Short-term psychosocial outcomes of adding a non-contrast abdominal computed tomography (CT) scan to the thoracic CT within lung cancer screening

OBJECTIVES

To evaluate psychological, social, and financial outcomes amongst individuals undergoing a non-contrast abdominal computed tomography (CT) scan to screen for kidney cancer and other abdominal malignancies alongside the thoracic CT within lung cancer screening.

SUBJECTS AND METHODS

The Yorkshire Kidney Screening Trial (YKST) is a feasibility study of adding a non-contrast abdominal CT scan to the thoracic CT within lung cancer screening. A total of 500 participants within the YKST, comprising all who had an abnormal CT scan and a random sample of one-third of those with a normal scan between 14/03/2022 and 24/08/2022 were sent a questionnaire at 3 and 6 months. Outcomes included the Psychological Consequences Questionnaire (PCQ), the short-form of the Spielberger State-Trait Anxiety Inventory, and the EuroQoL five Dimensions five Levels scale (EQ-5D-5L). Data were analysed using regression adjusting for participant age, sex, socioeconomic status, education, baseline quality of life (EQ-5D-5L), and ethnicity.

RESULTS

A total of 380 (76%) participants returned questionnaires at 3 months and 328 (66%) at 6 months. There was no difference in any outcomes between participants with a normal scan and those with abnormal scans requiring no further action. Individuals requiring initial further investigations or referral had higher scores on the negative PCQ than those with normal scans at 3 months (standardised mean difference 0.28 sd, 95% confidence interval 0.01-0.54; P = 0.044). The difference was greater in those with anxiety or depression at baseline. No differences were seen at 6 months.

CONCLUSION

Screening for kidney cancer and other abdominal malignancies using abdominal CT alongside the thoracic CT within lung cancer screening is unlikely to cause significant lasting psychosocial or financial harm to participants with incidental findings.

A preoperative supervised exercise program potentially improves long-term survival after elective abdominal aortic aneurysm repair

OBJECTIVE

A preoperative supervised exercise program (SEP) improves cardiorespiratory fitness and perioperative outcomes for patients undergoing elective abdominal aortic aneurysm (AAA) repair. The aim of this study was to assess the effect of a preoperative SEP on long-term survival of these patients. A secondary aim was to consider long-term changes in cardiorespiratory fitness and quality of life.

METHODS

Patients scheduled for open or endovascular AAA repair were previously randomized to either a 6-week preoperative SEP or standard management, and a significant improvement in a composite outcome of cardiac, pulmonary, and renal complications was seen following SEP. For the current analysis, patients were followed up to 5 years post-surgery. The primary outcome for this analysis was all-cause mortality. Data were analyzed on an intention to treat (ITT) and per protocol (PP) basis, with the latter meaning that patients randomized to SEP who did not attend any sessions were excluded. The PP analysis was further interrogated using a complier average causal effect (CACE) analysis on an all or nothing scale, which adjusts for compliance. Additionally, patients who agreed to follow-up attended the research center for cardiopulmonary exercise testing and/or provided quality of life measures.

RESULTS

ITT analysis demonstrated that the primary endpoint occurred in 24 of the 124 participants at 5 years, with eight in the SEP group and 16 in the control group (P = .08). The PP analysis demonstrated a significant survival benefit associated with SEP attendance (4 vs 16 deaths; P = .01). CACE analysis confirmed a significant intervention effect (hazard ratio, 0.36; 95% confidence interval, 0.16-0.90; P = .02). There was no difference between groups for cardiorespiratory fitness measures and most quality of life measures.

CONCLUSIONS

These novel findings suggest a long-term mortality benefit for patients attending a SEP prior to elective AAA repair. The underlying mechanism remains unknown, and this merits further investigation.

Aortoiliac graft-enteric fistula presenting as gastrointestinal hemorrhage: A report on a complex case management

Key Clinical Message

Iliac artery-enteric fistula is a rare cause of lower GI bleeding and can cause life-threatening consequences. A high degree of clinical suspicion is needed in patients with previous aortic surgery to allow early multidisciplinary intervention.

Abstract

This case study discusses the staged management of a 78-year-old patient presenting with life-threatening lower gastrointestinal (GI) bleeding secondary to an aortoiliac graft-enteric fistula (GEF) into the sigmoid colon on the background of an adenocarcinoma and diverticular disease. The patient had an aorto bi-iliac synthetic dacron graft repair of an abdominal aortic aneurysm (AAA) some 20 years ago. Here, we present a case of successful endovascular treatment of massive hemorrhage as a bridge to definitive second-stage dacron graft explant and autologous vein reconstruction with a simultaneous anterior resection.

End of Life Care and Advance Care Planning for Outpatients with Inoperable Aortic Aneurysms

OBJECTIVE

A significant proportion of patients with abdominal and thoracic aortic aneurysms (AA) do not proceed to intervention after reaching treatment threshold diameter due to a combination of poor cardiovascular reserve, frailty and aortic morphology. This patient cohort has a high mortality, however, until this study, there exist no studies on the end of life care conservatively managed patients receive.

DESIGN

This is a retrospective multicentre cohort study of 220 conservatively managed AA patients referred to Leeds Vascular Institute (UK) and Maastricht University Medical Centre (Netherlands) for intervention between 2017 and 2021.

METHODS

Demographic details, mortality, cause of death, advance care planning and palliative care outcomes were analysed to examine predictors of palliative care referral and efficacy of palliative care consultation.

RESULTS

A total of 1506 AA patients were seen over this time period, giving a non-intervention rate of 15%. There was a 3-year mortality rate of 55%, a median survival of 364 days and rupture was the reported cause of death in 18% of the decedents. Median follow up was 34 months. Only 8% of all patients and 16% of decedents received palliative care consultation, which took place a median of 3.5 days before death. Patients over 81 years of age were more likely to have advance care planning. Only 5% and 23% of conservatively managed patients had documentation of preferred place of death and care priorities respectively. Patients with palliative care consultation were more likely to have these in place.

CONCLUSION

Only a small proportion of conservatively treated patients had advance care planning and this was far below international guidelines on end of life care for adults, which recommend it for each of these patients. Pathways and guidance should be implemented to ensure patients not offered AA intervention receive end of life care and advance care planning.

