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Chervonski E, Muqri F, Jacobowitz GR, Rockman CB, Maldonado TS, Berland TL, Garg K, Cayne NS, Sadek M. Safety and efficacy of endovenous ablation in patients with a history of deep vein thrombosis. J Vasc Surg Venous Lymphat Disord 2024:101898. [PMID: 38677553 DOI: 10.1016/j.jvsv.2024.101898] [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] [Received: 02/29/2024] [Revised: 04/08/2024] [Accepted: 04/11/2024] [Indexed: 04/29/2024]
Abstract
OBJECTIVE Endovenous ablation is the standard of care for patients with symptomatic superficial venous insufficiency. For patients with a history of deep vein thrombosis (DVT), concern exists for an increased risk of postprocedural complications, particularly venous thromboembolism. The objective of this study was to evaluate the safety and efficacy of endovenous thermal ablation in patients with a history of DVT. METHODS The national Vascular Quality Initiative Varicose Vein Registry was queried for superficial venous procedures performed from January 2014 to July 2021. Limbs treated with radiofrequency or laser ablation were compared between patients with and without a DVT history. The primary safety end point was incident DVT or endothermal heat-induced thrombosis (EHIT) II-IV in the treated limb at <3 months of follow-up. The secondary safety end points included any proximal thrombus extension (ie, EHIT I-IV), major bleeding, hematoma, pulmonary embolism, and death due to the procedure. The primary efficacy end point was technical failure (ie, recanalization at <1 week of follow-up). Secondary efficacy end points included the risk of recanalization over time and the postprocedural change in quality-of-life measures. Outcomes stratified by preoperative use of anticoagulation (AC) were also compared among those with prior DVT. RESULTS Among 33,892 endovenous thermal ablations performed on 23,572 individual patients aged 13 to 90 years, 1698 patients (7.2%) had a history of DVT. Patients with prior DVT were older (P < .001), had a higher body mass index (P < .001), were more likely to be male at birth (P < .001) and Black/African American (P < .001), and had greater CEAP classifications (P < .001). A history of DVT conferred a higher risk of new DVT (1.4% vs 0.8%; P = .03), proximal thrombus extension (2.3% vs 1.6%; P = .045), and bleeding (0.2% vs 0.04%; P = .03). EHIT II-IV, pulmonary embolism, and hematoma risk did not differ by DVT history (P = NS). No deaths from treatment occurred in either group. Continuing preoperative AC in patients with prior DVT did not change the risk of any complications after endovenous ablation (P = NS) but did confer an increased hematoma risk among all endovenous thermal ablations and surgeries (P = .001). Technical failure was similar between groups (2.0% vs 1.2%; P = .07), although a history of DVT conferred an increased recanalization risk over time (hazard ratio, 1.90; 95% confidence interval, 1.46, 2.46; P < .001). The groups had comparable improvements in postprocedural venous clinical severity scores and Heaviness, Aching, Swelling, Throbbing, and Itching scores (P = NS). CONCLUSIONS Endovenous thermal ablation for patients with a history of DVT was effective. However, appropriate patient counseling regarding a heightened DVT risk, albeit still low, is critical. The decision to continue or withhold AC preoperatively should be tailored on a case-by-case basis.
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Affiliation(s)
| | - Furqan Muqri
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Glenn R Jacobowitz
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Caron B Rockman
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Thomas S Maldonado
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Todd L Berland
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Neal S Cayne
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Mikel Sadek
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY.
