European Multicenter Study on Cyanoacrylate Embolization of Incompetent Great Saphenous Veins

A systematic review and meta-analysis of mechanochemical endovenous ablation using Flebogrif for varicose veins: A summary of evidence

OBJECTIVE

In the present study, we reviewed and analyzed the currently available data on the Flebogrif device (Balton, Warsaw, Poland) to define its role in the global varicose vein treatment devices market.

METHODS

A systematic literature search was performed in MEDLINE, Embase, and the Cochrane Library. Studies were eligible if they had included patients treated using the Flebogrif for saphenous vein incompetence, had been reported in English, and had the full text available. The methodologic quality of the studies was assessed using the methodologic index for nonrandomized studies (MINORS) score. A random effects model was used to estimate the primary outcome of anatomic success, defined as the occlusion rate of the treated vein. The estimates are reported with the 95% confidence intervals (CIs). The secondary outcomes were clinical success, complication rate, pain during and after the procedure, and time to return to work.

RESULTS

A total of 392 patients are reported in the included studies. A total of 348 legs were treated with Flebogrif (in 6 patients both legs). A total of 50 patients/legs were treated with EVLA (Ammollo et al.). In conclusion, 348 Flebogrif procedures are performed in 392 patients. Four studies reported the 3-month anatomic success, and three studies reported the 12-month anatomic success. The pooled 3-month anatomic success rate was 95.6% (95% CI, 93.2%-98.0%). The 12-month anatomic success rate was 93.2% (95% CI, 90.3%-96.1%). The only major complication reported within 3 months was deep vein thrombosis, which developed in 0.3% of the patients. The minor complications of thrombophlebitis and hyperpigmentation had occurred in 13.3% to 14.5% and 3.3% to 10.0% of patients, respectively, within 3 months. The methodologic quality of the included studies was moderate.

CONCLUSIONS

Mechanochemical ablation using the Flebogrif device is a safe and well-tolerated procedure for the treatment of saphenous vein insufficiency. However, well-designed studies of sufficient sample size and follow-up are required to compare the effectiveness with other endovenous treatment modalities and define the definitive role of the Flebogrif device.

Ultrasound-guided cyanoacrylate injection for the treatment of incompetent perforator veins

Objective

The use of cyanoacrylate products (CA) in incompetent perforator vein (IPV) treatment has not been thoroughly examined. The primary objective of this study is to describe the technique of ultra sound guided direct injection of IPV with CA, and secondarily to determine early closure rates and safety of this technique.

Methods

A retrospective analysis of patients undergoing IPV injection at two centres between 2015-2018 was conducted. Demographics, CEAP classification and IPV location were collected. Outcomes were assessed at two follow-up appointments.

Results

A total of 83 perforator vein injections were completed. CEAP classifications include C2 – C6 classes. Location of perforators were posteromedial (6%), femoral canal (9%), paratibial (14%), and posterior-tibial (71%). IPV closure rates were 96.3% at initial follow-up (16 ± 2 days). Closure rates decreased to 86.5% at second follow-up (72 ± 9 days). There were no deep vein thromboses during follow-up. One patient developed septic thrombophlebitis that was successfully managed with antibiotics.

Conclusion

Ultrasound-guided CA glue injection is a simple and low risk procedure that effectively closes incompetent perforator veins.

A Retrospective Study of Deep Vein Insufficiency Treatment Device: ICT

Objective: This study aimed to evaluate the efficacy and safety of a newly developed, leak closure Internal Compression Therapy (ICT) (Invamed, Ankara, Turkey) device during a single-session procedure in a group of patients with primary deep valve incompetence. Methods: There were 286 patients who were diagnosed with deep venous reflux by duplex scanning. They underwent valvular leak operations to treat primary deep venous insufficiency. Follow-up visits were on the third day, first month, sixth month and twelfth month. At each visit, duplex scanning and a clinical examination were performed. Successful treatment was defined as deep vein valves without reflux. Any patency or reflux over 1 sec was considered a failure. Results: The study enrolled 286 patients with deep venous insufficiency. Procedural technical success was 100%. At the one-year follow-up, the overall success, among all patients, was 92%. No significant morbidity or mortality related to the procedure were observed. All patients had major improvements in venous clinical severity score (VCSS) scores postoperatively. VCSS scores at pre-intervention, and at the twelfth month, were 20.7±5.9 and 3.9±0.9, respectively (p<0.001). Conclusion: After the twelve-month follow-up, the postprocedural outcomes indicate the ICT device is safe and effective.