Analyzing Sex Differences in Intensity of Cardiovascular Disease Prevention Medications in Patients With Abdominal Aortic Aneurysms-A Single-Center Cross-Sectional Study

BACKGROUND

Patients with abdominal aortic aneurysm (AAA) are at a significant risk of cardiovascular events, similar to that of patients who have already experienced a major cardiac event. The European Society for Vascular Society AAA guidelines suggest that antiplatelet therapy and lipid-lowering therapy (LLT) should be considered in all patients with AAA. This study explores the overall prevalence and intensity of antithrombotic therapy and LLT, and lipid profile monitoring in a single center AAA surveillance cohort alongside any sex differences.

METHODS

This was a retrospective, single center, cross-sectional study of 614 patients enrolled in the AAA surveillance program of a tertiary vascular surgery unit. All patients undergoing at least 1 surveillance scan from January 1, 2018, to December 31, 2020, were assessed. Electronic hospital records linked to real-time primary care records were interrogated for data on demographics, comorbidities, antiplatelet and LLT prescriptions, and serum cholesterol laboratory results. An analysis of covariance test was used to account for the effects of confounding comorbidities.

RESULTS

Twenty-one percent of patients were not on antithrombotic therapy, and 20% of patients were not on LLT which reflects a group of patients receiving sub-optimal clinical care. In total, 47% of the cohort were on low/moderate intensity statin therapy which reflects a group of patients where care can be improved upon. Female sex was independently associated with a reduced likelihood of being prescribed LLT (P = 0.008, eta squared (η_p²) = 0.012, small effect size) but not antithrombotic therapy (P = 0.202). Fewer women underwent low-density lipoprotein cholesterol (LDL-C) monitoring (mean difference 9%, P = 0.040) and achieved the European Society of Cardiology-European Atherosclerosis Society- LDL-C target of <1.4 mmol/L (mean difference 9%, P = 0.040).

CONCLUSIONS

Overall, there is room for improvement in these aspects of cardiovascular risk prevention for both sexes. Sex differences in the prescription of LLT, the prevalence of lipid profile monitoring, and likelihood of achieving LDL-C targets exist among patients with AAA, with a lower prevalence in women.

The impact of flash glucose monitoring on adults with type 1 Diabetes' eating habits and relationship with food

AIM

To gain a better understanding of how the FreeStyle Libre (FSL) flash glucose monitor influences the eating habits and relationship with food of adults with type 1 diabetes (T1D).

METHODS

Reflexive thematic analysis was conducted on fifteen semi-structured interviews conducted with adults with T1D, exploring their experiences of at least one year of FSL use.

RESULTS

Four themes were constructed from the qualitative data: (1) Personal Food Story (what food represented before and after diabetes diagnosis), (2) New Opportunities (the FSL offered novel discoveries and increased self-confidence regarding food choices), (3) Body as a Machine (participants viewed their bodies as a collection of complex processes requiring continuous maintenance), and (4) re-evaluating Diabetes (participants expressed a shift in their expectations of themselves and their diabetes management). Although the FSL offered participants more freedom and flexibility with their eating, this was constrained by feeling forever under scrutiny from the data.

CONCLUSIONS

Findings suggest the FSL influences users' eating habits, including when, why, what and how much they eat. Participants described both the positive and negative impact of these changes on their emotional wellbeing and relationship with diabetes, arguing for a need to address patients' relationship with food in routine clinic care.

FT-IR spectroscopy analysis of HF-treated mineral soils, a direct approach for deciphering organo-mineral interactions

Soil organic matter (SOM) constitutes roughly 60% organic carbon (OC) and therefore plays a crucial role in regulating global climate. However, our understanding of the long-term dynamics of the soil carbon pool remains constrained by limitations in analytical approaches capable of providing high resolution molecular-level information from arguably the most complex biomaterial on the planet. In this contribution, we combine hydrofluoric acid (HF) treatment with a spectroscopic approach as a strategy to provide refined molecular-level information on the interactions between soil minerals and SOM. Critically, we have not seen the use of this combined approach anywhere in the literature and strongly believe that it could allow us to improve our overall understanding to the mechanisms and pathways that regulate SOM transformation. Results clearly illustrates which organic structures are preferentially adsorbed to soil minerals and are likely to be protected from degradation, as well as spatial co-variations of SOM with specific mineral components such as Al³⁺, Si⁴⁺ and dibasic cations such as Mg²⁺as a function of their importance in the interaction process.•Soil samples were collected from different land-use types in rural farming communities of the Upper Rio Grande Valley.•Samples were oven dried, disaggregated, sieved, treated with 10% HF, rinsed and oven dried.•Oven dried samples were subjected to Mid-infrared (4000-400 cm^-1), XRD and ED-XRF analyses.

The Yorkshire Kidney Screening Trial (YKST): protocol for a feasibility study of adding non-contrast abdominal CT scanning to screen for kidney cancer and other abdominal pathology within a trial of community-based CT screening for lung cancer

INTRODUCTION

Kidney cancer (renal cell cancer (RCC)) is the seventh most common cancer in the UK. As RCC is largely curable if detected at an early stage and most patients have no symptoms, there is international interest in evaluating a screening programme for RCC. The Yorkshire Kidney Screening Trial (YKST) will assess the feasibility of adding non-contrast abdominal CT scanning to screen for RCC and other abdominal pathology within the Yorkshire Lung Screening Trial (YLST), a randomised trial of community-based CT screening for lung cancer.

METHODS AND ANALYSIS

In YLST, ever-smokers aged 55-80 years registered with a general practice in Leeds have been randomised to a Lung Health Check assessment, including a thoracic low-dose CT (LDCT) for those at high risk of lung cancer, or routine care. YLST participants randomised to the Lung Health Check arm who attend for the second round of screening at 2 years without a history of RCC or abdominal CT scan within the previous 6 months will be invited to take part in YKST. We anticipate inviting 4700 participants. Those who consent will have an abdominal CT immediately following their YLST thoracic LDCT. A subset of participants and the healthcare workers involved will be invited to take part in a qualitative interview. Primary objectives are to quantify the uptake of the abdominal CT, assess the acceptability of the combined screening approach and pilot the majority of procedures for a subsequent randomised controlled trial of RCC screening within lung cancer screening.

