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Westby D, Gasior S, Twyford M, Power Foley M, Lowery A, Walsh SR. Pharmacological Thromboprophylaxis for VTE Post-Endovenous Ablation of Varicose Veins: Network Meta-Analysis. Vasc Endovascular Surg 2024:15385744241245079. [PMID: 38610070 DOI: 10.1177/15385744241245079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
OBJECTIVE Endovenous ablation has revolutionized treatment of varicose vein surgery but is associated with a risk of venous thromboembolism. There is no consensus regarding anticoagulation protocols for these patients. This network meta-analysis (NMA) aims to identify which anticoagulant is optimal in this cohort for clot prevention with minimal risk of adverse bleeding events. METHODS Library databases were searched for studies where patients were treated with one or more anticoagulants following endovenous ablation for varicose veins. The methodological quality of included studies was quantified using the Risk of Bias (ROB) assessment tools. Findings were reported using the meta-analysis of observational studies in epidemiology (MOOSE) checklist. Statistical analysis was carried out using metainsight (rpackage). RESULTS Observational data on just under 1500 patients prescribed post ablation anticoagulation (Rivaroxaban, Enoxaparin, Fondaparinux) were analyzed. Patient characteristics were comparable across the cohorts. 81 thrombotic and 40 minor bleeding events occurred in total. Overall rivaroxaban is found to be superior to the other agents. CONCLUSIONS This NMA indicates that prophylactic rivaroxaban is the highest ranked anticoagulant for thromboprophylaxis in patients post endovenous ablation for varicose veins, with a low risk of adverse bleeding. The choice whether to anticoagulate these patients is likely to remain at the discretion of the treating clinician.
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Affiliation(s)
- Daniel Westby
- Department of Vascular and Endovascular Surgery, University Hospital Galway, Galway, Ireland
| | - Sara Gasior
- Department of Vascular and Endovascular Surgery, University Hospital Galway, Galway, Ireland
| | - Mark Twyford
- Department of Vascular and Endovascular Surgery, University Hospital Galway, Galway, Ireland
| | - Megan Power Foley
- Department of Vascular and Endovascular Surgery, University Hospital Galway, Galway, Ireland
| | - Aoife Lowery
- Discipline of Surgery, University of Galway, Galway, Ireland
| | - Stewart R Walsh
- Department of Vascular and Endovascular Surgery, University Hospital Galway, Galway, Ireland
- Discipline of Surgery, University of Galway, Galway, Ireland
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Keohane C, Westby D, Nolan FC, Twyford M, Tawfick W, Walsh SR. Hyperbaric Oxygen as an Adjunct in the Treatment of Venous Ulcers: A Systematic Review. Vasc Endovascular Surg 2023:15385744231162924. [PMID: 36891617 DOI: 10.1177/15385744231162924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
BACKGROUND The use of Hyperbaric Oxygen Therapy (HBOT) in diabetic wounds has been studied extensively. Even though venous insufficiency is the most common cause of lower limb ulceration, there is comparatively little evidence regarding the use of HBOT for Venous Leg Ulcers (VLU). We performed a systematic-review to evaluate and synthesise available evidence, to evaluate whether patients with VLU, when treated with HBOT, had greater rates of (i) complete VLU healing or (ii) reduction in VLU area, than controls. METHODS In keeping with PRISMA guidelines, database searches of PubMed, Scopus and Embase was performed. After removal of duplicates, titles were screened for relevance by two authors, then abstracts, and in turn full text manuscripts. Data were extracted from relevant sources including one published abstract. Included studies were assessed for risk of bias using the Risk of Bias 2 (RoB-2) and Risk Of Bias In Nonrandomized Studies (ROBINS-I) tools. RESULTS Six studies were included. There was significant heterogeneity across the studies, with no standard control intervention, method of outcome reporting, or duration of follow up. Two studies reported 12 week follow up results and pooled analysis of complete ulcer healing showed no statistically significant difference between HBOT and controls for the outcome of complete ulcer healing OR 1.54 (95%CI = .50-4.75) P = .4478. A similar non-signifiacnt result was seen in four studies reporting 5-6 week follow up; OR 5.39 (95%CI = .57-259.57) P = .1136. Change in VLU area was reported in all studies, and pooled standardised mean difference was 1.70 (95%CI = .60 to 2.79) P = .0024, indicating a statistically significant benefit of HBOT in reducing ulcer area. CONCLUSION Existing evidence suggests that HBOT does not significantly affect complete healing of VLU. There is a statistically significant benefit in terms of reducing ulcer size, though in the absence of ulcer healing the clinical significance of this is not established. Current evidence does not justify widespread use of HBOT for VLU.