Early results of an Asian prospective multicenter VenaSeal real-world postmarket evaluation to investigate the efficacy and safety of cyanoacrylate endovenous ablation for varicose veins

OBJECTIVE

The aim of A Singapore VenaSeal Real-World Post-Market Evaluation Study (ASVS) was to evaluate the performance of cyanoacrylate closure (CAC) for varicose veins in a prospective multiracial Singaporean Asian cohort. We report early clinical and patient satisfaction outcomes at 3 months after intervention.

METHODS

There were 100 patients (151 legs; 156 truncal veins) who underwent CAC between April and December 2018. Of the 151 legs, 49 (32.5%) were treated for great saphenous vein (GSV) incompetence, 96 (63.6%) for bilateral GSV incompetence, 1 (0.7%) for small saphenous vein (SSV) incompetence, and 5 (3.3%) for combined unilateral GSV and SSV reflux. At baseline, 68 legs (45.0%) had C4 to C6 disease, and 67 legs (44.4%) had concomitant multiple stab avulsions. Patients were reviewed at 2 and 12 weeks by duplex ultrasound to check for venous recanalization (defined as ≥5 cm in length), pain score, revised Venous Clinical Severity Score, EuroQol-5 Dimension questionnaire score, Aberdeen Varicose Vein Questionnaire score, 14-item Chronic Venous Insufficiency Questionnaire (CIVIQ-14) for quality of life measures, and patient satisfaction. Time to return to work and normal activities were also recorded.

RESULTS

There were 59 female patients, and mean age was 60.1 ± 12.7 years. There was 100% technical success. Patients tolerated the procedure well and reported low periprocedural pain (mean pain score, 2.9 [range, 0-9]). Patient surveys at the 3-month interval showed high satisfaction rates, with 72 of 91 (79.1%) being extremely or very satisfied. By day 10, of 100 patients, 93 (93%) resumed daily activities, whereas 36 (36%) had returned to work. At 2 weeks, GSV and SSV were completely occluded in 150 of 150 (100%) and 6 of 6 (100%) veins, respectively. At 3 months, GSV and SSV occlusion rates were 140 of 141 (99.3%) and 6 of 6 (100%), respectively. Transient superficial phlebitis was reported in 27 of 151 (18 %) legs, which was self-limited. At 3 months, revised Venous Clinical Severity Score improved from 5.00 (range, 1.00-18.00) to 1.00 (0.00-10.00; P < .001); EuroQol-5 Dimension score, from 0.686 (-0.382 to 1.00) to 1.00 (0.12-1.00; P < .001); Aberdeen Varicose Vein Questionnaire score, from 17.14 (1.29-61.15) to 4.83 (0.00-57.12; P < .001); and 14-item Chronic Venous Insufficiency Questionnaire, from 19.64 (1.79-73.21) to 7.14 (0.00-51.79; P < .001).

CONCLUSIONS

CAC has a high safety profile and is an effective way to block refluxing truncal veins in Asian patients at early follow-up. Patients are highly satisfied and report low postoperative pain. There is significant continued quality of life improvement at 3 months. Early results are encouraging, but we await further prospective long-term follow-up from the study.

Cyanoacrylate closure for peripheral veins: Consensus document of the Australasian College of Phlebology

Background

Cyanoacrylates are fast-acting adhesives used in procedural medicine including closure of superficial wounds, embolization of truncal vessels pre-operatively, vascular anomalies, visceral false aneurysms, endoleaks, gastrointestinal varices and gastrointestinal bleeding. More recently, catheter-directed cyanoacrylate adhesive closure was introduced as an alternative to endovenous thermal ablation (ETA) to occlude superficial veins of the lower limbs.

Objectives

To formulate policies for the safe and effective delivery of cyanoacrylate adhesive closure procedures in Australasia, based on current experience and evidence.

Methods

A panel of phlebologists including vascular surgeons, interventional radiologists, dermatologists and research scientists systematically reviewed the available data on cyanoacrylate products used in medicine and shared personal experience with the procedure. The reviewed material included bibliographic and biomedical data, material safety data sheets and data requested and received from manufacturers. Results and recommendations: Cyanoacrylate adhesive closure appears to be an effective treatment for saphenous reflux with occlusion rates at 36 months of 90–95%. We recommend a maximum dose of 10 mL of cyanoacrylate per treatment session. Serious complications are rare, but significant. Hypersensitivity to acrylates is reported in 2.4% of the population and is an important absolute contraindication to cyanoacrylate adhesive closure. 1 Post-procedural inflammatory reactions, including hypersensitivity-type phlebitis, occur in 10–20% of patients. 2 In the long term, cyanoacrylate adhesive closure results in foreign-body granuloma formation within 2–12 months of the procedure. We recommend against the use of cyanoacrylate adhesive closure in patients with uncontrolled inflammatory, autoimmune or granulomatous disorders (e.g. sarcoidosis). Caution should be exercised in patients with significant active systemic disease or infection and alternative therapies such as thermal ablation and foam sclerotherapy should be considered.