ETHICS AND DISSEMINATION

YKST was approved by the North West-Preston Research Ethics Committee (21/NW/0021), and the Health Research Authority on 3 February 2021. Trial results will be disseminated at clinical meetings, in peer-reviewed journals and to policy-makers. Findings will be made available to participants via the study website (www.YKST.org).

TRIAL REGISTRATION NUMBERS

NCT05005195 and ISRCTN18055040.

Palliative Care Interventions for Peripheral Artery Disease: A Systematic Review and Narrative Synthesis

Background: Peripheral artery disease (PAD) encompasses conditions with poor outcome and severe suffering, both mentally and physically, yet utilization and research into palliative care interventions remain sparse. Objective: The purpose of this study is to identify existing evidence on palliative care intervention for chronic limb threatening ischaemia (CLTI) and abdominal aortic aneurysm (AAA). Design: We conducted a PROSPERO-registered systematic review of studies published between 1991 and 2020 in which people with PAD received palliative care interventions and at least one patient outcome was recorded. For the purpose of this study, a palliative care intervention was defined as one which aims primarily to reduce negative impact of PAD on patients' and/or caregivers' physical, emotional, psychological, social, or spiritual condition. Results: A total of 8 studies involving 87,024 patients met the inclusion criteria (4 cohort studies and 4 cross-sectional studies). Methodological quality ranged from low to moderate. The small number of studies and study heterogeneity precluded meta-analysis. Regarding our primary outcomes, only two articles recorded patient-reported outcomes. Five articles found an association between palliative care and reduction in health care utilization, a secondary outcome of the study. Most of the studies reported that palliative care was likely underused. Only two of the studies included non-hospital patients. Conclusion: Despite high mortality and morbidity associated with PAD, evidence of the effectiveness of palliative care in this group of patients is lacking. There are only a handful of articles on palliative care for people with PAD, and the majority are small, methodologically flawed and lack meaningful patient-reported outcomes. High-quality research of palliative care interventions in patients with PAD is urgently needed to better understand the impact of palliative care on quality of end of life and to develop and evaluate service-level interventions.

The Content of Pre-habilitative Interventions for Patients Undergoing Repair of Abdominal Aortic Aneurysms and Their Effect on Post-Operative Outcomes: A Systematic Review

OBJECTIVE

Patients requiring abdominal aortic aneurysm (AAA) repair are at risk of post-operative complications due to poor pre-operative state. Pre-habilitation describes the enhancement of functional capacity and tolerance to an upcoming physiological stressor, intended to reduce those complications. The ability to provide such an intervention (physical, pharmacological, nutritional, or psychosocial) between diagnosis and surgery is a growing interest, but its role in AAA repair is unclear. This paper aimed to systematically review existing literature to better describe the effect of pre-habilitative interventions on post-operative outcomes of patients undergoing AAA repair.

DATA SOURCES

EMBASE and Medline were searched from inception to October 2020. Retrieved papers, systematic reviews, and trial registries were citation tracked.

REVIEW METHODS

Randomised controlled trials (RCTs) comparing post-operative outcomes for adult patients undergoing a period of pre-habilitation prior to AAA repair (open or endovascular) were eligible for inclusion. Two authors screened titles for inclusion, assessed risk of bias, and extracted data. Primary outcomes were post-operative 30 day mortality, composite endpoint of 30 day post-operative complications, hospital length of stay (LOS), and health related quality of life (HRQL) outcomes. The content of interventions was extracted and a narrative analysis of results undertaken.

RESULTS

Seven RCTs with 901 patients were included (three exercise based, two pharmacological based, and two nutritional based). Risk of bias was mostly unclear or high and the clinical heterogeneity between the trials precluded data pooling for meta-analyses. The quality of intervention descriptions was highly variable. One exercise based RCT reported significantly reduced hospital LOS and another improved HRQL outcomes. Neither pharmacological nor nutritional based RCTs reported significant differences in primary outcomes.

CONCLUSION

There is limited evidence to draw clinically robust conclusions about the effect of pre-habilitation on post-operative outcomes following AAA repair. Well designed RCTs, adhering to reporting standards for intervention content and trial methods, are urgently needed to establish the clinical and cost effectiveness of pre-habilitation interventions.

Group practice impacts on patients, physicians and healthcare systems: a scoping review

OBJECTIVE

To identify the advantages and disadvantages that group practices have on patients, physicians and healthcare systems.

STUDY DESIGN

A scoping review was performed based on the methodology proposed by Arksey and O'Malley, and refined by Levac et al. Titles and abstracts were screened by two reviewers. A quantitative analysis was performed to assess the type, year and region of publication, as well as the population studied. A qualitative descriptive analysis was performed to identify common themes.

STUDY SETTING

MEDLINE, EMBASE and Cochrane databases were searched from database inception to October 2018 for papers which assessed outcomes relevant to the research question.

RESULTS

Our search strategy returned 2408 papers and 98 were included in the final analysis. Most papers were from the USA, were surveys and assessed physician outcomes. Advantages of group practices for patients included improved satisfaction and quality of care. Studies of physicians reported improved quality of life and income, while disadvantages included increased stress due to poor interpersonal relationships. Studies of healthcare systems reported improved efficiency and better utilisation of resources.

CONCLUSIONS

Group practices have many benefits for patients and physicians. However, further work needs to be done assessing patient outcomes and establishing the elements that make a group practice successful.

Identifying the research priorities of healthcare professionals in UK vascular surgery: modified Delphi approach

Background

The Vascular Research Collaborative was established to develop a national research strategy for patients with vascular disease in the UK. This project aimed to establish national research priorities in this patient group.

Methods

A modified Delphi approach, an established method for reaching a consensus opinion among a group of experts in a particular field, was used to survey national multidisciplinary vascular clinical specialists. Two rounds of online surveys were conducted involving the membership of the Vascular Society, Society of Vascular Nurses, Society for Vascular Technology, and the Rouleaux Club (vascular surgical trainees). The first round invited any suggestions for vascular research topics. A steering group then collated and rationalized the suggestions, categorizing them by consensus into pathological topics and research categories, and amalgamating the various questions relating to the same fundamental issue into a single question. The second round involved recirculating these questions to the same participants for priority scoring.

