Saphenofemoraler Neoreflux nach Lasertherapie, Crossektomie/ Stripping oder Crossektomie/ Lasertherapie

Einleitung: In der vorliegenden Arbeit gilt es, mittelfristige Refluxbefunde nach 2 und 6 Monaten sowie die klinischen und sonografischen Befunde im Bereich der Magnacrosse zu beschreiben, die für eine langfristige Entwicklung von Bedeutung sein könnten.

Material und Methode: Die offene multizentrisch prospektiv randomisierte kontrollierte 3-armige Vergleichsstudie zwischen der endoluminalen Lasertherapie und der invaginierend durchgeführten modifizierten offen operativen Therapie der Stammvarikosis der Vena saphena magna (VSM) hat den primären Endpunkt der Beobachtung der mittelund langfristigen Rezidiventwicklung mit einem Ausgangspunkt im Inguinalbereich. (Laserprozedur mit 980 nm Laser (Biolitec), Continous-Mode-Verfahren mit 30 Watt). Um die Bedeutung der Crossektomie in Bezug zur Entstehung eines Crosserezidivs herauszuarbeiten wurde eine dritte Gruppe gebildet, in der die Lasertherapie des Stammvenenabschnitts mit einer Crossektomie der Vena saphena magna kombiniert wurde.

Ergebnisse: 449 Patienten wurden perioperativ und nach 2 Monaten untersucht. 388 Patienten konnten nach 6 Monaten nachuntersucht werden. Nach 2 und 6 Monaten zeigten sich signifikant mehr inguinale Refluxe und Seitenäste in den Lasergruppen.

Ausblick: Die Befunde werden in einer derzeit laufenden Nachuntersuchung überprüft und auf ihre klinische Relevanz für das Langzeitergebnis getestet.

Endovenous laser ablation with and without high ligation compared to high ligation and stripping for treatment of great saphenous varicose veins: Results of a multicentre randomised controlled trial with up to 6 years follow-up

Objectives

High ligation and stripping was compared to endovenous laser ablation for the therapy of great saphenous vein varicosity. Long-term efficacy was assessed in terms of avoidance of inguinal reflux and mechanisms of recurrence were investigated.

Design

Multicentre, randomised, three-arm, parallel trial.

Materials and methods

A total of 449 patients were randomised into three different treatment groups: high ligation and stripping group ( n = 159), endovenous laser ablation group ( n = 142; 980 nm, 30 W continuous mode, bare fibre) or a combination of laser ablation with high ligation (endovenous laser ablation group/ high ligation group, n = 148). Patients were examined clinically and by duplex ultrasound once a year. The primary end point of this study is inguinal reflux at the saphenofemoral junction after 2 years. This paper presents secondary data on sonographically determined inguinal reflux and clinical recurrences in the treated area after up to 6 years of follow-up.

Results

Median time to follow-up was 4.0 years; the mean time follow-up 3.6 years. Follow-up rates were: 2 years 74%, 3 years 47%, 4 years 39%, 5 years 36% and 6 years 31%. Most reflux into the great saphenous vein appeared in the endovenous laser ablation group (after 6 years: high ligation/stripping versus endovenous laser ablation p = 0.0102; high ligation/endovenous laser ablation vs. endovenous laser ablation p < 0.0002). Furthermore, more refluxive side branches were also observed in the endovenous laser ablation group (after 6 years high ligation/stripping vs. endovenous laser ablation p = 0.0569; high ligation/endovenous laser ablation vs. endovenous laser ablation p = 0.0111). In terms of clinical recurrence during the 6 years post therapy, no significant differences between the three treatment groups were observed ( p values from log-rank test: high ligation/stripping vs. endovenous laser ablation p = 0.5479; high ligation/stripping vs. high ligation/endovenous laser ablation p = 0.2324; high ligation/endovenous laser ablation vs. endovenous laser ablation p = 0.0848). The postoperative decline and later development in Class C (clinical etiological anatomical pathological) went parallel in all groups.

Conclusions

Clinical recurrence appears with the same frequency in all three treatment groups, but the responsible pathological mechanisms seem to differ. Most reflux into the great saphenous vein and side branches appears after endovenous laser ablation, whereas more saphenofemoral junction-independent recurrences are seen after high ligation/stripping.