Conclusions

Cyanoacrylate adhesive closure appears to be an effective endovenous procedure, with short-term closure rates comparable to ETA and therefore greater efficacy than traditional surgery for treating superficial veins of the lower limbs. Ongoing data collection is required to establish the long-term safety.

European College of Phlebology guideline for truncal ablation

Background

The purpose of the guideline was to achieve consensus in the care and treatment of patients with chronic venous disease, based on current evidence.

Method

A systematic literature search was performed in PubMed, Embase, Cinahl, and the Cochrane library up until 1 February 2019. Additional relevant literature were added through checking of references. Level of evidence was graded through the GRADE scale and recommendations were concluded.

Results

For the treatment of great and small saphenous vein reflux, endovenous ablation with laser or radiofrequency was recommended in preference to surgery or foam sclerotherapy. If tributaries are to be treated it should be done in the same procedure. Treatment with mecanicochemical ablation and glue can be used but we still need long term follow up results.

Conclusion

For the treatment of truncal varicosities, endovenous ablation with laser or radiofrequency combined with phlebectomies is recommended before surgery or foam.

Endovenous cyanoacrylate glue to treat varicose veins and chronic venous insufficiency—Experience gained from our first 100+ truncal venous ablations in a multi-ethnic Asian population using the Medtronic VenaSeal™ Closure System

Objectives

The aim of this prospective single-centre study is to assess the effectiveness and patient experience of the VenaSeal™ Closure System, a novel non-thermal, non-tumescent catheter technique, which uses cyanoacrylate glue to occlude the refluxing truncal superficial veins to treat varicose veins and chronic venous insufficiency, in a multi-ethnic Asian population from Singapore.

Methods

Seventy-seven patients (93 legs; 103 procedures) underwent VenaSeal™ Closure System ablation. Forty-nine (63.6%) for great saphenous vein incompetence, 16 (20.8%) bilateral great saphenous vein, 2 (2.6%) small saphenous vein and 10 (13.0%) combined unilateral great saphenous vein and small saphenous vein/anterior thigh vein reflux. In addition, 65/93 legs (69.9%) had C4–C6 disease. Patients were reviewed at 2 weeks, 3, 6 and 12 months post-procedure.

Results

There was 100% technical success. 28/77 (36.4%) underwent concomitant phlebectomies. All procedures were well tolerated with a mean post-operative pain score of 3.0 (range: 0–5). After three months, median patient satisfaction was 9.0 (interquartile range: 7.0–10.0). At two-week follow-up, the great saphenous vein was completely occluded in 88/88 (100%) veins and small saphenous vein completely closed in 11/11 (100%) veins. At three-month follow-up, the great saphenous vein was occluded in 51/53 (96.2%) veins and small saphenous vein completely closed in 5/5 (100%) veins. At six-month follow-up, the great saphenous vein was completely occluded in 42/45 (93.3%) veins and small saphenous vein completely closed in 5/7 (71.4%) veins. At one year, great saphenous vein and small saphenous vein occlusion rates were 54/59 (91.5%) and 5/8 (62.5%), respectively. There was one deep vein thrombosis. Transient superficial phlebitis was reported in 10/93 (10.8%) legs, which were all self-limiting. There were 9/103 (8.7%) anatomical recurrences, but no patients required re-intervention as they were asymptomatic.

Conclusions

Cyanoacrylate glue is a safe and efficacious modality to ablate refluxing saphenous veins in Asian patients in the short term. There is a high satisfaction rate and peri-procedural pain is low. Early results are promising but further evaluation and longer term follow-up are required.

Twelve-month efficacy and complications of cyanoacrylate embolization compared with radiofrequency ablation for incompetent great saphenous veins

OBJECTIVE

In this study, the clinical results of radiofrequency ablation (RFA) and n-butyl-cyanoacrylate embolization (CAE) methods were compared in the treatment of incompetent great saphenous veins (GSVs).

METHODS

We analyzed retrospectively 244 patients (128 patients in the RFA group, 116 patients in the CAE group) with incompetent GSVs who were treated with RFA and CAE according to the patients' choice between June 2013 and June 2016. All patients were thoroughly examined preoperatively and at 1, 3, 6, and 12 months after the operation, and the clinical results and the quality of life were evaluated. Color Doppler ultrasound (CDUS) results were compared between two groups after the operation and at 12 months. Complete vein occlusion was defined as the success of the treatment.