Results

Round 1 resulted in 1231 suggested research questions from 481 respondents. Steering group collation and rationalization resulted in 83 questions for ranking in round 2. The second round resulted in a hierarchical list of vascular research priorities. The highest scoring priorities addressed topics related to critical lower-limb ischaemia, diabetic foot disease, amputation, wound healing, carotid plaque morphology, and service organization/delivery.

Conclusion

It is anticipated that these results will drive the UK national vascular research agenda for the next 5–10 years. It will facilitate focused development and funding of new research projects in current clinical areas of unmet need where potential impact is greatest.

Improving the treatment of pre-operative anemia in hepato-pancreato-biliary patients: a quality improvement initiative

Background

Pre-operative anemia is a common, but treatable, condition encountered by surgical patients. It has been associated with increased perioperative complications, length of stay, and blood transfusions. The aim of this project was to increase the treatment rate of pre-operative anemia to 75% of patients consented for major hepato-pancreato-biliary (HPB) surgery.

Methods

This was an interrupted time series study and a spread initiative from a similar project in a colorectal surgery population. Interventions included an anemia screening and treatment algorithm, standardized blood work, referral to a patient blood management program, and standardized oral iron prescriptions. The primary outcome measure was the change in pre-operative anemia treatment rate and the secondary outcome measure was the post treatment increase in hemoglobin.

Results

A total of 208 patients were included (n = 124 pre-intervention and n = 84 post-intervention). Anemia was present in 39.9% of patients. The treatment rate of pre-operative anemia increased to 44.1% from 28.6%. The mean hemoglobin increased from 110 g/L to 119 g/L in patients who were treated (p = 0.03). There was no significant increase or decrease in blood transfusions or mean number of red cell units transfused per patient. Screening rates for pre-operative anemia increased from 41.1 to 64.3% and appropriate referrals to the patient blood management program increased from 14.3 to 67.6%.

Conclusions

This study demonstrates a small scale spread initiative focused on the treatment of pre-operative anemia. Although the goal to treat 75% of anemic patients was not reached, an effective referral pathway to an existing patient blood management program was developed, and a significant increase in the mean hemoglobin in anemic patients who have been treated pre-operatively was demonstrated.

A randomised controlled trial of perivenous tumescent anaesthesia in addition to general anaesthesia for surgical ligation and stripping of the great saphenous vein

INTRODUCTION

Open surgical ligation and stripping of the great saphenous vein is a highly cost-effective treatment when compared with conservative management and foam sclerotherapy but has limitations including post-operative morbidity and pain. This study aims to identify if the addition of tumescent anaesthesia could improve patient outcomes following treatment.

METHODS

Patients with primary superficial venous incompetence undergoing open surgical ligation and stripping of the great saphenous vein were randomised to either General Anaesthesia (GA) alone (GA) procedure or the addition of tumescent (G + T). The primary outcome was bodily pain (within SF-36) at one week. Additional outcomes included post-procedural pain score (100 mm visual analogue scale), complications and quality of life.

RESULTS

A total of 90 patients were randomised for inclusion. There was no significant difference in primary outcome; bodily pain at one week. Secondary outcome of 4-h post-procedural scores were significantly lower in the G + T group (32 (20-54) mm vs. (GA alone) 56 (24-70) mm (P = 0.016)). Complications were minor and equivalent. Both groups saw a significant increase (worsening) in Aberdeen Varicose Vein Questionnaire scores at week 1 with the G + T group faring worse at six weeks (10.0 (Interquartile Range [IQR] 5.6-17.9) vs. 4.3 (IQR 2.7-7.9) P = 0.004).

CONCLUSION

The G + T group did not demonstrate a significant difference in the one-week bodily pain domain. The addition of tumescent anaesthesia does improve immediate post-operative pain but appears to negatively impact on six-week quality of life. EudraCT Number: 2011-005574-39.

Use of photograph-based telemedicine in postoperative wound assessment to diagnose or exclude surgical site infection

OBJECTIVE

This study aims to assess whether a clinician reviewing photographs of a wound was an acceptable substitute for clinical review in order to identify or exclude surgical site infection (SSI).

METHOD

We undertook a mixed methods study consisting of a qualitative public involvement exercise and a prospective, non-randomised, single-centre study of patients undergoing clean or clean-contaminated vascular surgery. For the qualitative study, two semi-structured focus group interviews were conducted. For the prospective study, patients were invited to attend a wound review at 5-7 days and 30 days postoperatively. At review, wounds were scored by a study nurse or doctor, according to the ASEPSIS scale. Anonymised wound photographs were taken and independently reviewed, and ASEPSIS scored by two independent investigators blinded to the original 'clinical review' ASEPSIS score.

RESULTS

In the qualitative study, three female patients were interviewed across two dates. Emerging themes included the burden of SSI, hospital follow-up and telemedical follow-up. A total of 37 patients with a mean age of 61.14 years were included in the quantitative analysis. There was a total of 53 wound reviews. There was >85% agreement between photograph and clinical reviewers in all categories except erythema. The specificity of photograph review for diagnosis of SSI was 90%. The intraclass correlation coefficient for total ASEPSIS score was R=0.806 (95% CI 0.694, 0.881), indicating strong reliability between reviewers.

CONCLUSION

Our data shows that, in the assessment of SSI, there is good correlation between face-to-face clinical and remote photographic review. Incorporating this method of wound assessment into a postoperative follow-up care pathway may save patients and clinicians from unnecessary hospital visits, particularly when conducting health research.

A pilot feasibility randomised clinical trial comparing dialkylcarbamoylchloride-coated dressings versus standard care for the primary prevention of surgical site infection

A surgical site infection (SSI) may occur in up to 30% of procedures and results in significant morbidity and mortality. We aimed to assess the feasibility of conducting a randomised controlled trial (RCT) examining the use of dialkylcarbamoylchloride (DACC)‐impregnated dressings, which bind bacteria at the wound bed, in the prevention of SSI in primarily closed incisional wounds. This pilot RCT recruited patients undergoing clean or clean‐contaminated vascular surgery. Participants were randomised intraoperatively on a 1:1 basis to either a DACC‐coated dressing or a control dressing. Outcomes were divided into feasibility and clinical outcomes. The primary clinical outcome was SSI at 30 days (assessed using Centers for Disease Control criteria and Additional treatment, Serous discharge, Erythema, Purulent exudate, Separation of the deep tissues, Isolation of bacteria and duration of inpatient Stay scoring methods). This study recruited 144 patients in 12 months at a median rate of 10 per month. Eligibility was 73% and recruitment 60%. At 30 days, there was a 36.9% relative risk reduction in the DACC‐coated arm (16.22% versus 25.71%, odds ratio 0.559, P = 0.161). The number needed to treat was 11 patients. A large‐scale RCT is both achievable and desirable given the relative risk reduction shown in this study. Further work is needed to improve the study protocol and involve more centres in a full‐scale RCT.