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Affiliation(s)
- Colum Keohane
- Specialist Registrar, Vascular Surgery, 8799National University of Ireland Galway, Galway, Ireland
| | - Daniel Westby
- Specialist Registrar, Vascular Surgery, 8799National University of Ireland Galway, Galway, Ireland
| | - Fiona C Nolan
- Specialist Registrar, Vascular Surgery, 8799National University of Ireland Galway, Galway, Ireland
| | - Mark Twyford
- Specialist Registrar, Vascular Surgery, 8799National University of Ireland Galway, Galway, Ireland
| | - Wael Tawfick
- Clinical Lecturer, 8799National University of Ireland Galway, Galway, Ireland
| | - Stewart R Walsh
- Professor of Vascular Surgery University Hospital Galway, and Associate Director Lambe Institute for Translational Research, 8799National University of Ireland Galway, Galway, Ireland
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Keohane CR, Westby D, Twyford M, Ahern T, Tawfick W, Walsh SR. Axial ablation versus terminal interruption of the reflux source (AAVTIRS): a randomised controlled trial. Trials 2022; 23:483. [PMID: 35689289 PMCID: PMC9188187 DOI: 10.1186/s13063-022-06440-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 05/31/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Treatment of superficial venous reflux has been shown to improve ulcer healing time and reduce the risk of ulcer recurrence. Terminal ablation of the reflux source (TIRS) is an alternative to formal endovenous ablation or surgery which can be performed by injecting sclerosant foam into the peri-ulcer plexus of the veins. TIRS has been shown to be successful and in our experience is the option preferred by many patients, when offered as an alternative to axial ablation (AA). AIM To determine if the proportion of ulcers healed within 6 months of endovenous treatment differs between patients undergoing AA of varicose veins or TIRS by peri-ulcer foam sclerotherapy. METHODS AAVTIRS is an assessor-blinded randomised controlled trial. Patients will be recruited from a dedicated ulcer clinic in Roscommon University Hospital and from the vascular surgical clinics in University Hospital Galway. All patients attending the ulcer clinic will be screened for eligibility. RANDOMISATION Random computer-generated sequence is stratified by ulcer size. Allocation will be concealed using sealed opaque envelopes. BLINDING Assessors reviewing wounds at follow -p visits will be blinded to patient allocation. PRIMARY ENDPOINT The proportion of ulcers healed within 6 months of enrolment. DISCUSSION This will be the first time that TIRS has been evaluated with a properly powered randomised trial in the setting of venous ulcer management. Streamlining the management of venous ulcers has broad health economic benefits. If it is found that TIRS is superior or non-inferior to AA, then a less expensive, less invasive injection can be offered as an alternative to AA in an attempt to encourage the healing of venous ulcers. If AA is found to be superior to TIRS, then this would suggest that all patients undergoing ablation in the management of venous ulcers should have their superficial reflux fully treated, building on the evidence of the EVRA trial. TRIAL REGISTRATION ClinicalTrials.gov NCT04484168. Registered on 23 July 2020.
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Affiliation(s)
- C R Keohane
- University Hospital Galway, Galway, Ireland. .,National University of Ireland Galway, Galway, Ireland.