RESULTS

There was no significant difference between patients treated with RFA or CAE in terms of demographic and clinical features. In CDUS after operation, total occlusion was detected in the saphenous vein in both groups. At the 12-month CDUS, complete occlusion of the GSV was observed in 99.5% of the CAE group and 96.6% of the RFA group (P = .072). Skin burn, which we consider a major complication, occurred only in one patient. No other major complications were seen in either group. Severe pain, ecchymosis, and sensitivity were the most common of the side effects, and these were significantly higher in RFA group than in CAE group. Severe pain occurred in 12.5% of the RFA patients and 4.3% of the CAE patients (P = .042), ecchymosis occurred in 20.3% of the RFA patients and 12% of the CAE patients (P = .044), and sensitivity occurred in 21.9% of the RFA patients and 12.1% of the CAE patients (P = .038), respectively.

CONCLUSIONS

Based on the present data, our findings suggest that CAE is as effective as RFA ablation with similar rates of successful occlusion and can be associated with less pain and fewer complications than RFA; it also may yield better patient comfort. The current results should be verified with further randomized, controlled trials with longer term follow-up and larger patient groups.

Expert review on the VenaSeal® system for endovenous cyano-acrylate adhesive ablation of incompetent saphenous trunks in patients with varicose veins

INTRODUCTION

The treatment of incompetent truncal veins has been innovated by the introduction of minimally invasive non-thermal non-tumescent (NTNT) techniques. One of these consists of the use of cyanoacrylate glue to occlude the vein lumen by means of the VenaSeal device. Areas covered: This expert-review aims to evaluate NTNT ablation of incompetent saphenous trunks using the VenaSeal device. Expert commentary: Cyanoacrylate adhesive embolization of incompetent truncal veins using the VenaSeal device is a safe and efficacious innovative technique. Further studies are needed to evaluate anatomical and clinical outcomes at long term.

A new non-tumescent endovenous ablation method for varicose vein treatment: Early results of N-butyl cyanoacrylate (VariClose®)

Objective

This report aims to present the early results of a retrospective study of the use of N-butyl cyanoacrylate (VariClose®)-based non-tumescent endovenous ablation for the treatment of patients with varicose veins.

Method

One hundred and eighty patients with varicose veins due to incompetent saphenous veins were treated with the VariClose® endovenous ablation method between May 2014 and November 2014. The patient sample consisted of 86 men and 94 women, with a mean age of 47.7 ± 11.7 years. The patients had a great saphenous vein diameter greater than 5.5 mm and a small saphenous vein diameter greater than 4 mm in conjunction with reflux for more than 0.5 s. Patients with varicose veins were evaluated with venous duplex examination, Clinical, Etiological, Anatomical and Pathophysiological classification (CEAP), and their Venous Clinical Severity Scores were recorded.

Results

The median CEAP score of patients was three, and the saphenous vein diameters were between 5.5 and 14 mm (mean of 7.7 ± 2.1 mm). A percutaneous entry was made under local anesthesia to the great saphenous vein in 169 patients and to the small saphenous vein in 11 patients. Duplex examination immediately after the procedure showed closure of the treated vein in 100% of the treated segment. No complications were observed. The mean follow-up time was 5.5 months (ranging from three to seven months). Recanalization was not observed in any of the patients during follow-up. The average Venous Clinical Severity Scores was 10.2 before the procedure and decreased to 3.9 after three months (p < 0.001).

Conclusion

The application of N-butyl cyanoacrylate (VariClose®) is an effective method for treating varicose veins; it yielded a high endovenous closure rate, with no need for tumescent anesthesia. However, long-term results are currently unknown.

Cyanoacrylate adhesive perforator embolization (CAPE) of incompetent perforating veins of the leg, a feasibility study

Consideration of treating incompetent perforating veins remains a conundrum based on scientific evidence available till date. While subfascial endoscopic perforator surgery (SEPS) proved to be a worthy alternative for open surgery, other even less invasive techniques were being introduced by the late nineties of the last century. Percutaneous thermo-ablation techniques are still being used today and seem more effective than non-thermal techniques. However, thermal techniques require anaesthesia and potentially may cause inadvertent damage to surrounding tissues such as nerves. Cyanoacrylate adhesive has a proven record, but not for the treatment of chronic venous disease of the leg. Innovation has led to the development of the VenaSeal® Sapheon Closure System which has been designed to use a modified cyanoacrylate glue as a new therapy for truncal vein incompetence. This paper explores the feasibility of ultrasound guided cyanoacrylate adhesive perforator embolization (CAPE). Results show a 76% occlusion rate of incompetent perforating veins without serious complications leading to the conclusion that further investigation with a dedicated delivery device in a larger patient population is warranted.