A prospective observational cohort study of concomitant versus sequential phlebectomy for tributary varicosities following axial mechanochemical ablation

Introduction

Endovenous mechanochemical ablation (MOCA) is an increasingly popular non-thermal non-tumescent technique used to treat axial reflux in patients with superficial venous incompetence. However, the optimal management of varicose tributaries following this technique is unknown and may impact on patient outcomes. This study compares MOCA with concomitant phlebectomy (MOCAP) versus ablation with sequential phlebectomy if required (MOCAS).

Methods

Patients with symptomatic Comprehensive Classification System for Chronic Venous Disorders (CEAP C2–C6) unilateral axial reflux were studied. Patient choice determined whether concomitant treatment of varicosities was carried out. The primary outcome was the Aberdeen Varicose Veins Questionnaire (AVVQ) at one year. Secondary outcomes included: Venous Clinical Severity Scores (VCSS), EuroQol 5-Domain quality of life scores, complications, procedure duration, procedural and post-operative pain scores and need for secondary procedures. Outcomes were assessed at baseline and then one week, six weeks, six months and one year post intervention.

Results

Fifty patients underwent MOCAP and 33 patients MOCAS. The two groups were comparable at baseline. MOCAP was associated with lower (better) AVVQ scores at six weeks (3.4 (0.5–6.0) vs. 6.1 (1.8–12.1); P = 0.009) and at six months (1.6 (0.0–4.5) vs. 3.34 (1.8–8.4); P = 0.009) but by one year the difference was no longer statistically significant (1.81 (0.0–4.5) vs. 3.81 (0.2–5.3); P = 0.099). MOCAP was associated with longer procedural duration (45 min (36–56) vs. 30 min (25–37); P < 0.001) and higher maximal periprocedural pain (31 (21–59) vs. 18 (7–25); P = 0.001). VCSS at all time points were lower in favour of MOCAP (0 (0–1) vs. 1 (0–3); P < 0.001). MOCAP was associated with fewer episodes of clinically significant thrombophlebitis (6 of 50 (12%) vs. 10 of 33 (30%); P = 0.039) and lower numbers of secondary procedures (2 (4%) vs. 6 (18%); P = 0.032).

Conclusion

Concomitant treatment of tributary varicosities following MOCA improves quality of life and clinical severity, while reducing rates of re-intervention and post-operative thrombophlebitis compared to sequential treatment. The penalty is a modest increase in procedural duration and discomfort. Further evidence from longer-term follow-up is needed.

Mechanochemical ablation for the treatment of superficial venous incompetence: A cohort study of a single centre's early experience

Background

Mechanochemical ablation is an innovative non-thermal method of treating symptomatic axial superficial venous incompetence. This is a single-centre cohort study aiming to investigate the technical efficacy and clinical effectiveness at one year.

Methods

Patients with primary, unilateral, symptomatic axial incompetence were offered treatment with mechanochemical ablation using ClariVein® with 1.5% sodium tetradecyl sulphate. Assessments including clinical examination, duplex ultrasound and patient-reported health-related quality of life were performed at baseline and weeks 1, 6, 26 and 52.

Results

Thirty-two patients were recruited to the study. Complete target vein occlusion at one year was found in 21 (75%) patients. Six patients (21.4%) required secondary procedures, of which three had axial endovenous thermal ablation and three required ambulatory phlebectomy with perforator ligation. There was a significant improvement in the median (interquartile range) Venous Clinical Severity Score from baseline 6 (5–8) to a score of 1 (0–2) at one year (p < 0.001). There was also a significant improvement in health-related quality of life, both generic (p = 0.001) and disease specific (p < 0.001). One patient (3.1%) had a post-procedural non-fatal pulmonary embolus.

Conclusions

Mechanochemical ablation is a feasible and effective treatment for superficial venous incompetence. When using consensus definitions for anatomical closure, results for mechanochemical ablation may be less favourable than previously reported. Further studies are required to compare clinical and technical outcomes following mechanochemical ablation to other methods of endovenous ablation.

Compliance with NICE guidelines when commissioning varicose vein procedures

Background

Varicose veins impair quality of life and can lead to chronic leg ulcers. National Institute for Health and Care Excellence (NICE) guidelines (CG168) set out evidence-based standards for patient management. In England, Clinical Commissioning Groups (CCGs) fund NHS care within their locality. The objective of this study was to evaluate CCGs' commissioning policies and compare them with CG168.

Methods

Searches were made for the published policies of all 206 English CCGs. They were reviewed for compliance with NICE guidelines and the associated quality standard. Areas of disagreement were analysed for themes.

Results

Some 203 CCGs (98·5 per cent) had a published policy and 190 (93·6 per cent) of these were published after publication of CG168. Only 73 of the policies (36·0 per cent) were compliant with CG168. Treatment was restricted on the basis of clinical disease severity in 119 CCGs (58·6 per cent); 29 (14·3 per cent) stipulated delay of treatment using a 'trial' of conservative treatment; 22 (10·8 per cent) used lifestyle-related factors such as BMI and smoking status to ration treatment. Treatment was commissioned for uncomplicated symptomatic varicose veins in 87 CCGs (42·9 per cent), but some applied additional rationing mechanisms; 109 CCGs (53·7 per cent) would treat oedema, 183 (90·1 per cent) would treat skin and soft tissue damage, 202 (99·5 per cent) healed ulceration, and all would allow active ulcers to be treated.

Discussion

The majority of CCGs in England have commissioning policies that contradict NICE guidelines. Rationing strategies include disease severity, delay and patient lifestyle-related factors, creating unwarranted geographical variation for varicose vein treatment, disregarding the NHS Constitution for England, and perhaps leading to an increase in costly treatment of chronic complications in the long term.