| | - D Westby
- Roscommon University Hospital, Roscommon, Ireland.,National University of Ireland Galway, Galway, Ireland
| | - M Twyford
- University Hospital Galway, Galway, Ireland.,National University of Ireland Galway, Galway, Ireland
| | - T Ahern
- University Hospital Galway, Galway, Ireland.,National University of Ireland Galway, Galway, Ireland
| | - W Tawfick
- University Hospital Galway, Galway, Ireland.,National University of Ireland Galway, Galway, Ireland
| | - S R Walsh
- University Hospital Galway, Galway, Ireland.,Lambe Institute for Translational Research, National University of Ireland Galway, Newcastle Rd, Galway, Ireland
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Keohane CR, Twyford M, Hannon E, Tawfick W, Walsh SR. Medical management of PAD: Expand or consolidate? Ann Acad Med Singap 2021; 50:376-378. [PMID: 34100514 DOI: 10.47102/annals-acadmedsg.2021163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Colum R Keohane
- Discipline of Surgery, Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland
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Healy DA, Twyford M, Moloney T, Kavanagh EG. Systematic review on the incidence and management of endovenous heat-induced thrombosis following endovenous thermal ablation of the great saphenous vein. J Vasc Surg Venous Lymphat Disord 2021; 9:1312-1320.e10. [PMID: 33618065 DOI: 10.1016/j.jvsv.2021.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 02/04/2021] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Donagh A Healy
- Department of Vascular Surgery, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, Northern Ireland
| | - Mark Twyford
- Department of Vascular Surgery, University Hospital Limerick, University of Limerick School of Medicine, Limerick, Ireland
| | - Tony Moloney
- Department of Vascular Surgery, University Hospital Limerick, University of Limerick School of Medicine, Limerick, Ireland.
| | - Eamon G Kavanagh
- Department of Vascular Surgery, University Hospital Limerick, University of Limerick School of Medicine, Limerick, Ireland
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Nason GJ, McNamara F, Twyford M, O'Kelly F, White S, Dunne E, Durkan GC, Giri SK, Smyth GP, Power RE. Efficacy of vacuum erectile devices (VEDs) after radical prostatectomy: the initial Irish experience of a dedicated VED clinic. Int J Impot Res 2016; 28:205-208. [PMID: 27225711 DOI: 10.1038/ijir.2016.23] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 03/15/2016] [Accepted: 04/24/2016] [Indexed: 01/07/2023]
Abstract
Controversy exists regarding optimal penile rehabilitation program following radical prostatectomy (RP). Vacuum erectile devices (VEDs) have become an important component of penile rehabilitation protocols. The aim of this study was to assess the efficacy and patient satisfaction of a dedicated VED clinic. A voluntary telephone questionnaire was performed of all patients who attended a VED clinic to date in two university teaching hospitals. Patient demographics, histopathological characteristics and functional status (International Index of Erectile Function (IIEF) scores) were obtained from a retrospective review of a prospectively maintained database. Sixty-five men attended the dedicated VED clinic in the two university teaching hospitals. Forty-men (76.3%) men purchased a VED following the dedicated clinic. There was significant differences noted between the mean preoperative and the 3-month postoperative IIEF scores (22.08±3.16 vs 11.3±3.08, P=0.0001) and between the 3-month postoperative IIEF score and the post-VED use IIEF score (11.3±3.08 vs 16.74±2.62, P=0.0001). Despite VED use, there was a significant reduction in erectile function from presurgery status (22.08±3.16 vs 16.74±2.62, P=0.0001). All patients reported that the dedicated VED was helpful and would recommend it to other patients. Our study demonstrates that, despite a reduction in erectile function after RP, successful erections are attainable with a VED. There is potential and need for the development of a standard penile rehabilitation program and treatment of ED after RP internationally.
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Affiliation(s)
- G J Nason
- Department of Urology, Beaumont Hospital, Dublin, Ireland
| | - F McNamara
- Department of Urology, Beaumont Hospital, Dublin, Ireland.,Department of Urology, University Hospital Limerick, Limerick, Ireland
| | - M Twyford
- Department of Urology, Beaumont Hospital, Dublin, Ireland
| | - F O'Kelly
- Department of Urology, Beaumont Hospital, Dublin, Ireland
| | - S White
- Department of Urology, Beaumont Hospital, Dublin, Ireland
| | - E Dunne
- Department of Urology, Beaumont Hospital, Dublin, Ireland
| | - G C Durkan
- Department of Urology, University Hospital Limerick, Limerick, Ireland.,Department of Urology, University College Hospital Galway, Galway, Ireland
| | - S K Giri
- Department of Urology, University Hospital Limerick, Limerick, Ireland
| | - G P Smyth
- Department of Urology, Beaumont Hospital, Dublin, Ireland
| | - R E Power
- Department of Urology, Beaumont Hospital, Dublin, Ireland
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