Endovenous laser ablation with and without high ligation compared with high ligation and stripping in the treatment of great saphenous varicose veins: initial results of a multicentre randomized controlled trial

OBJECTIVES

To compare reflux recurrences at the saphenofemoral junction after endovenous laser ablation (EVLA) with or without high ligation with high ligation and stripping (HL/ST) of the great saphenous vein (GSV) in patients with varicosity of the GSV. Design Multicentre, randomized, three-arm, parallel trial. Material and Methods Patients with varicosity of the GSV were randomized to one of three groups: HL/ST, laser ablation (980 nm) or a combination of laser ablation with high ligation (EVLA/HL). Patients were examined clinically and by ultrasound pre- and postoperatively and after two months. The primary endpoint of this ongoing study is the inguinal venous reflux (IVR) in the proximal section of the GSV after two years. We present data after two months. Secondary endpoints include postoperative ecchymosis, pain or discomfort, saphenous syndrome. Groups were compared by chi-squared test.

RESULTS

A total of 449 patients were randomized; mean age 48 years and 71.2% were women. Postoperative ecchymosis developed among 69.2% in the HL/ST group, in 50.4% of the EVLA group and in 50.3% of the EVLA/HL group (P = 0.0007). Postoperative pain after one day occurred in 32.7% in the HL/ST group. Discomfort occurred after surgery in 37.3% in the EVLA group, and in 50.0% in the EVLA/HL group (P = 0.0069). Early postoperative nervus saphenous syndrome developed in 0.6% in the HL/ST group, in 3.7% in the EVLA group and in 6.1% in the EVLA/HL group (P = 0.0341). After two months, IVR persisted in 38 cases (8.5%) in the laser group, in 10 (2.2%) in the EVLA/HL group and none in the HL/ST group (P = 0.6800).

CONCLUSIONS

After two months IVR was more often seen in both EVLA groups compared with the HL/ST group. There were significantly more postoperative ecchymosis in the HL/ST. Postoperative pain occurred significantly more often in the EVLA/HL group. Peri- and postoperative data showed significant differences between the three groups. For definitive results concerning the primary endpoint of IVR the later follow-up has to be waited for.

Proximal deep venous thrombosis following PTA of the superficial femoral artery--an obligation to disclose a complication that is rarely taken into account

We report two cases of femoral vein thrombosis after arterial PTA and subsequent pressure stasis. We discuss the legal consequences of these complications for information policies. Because venous thrombembolism following an arterial PTA might cause serious sequel or life threatening complications, there is a clear obligation for explicit information of the patients about this rare complication.

[Strategic risk reduction in the operative therapy for abdominal aortic aneurysms]

Advances in early diagnosis of abdominal aortic abnormalities, enhanced pre-and post-surgical care and improved pharmacological treatment, as well as new interventional strategies and surgical techniques have led to a considerable increase of those patients, who undergo surgical therapy, either using classical trans-abdominal open or endovascular techniques. These patients, as a result of their often underlying multi-morbidity, are prone to secondary complications that often require individual solutions. We present and discuss two cases of post-surgical complications that required individual strategies for risk reduction. The first case demonstrates the endovascular approach to a complication following open aortic surgery, the second describes a surgical intervention to solve a problem following endovascular therapy.

Iatrogener Verschluss der Arteria femoralis communis nach Krossektomie der Vena saphena magna

Der Fall eines arteriellen Verschlusses bei einer Krossektomie der Vena saphena magna wird mit seiner Klinik, dem histologischem Nachweis des Verschlusses, seiner Ursache und den Konsequenzen dargestellt. Die Diskussion berücksichtigt in der Literatur geschilderte Majorkomplikationen dieser Operation.

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Five months after the initial abdominal surgery, a female patient presented with a deep venous thrombosis of the right leg. A guide wire, lost during perisurgical insertion of a central venous catheter using Seldinger's technique, was identified and surgically removed. The guide wire had previously remained undetected despite regular radiological controls. The article presents details of the case together with a review of the literature regarding potential complications of Seldinger's technique. Common reasons and possible options for preventive and therapeutic strategies will be discussed.

[Biodegradation of a PTFE prosthesis]

Processes of biodegradation of PTFE--as they were not seen before for this type of graft--are demonstrated by clinical examples. As it is possible to subsume these results to regularly described processes of incorporation of alloplastic material, it is to be expected that there will be more cases than those observed by us up to now.