Long-term outcomes of endovenous laser ablation and conventional surgery for great saphenous varicose veins

BACKGROUND

Clinical guidelines recommend endovenous laser ablation (EVLA) over surgery based on short-term evidence, yet there are few studies reporting mid- to long-term outcomes. The aim of this study was to report the 5-year outcomes from an RCT of surgery versus EVLA for treatment of symptomatic great saphenous varicose veins.

METHODS

Patients with symptomatic varicose veins due to great saphenous vein (GSV) incompetence were followed up 5 years after enrolment in a randomized trial of either surgery (saphenofemoral junction ligation, GSV strip to the knee and multiple avulsions of varicosities) or EVLA plus multiple avulsions. Outcomes included: clinical recurrence, defined as new varicose veins greater than 3 mm in diameter; Venous Clinical Severity Score (VCSS); quality of life measured by means of Short Form 36, EuroQol Five Dimensions (EQ-5D™) and Aberdeen Varicose Vein Questionnaire (AVVQ); patient satisfaction; and duplex ultrasound examination (DUS) findings.

RESULTS

Some 218 of the 276 patients enrolled in the trial (79·0 per cent) were available for follow-up. Clinical recurrence was more frequent following surgery than EVLA at 5 years (34·3 versus 20·9 per cent; P = 0·010). Both groups demonstrated sustained significant improvements at 5 years over baseline in VCSS (surgery: median (i.q.r.) 1 (0-2) from 4 (3-5), P < 0·001; EVLA: 0 (0-1) from 4 (3-5), P < 0·001), AVVQ (surgery: 4·59 (0·56-9·78) from 13·69 (9·81-18·11), P < 0·001; EVLA: 3·35 (0·17 to 6·55) from 12·73 (9·41-17·32), P < 0·001) and EQ-5D™ (surgery: 1·000 (0·796-1·000) from 0·859 (0·796-1·000), P = 0·002; EVLA: 1·000 (0·796-1·000) from 0·808 (0·796-1·000), P = 0·002). VCSS was better for EVLA than surgery at 5 years (P = 0·031). Technical success assessed by DUS remained high at 5 years (85·4 per cent for surgery and 93·2 per cent for EVLA; P = 0·074). DUS-detected anatomical patterns of recurrence differed between the groups.

CONCLUSION

EVLA was more effective than surgery in preventing clinical recurrence 5 years after treatment of great saphenous varicose veins. Patient-reported outcome measures were similar. Registration number: NCT00759434 (http://www.clinicaltrials.gov).

Extracorporeal shockwave therapy for intermittent claudication: Medium-term outcomes from a double-blind randomised placebo-controlled pilot trial

Objectives Peripheral arterial disease most commonly presents as intermittent claudication (IC). Early evidence has suggested that extracorporeal shockwave therapy is efficacious in the short term for the management of intermittent claudication. The objective of this pilot trial was to evaluate the medium-term efficacy of this treatment. Methods This double-blind randomised placebo-controlled pilot trial randomised patients with unilateral intermittent claudication in a 1:1 fashion to receive extracorporeal shockwave therapy or a sham treatment for three sessions per week over three weeks. Primary outcomes were maximum walking distance and intermittent claudication distance using a fixed-load treadmill test. Secondary outcomes included pre- and post-exertional ankle-brachial pressure indices, safety and quality of life assessed using generic (SF36, EQ-5D-3L) and disease-specific (vascular quality of life) measures. All outcome measures were assessed at 12 months post-treatment. Results Thirty participants were included in the study (extracorporeal shockwave therapy, n = 15; sham, n = 15), with 26 followed up and analysed at 12 months (extracorporeal shockwave therapy, n = 13; sham, n = 13). Intragroup analysis demonstrated significant improvements in maximum walking distance, intermittent claudication distance and post-exertional ankle-brachial pressure indices ( p < 0.05) in the active treatment group, with no improvements in pre-exertional ankle-brachial pressure indices. Significant improvements in quality of life were observed in 3 out of 19 domains assessed in the active group. A re-intervention rate of 26.7% was seen in both groups. Conclusions These findings suggest that extracorporeal shockwave therapy is effective in improving walking distances at 12 months. Although this study provides important pilot data, a larger study is needed to corroborate these findings and to investigate the actions of this treatment.

ISRCTN

NCT02652078.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Endovenous laser ablation versus mechanochemical ablation with ClariVein(®) in the management of superficial venous insufficiency (LAMA trial): study protocol for a randomised controlled trial

Background

Endovenous thermal techniques, such as endovenous laser ablation (EVLA), are the recommended treatment for truncal varicose veins. However, a disadvantage of thermal techniques is that it requires the administration of tumescent anaesthesia, which can be uncomfortable. Non-thermal, non-tumescent techniques, such as mechanochemical ablation (MOCA) have potential benefits. MOCA combines physical damage to endothelium using a rotating wire, with the infusion of a liquid sclerosant. Preliminary experiences with MOCA showed good results and less post-procedural pain.

Methods/Design

The Laser Ablation versus Mechanochemical Ablation (LAMA) trial is a single-centre randomised controlled trial in which 140 patients will be randomly allocated to EVLA or MOCA. All patients with primary truncal superficial venous insufficiency (SVI) who meet the eligibility criteria will be invited to participate in this trial. The primary outcomes are intra-procedural pain and technical efficacy at 1 year, defined as complete occlusion of target vein segment and assessed using duplex ultrasound. Secondary outcomes are post-procedural pain, analgesia use, procedure time, clinical severity, generic and disease-specific quality of life, bruising, complications, satisfaction, cosmesis, time taken to return to daily activities and/or work, and cost-effectiveness analysis following EVLA or MOCA. Both groups will be evaluated on an intention-to-treat basis.

Discussion

The aim of the LAMA trial is to establish whether MOCA is superior to the current first-line treatment, EVLA. The two main hypotheses are that MOCA may cause less initial pain and disability allowing a more acceptable treatment with an enhanced recovery. The second hypothesis is that this may come at a cost of decreased efficacy, which may lead to increased recurrence and affect longer term quality of life, increasing the requirement for secondary procedures.

Trial registration

ClinicalTrials.gov identifier: NCT02627846, registered 8 December 2015

EudraCT number: 2015-000730-30

REC ref: 15/YH/0207

R&D ref: R1788

Defining the optimum tumescent anaesthesia solution in endovenous laser ablation

Objectives To produce a tumescent anaesthesia solution with physiological pH for endovenous thermal ablation and evaluate its influence on peri- and postoperative pain, clinical and quality of life outcomes, and technical success. Methods Tumescent anaesthetic solution (0.1% lidocaine with 1:2,000,000 epinephrine) was titrated to physiological pH by buffering with 2 ml incremental aliquots of 8.4% sodium bicarbonate. Patients undergoing great saphenous vein endovenous laser ablation and ambulatory phlebectomy were studied before and after introduction of buffered tumescent anaesthetic. Primary outcome was perioperative pain measured on a 10 cm visual analogue scale. Secondary outcomes were daily pain scores during the first postoperative week, complications, time to return to normal activity, patient satisfaction, generic and disease-specific quality of life, and technical success. Patients were assessed at baseline, and at 1, 6 and 12 weeks following the procedure. Results A physiological pH was achieved with the addition of 10 ml of 8.4% sodium bicarbonate to 1 l of standard tumescent anaesthetic solution. Sixty-two patients undergoing great saphenous vein endovenous laser ablation with phlebectomy were recruited before and after the introduction of buffered tumescent anaesthetic solution. Baseline and operative characteristics were well matched. The buffered solution was associated with significantly lower (median (interquartile range)) periprocedural pain scores (1 (0.25-2.25) versus 4 (3-6), p < 0.001) and postoperative pain score at the end of the treatment day (1.8 (0.3-2.8) versus 3.0 (1.2-5.2), p = 0.033). There were no significant differences in postoperative pain scores between the groups at any other time. There were no significant differences in other clinical outcomes between the groups. Both groups demonstrated significant improvements in generic and disease-specific quality of life, with no intergroup differences. Both groups demonstrated 100% ultrasonographic technical success at all time points. Conclusions Buffering of tumescent anaesthetic solution during endovenous thermal ablation is a simple, safe, inexpensive and effective means of reducing perioperative and early postoperative pain.

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.

Improving access to dental care for vulnerable children; further development of the Back2School programme in 2013

This paper describes a service evaluation of a dental treatment programme providing care to children not normally taken to the dentist. It explains the extension of the Back2School programme from the pilot phase and assesses if a mobile dental unit (MDU) can provide a high quality service. The public health competencies it illustrates include oral health improvement, developing and monitoring quality dental services, and collaborative working.

A randomized clinical trial of endovenous laser ablation versus conventional surgery for small saphenous varicose veins

BACKGROUND

This randomized clinical trial compared endovenous laser ablation (EVLA) and surgical ligation with attempted stripping in the treatment of small saphenous vein (SSV) insufficiency. The early results demonstrated that EVLA was more likely to eradicate axial reflux and was also associated with a faster recovery, lower periprocedural pain, and fewer sensory complications. The aim of this 2-year follow-up was to establish whether these benefits remained stable over time and whether these improved technical outcomes were associated with less clinical recurrence.

METHODS

Patients with primary saphenopopliteal junction and SSV reflux were randomized to EVLA or saphenopopliteal junction ligation and attempted stripping/excision. Outcomes assessed at 2 years included the presence of residual or recurrent reflux, clinical recurrence, sensory complications, the need for secondary intervention, and patient-reported quality of life on the Aberdeen Varicose Veins Questionnaire, SF-36, and EuroQol.

RESULTS

Of 106 patients who were equally randomized and successfully treated according to the protocol, 88 (83%) were successfully assessed at 2 years. The groups were comparable at baseline. At 2 years, EVLA remained superior to surgery in eradicating axial reflux in 36 patients (81.2%) compared with 29 (65.9%) in the surgery group (P = .002). There was no significant difference in clinical recurrence (EVLA: seven of 44 [16%] vs surgery: 10 of 44 [23%]; P = .736), sensory disturbance (EVLA: one [2.4%] vs surgery vs three [6.8%]; P = 1.000) or any quality of life domain.

CONCLUSIONS

The results of treatment of SSV insufficiency with EVLA appear durable up until 2 years. The study does not appear to suggest that the improved abolition of reflux after EVLA compared with surgery is associated with superior outcomes than those seen after surgery by this time point, because equal effect was shown in both groups. The sensory disturbance associated with surgery appears to settle over this time frame. EVLA is therefore superior in the short-term and not inferior by 2 years.

Evaluation of lactate detection using selective multiple quantum coherence in phantoms and brain tumours

Lactate is a product of glucose metabolism. In tumour tissues, which exhibit enhanced glycolytic metabolism, lactate signals may be elevated, making lactate a potential useful tumour biomarker. Methods of lactate quantitation are complicated because of overlap between the lactate methyl doublet CH3 resonance and a lipid resonance at 1.3 ppm. This study presents the use of a selective homonuclear multiple quantum coherence transfer sequence (SelMQC-CSI), at 1.5 T, to better quantify lactate in the presence of lipids. Work performed on phantoms showed good lactate detection (49%) and lipid suppression (98%) efficiencies. To evaluate the method in the brain, the sequence was tested on a group of 23 patients with treated brain tumours, either glioma (N=20) or secondary metastases in the brain (N=3). Here it was proved to be of use in determining lactate concentrations in vivo. Lactate was clearly seen in SelMQC spectra of glioma, even in the presence of lipids, with high grade glioma (7.3 ± 1.9 mM, mean ± standard deviation) having higher concentrations than low grade glioma (1.9 ± 1.5 mM, p=0.048). Lactate was not seen in secondary metastases in the brain. SelMQC-CSI is shown to be a useful technique for measuring lactate in tumours whose signals are otherwise contaminated by lipid.

Clinical outcomes and quality of life 5 years after a randomized trial of concomitant or sequential phlebectomy following endovenous laser ablation for varicose veins

Background

Endovenous laser ablation (EVLA) is a popular treatment for superficial venous insufficiency. Debate continues regarding the optimal management of symptomatic varicose tributaries following ablation of the main saphenous trunk. This randomized trial compared the 5-year outcomes of endovenous laser therapy with ambulatory phlebectomy (EVLTAP) with concomitant ambulatory phlebectomy, and EVLA alone with sequential treatment if required following a delay of at least 6 weeks.

Methods

Patients undergoing EVLA for great saphenous vein insufficiency were randomized to receive EVLTAP or EVLA alone with sequential phlebectomy, if required. Outcomes included disease-specific quality of life (QoL) (Aberdeen Varicose Vein Questionnaire; AVVQ), requirement for secondary procedures, clinical severity (Venous Clinical Severity Score; VCSS), residual and recurrent varicose tributaries, and generic QoL. Patients were followed up for 5 years.

Results

Fifty patients were randomized equally into two parallel groups. The EVLTAP group had lower VCSS scores at 12 weeks (median 0 (i.q.r. 0–1) versus 2 (0–2); P &lt;0·001), and lower AVVQ scores at 6 weeks (median 7·9 (i.q.r. 4·1–10·7) versus 13·5 (10·9–18·1); P &lt; 0·001) and 12 weeks (2·0 (0·4–7·7) versus 9·6 (2·2–13·8); P = 0·015). VCSS and AVVQ scores were equivalent by 1 year, but only after 16 of 24 patients in the EVLA group, compared with one of 25 in the EVLTAP group (P &lt; 0·001), had received a secondary intervention. From 1 to 5 years both groups had equivalent outcomes.

Conclusion

EVLA with either concomitant or sequential management of tributaries is acceptable treatment for symptomatic varicose veins, with both treatments achieving excellent results at 5 years. Concomitant treatment of varicosities is associated with optimal improvement in both clinical disease severity and QoL.

Endovenous thermal ablation for healing venous ulcers and preventing recurrence

BACKGROUND

Venous leg ulcers represent the worst extreme within the spectrum of chronic venous disease. Affecting up to 3% of the adult population, this typically chronic, recurring condition significantly impairs quality of life, and its treatment places a heavy financial burden upon healthcare systems. The current mainstay of treatment for venous leg ulcers is compression therapy, which has been shown to enhance ulcer healing rates. Open surgery on the veins in the leg has been shown to reduce ulcer recurrence rates, but it is an unpopular option and many patients are unsuitable. The efficacy of the newer, minimally-invasive endovenous thermal techniques has been established in uncomplicated superficial venous disease, and these techniques are now beginning to be used in the management of venous ulceration, though the evidence for this treatment is currently unclear. It is hypothesised that, when used with compression, ablation may further reduce pressures in the leg veins, resulting in improved rates of healing. Furthermore, since long-term patient concordance with compression is relatively poor, it may prove more popular, effective and cost-effective to provide a single intervention to reduce recurrence, rather than life-long treatment with compression.

OBJECTIVES

To determine the effects of superficial endovenous thermal ablation on the healing, recurrence and quality of life of people with active or healed venous ulcers.

SEARCH METHODS

In August 2013 we searched Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. There were no restrictions on the language of publication but there was a date restriction based on the fact that superficial endovenous thermal ablation is a comparatively new medical technology.

SELECTION CRITERIA

Randomised clinical trials comparing endovenous thermal ablative techniques with compression therapy alone for venous leg ulcers were eligible for inclusion. Trials had to report on at least one objective measure of ulcer healing (primary outcome) such as proportion of ulcers healed at a given time point, time to complete healing, change in ulcer size, proportion of ulcers recurring over a given time period, or at a specific point, and ulcer-free days. Secondary outcomes sought included patient-reported quality of life, economic data and adverse events.

DATA COLLECTION AND ANALYSIS

Details of potentially eligible studies were extracted and summarised using a data extraction table. Data extraction and validity assessment were performed independently by two review authors, and any disagreements resolved by consensus or by arbitration of a third review author.

MAIN RESULTS

No eligible randomised controlled trials were identified. There is an absence of evidence regarding the effects of superficial endovenous thermal ablation on ulcer healing, recurrence or quality of life of people with venous leg ulcer disease.

AUTHORS' CONCLUSIONS

The review identified no randomised controlled trials on the effects on ulcer healing, recurrence or quality of life, of superficial endovenous thermal ablation in people with active or healed venous leg ulcers. Adequately-powered, high quality randomised controlled trials comparing endovenous thermal ablative interventions with compression therapy are urgently required to explore this new treatment strategy. These should measure and report outcomes that include time to ulcer healing, ulcer recurrence, quality of life and cost-effectiveness.

Comparison of 12-W Versus 14-W Endovenous Laser Ablation in the Treatment of Great Saphenous Varicose Veins

Introduction:

Endovenous laser ablation (EVLA) has been demonstrated to be an effective treatment for lower limb varicose veins in the short and midterm results. This study reports the 5-year outcomes of EVLA technique at different power settings.

Methods:

Patients with primary symptomatic, unilateral varicose veins secondary to saphenofemoral junction (SFJ) incompetence and great saphenous vein (GSV) reflux were recruited and randomized to either 12W (intermittent laser withdrawal) or 14W (continuous laser withdrawal). They were assessed at baseline, 1, 6, 12, 52, 104 weeks, and 5 years. Outcome measures included: Venous Clinical Severity Score (VCSS), pain scores, time taken to return to normal functions, complications, recurrence, quality of life (QoL), and duplex ultrasound findings.

Results:

76 consecutive patients, M: F 30:46, median age 54(IQR: 37.3-59) years were randomized.

Intragroup analysis:

Significant improvement was seen in both groups in VCSS, pain scores, Aberdeen varicose vein questionnaire (AVVQ) scores, Shortform-36 (SF-36) and Euroqol (EQ-5D) domains over the follow-up period ( P < 0.05).

Intergroup analysis:

Over 5 years, clinically recurrent varicosities and duplex detected SFJ incompetence was less frequent and patient satisfaction with cosmetic outcome significantly higher in the 14W group ( P < 0.05). There was no significant difference between the groups in duration of procedure, postoperative pain scores, return to normal functioning, complications, VCSS, disease specific (AVVQ) and generic (SF36, EQ-5D) QoL measures ( P > 0.05).

Conclusion:

Late outcomes following EVLA were superior for the 14W continuous power settings achieving better long term venous occlusion and lowered recurrence rates without increasing post-operative morbidity. Hence 14W continuous setting should be the energy delivery mode of choice.