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Wiske C, Chervonski E, Rockman CB, Jacobowitz GR, Sadek M. Venous ablation procedures by provider type, including advanced practice providers. J Vasc Surg Venous Lymphat Disord 2024:101872. [PMID: 38518987 DOI: 10.1016/j.jvsv.2024.101872] [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] [Received: 12/14/2023] [Revised: 01/17/2024] [Accepted: 03/07/2024] [Indexed: 03/24/2024]
Abstract
OBJECTIVE The necessary training and certification of providers performing venous ablation has become a topic of debate in recent years. As venous interventions have shifted away from the hospital, the diversity of provider backgrounds has increased. We aimed to characterize superficial venous ablation practice patterns associated with different provider types. METHODS We analyzed Medicare Fee-For-Service data from 2010 through 2018. Procedures were identified by their Current Procedural Terminology code and included radiofrequency ablation, endovenous laser ablation, chemical adhesive ablation (ie, VenaSeal; Medtronic, Inc), and mechanochemical ablation. These procedures were correlated with the practitioner type to identify provider-specific trends. RESULTS Between 2010 and 2018, the number of ablation procedures increased by 107% from 114,197 to 236,558 per year (P < .001). Most procedures were performed by surgeons without vascular board certification (28.7%; 95% confidence interval [CI], 28.7%-28.8%), followed by vascular surgeons (27.1%; 95% CI, 27.0%-27.2%). Traditionally noninterventional specialties, which exclude surgeons, cardiologists, and interventional radiologists, accounted for 14.1% (95% CI, 14.1%-14.2%), and APPs accounted for 3.5% (95% CI, 3.4%-3.5%) of all ablation procedures during the study period. The total number of ablations increased by 9.7% annually (95% CI, 9.7%-9.8%), whereas procedures performed by APPs increased by 62.0% annually (95% CI, 61.6%-62.4%). There were significant differences between specialties in the use of nonthermal ablation modalities: APPs had the highest affinity for nonthermal ablation (odds ratio [OR], 2.60; 95% CI, 2.51-2.69). Cardiologists were also more likely to use nonthermal ablation (OR, 1.62; 95% CI, 1.59-1.66). Similarly, the uptake of new nonthermal technology (ie, chemical adhesives) was greatest among APPs (OR, 3.57; 95% CI, 3.43-3.70) and cardiologists (OR, 1.86; 95% CI, 1.81-1.91). Vascular surgeons were less likely to use nonthermal modalities (OR, 0.95; 95% CI, 0.92-0.97), including new nonthermal technology in the first year of availability (OR, 0.93; 95% CI, 0.90-0.95). CONCLUSIONS The use of venous procedures has increased rapidly during the past decade, particularly as endovenous ablations have been performed by a wider practitioner base, including APPs and noninterventionalists. Practice patterns differ by provider type, with APPs and cardiologists skewing more toward nonthermal modalities, including more rapid uptake of new nonthermal technology. Provider-specific biases for specific ablation modalities might reflect differences in training, skill set, the need for capital equipment, clinical privileges, or reimbursement. These data could help to inform training paradigms, the allocation of resources, and evaluation of appropriateness in a real-world setting.
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Affiliation(s)
- Clay Wiske
- Division of Vascular & Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY; Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA.
| | | | - Caron B Rockman
- Division of Vascular & Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Glenn R Jacobowitz
- Division of Vascular & Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Mikel Sadek
- Division of Vascular & Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
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Louden CD, Clark J, Yanquez F, Labropoulos N, DiMaggio P, Leon LR. Severe adverse reactions after cyanoacrylate endovenous ablation. J Vasc Surg Cases Innov Tech 2023; 9:101309. [PMID: 37767344 PMCID: PMC10520435 DOI: 10.1016/j.jvscit.2023.101309] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/09/2023] [Indexed: 09/29/2023] Open
Abstract
Hypersensitivity reactions after endovenous ablation with cyanoacrylate are relatively common, mild, and self-limited. However, rare cases of severe hypersensitivity reactions have occurred. To date and to the best of our knowledge, only two other cases requiring vein excision have been reported, and we present the third. Even rarer are cases with severe reactions featuring cyanoacrylate extravasation with skin perforation. In the present report, we describe the second case of skin perforation after successful cyanoacrylate endovenous glue embolization. The mechanism of these severe hypersensitivity reactions is unknown. Clinicians should to consider this as a possible complication when using cyanoacrylate. Although rare, patients should also be advised of this adverse event when considering this alternative.
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Affiliation(s)
| | - Jennifer Clark
- Vascular and Endovascular Surgery, US Heart and Vascular, Nashville, TN
| | | | - Nicos Labropoulos
- Vascular and Endovascular Surgery, Stony Brook University, Stony Brook, NY
| | - Paul DiMaggio
- Department of Pathology, Tucson Medical Center, Tucson, AZ
| | - Luis R. Leon
- Department of Physiology, University of Arizona, Tucson, AZ
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Tan J, Chen Y, Huang J, Xu W. A systematic review of endovenous ablation for the treatment of small saphenous varicose veins. VASA 2023; 52:355-365. [PMID: 37779391 DOI: 10.1024/0301-1526/a001091] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Insufficiency of the small saphenous vein causes 15% of varicose veins in the lower extremities. Endovenous ablation for the treatment of small saphenous vein varices has become a trend, and an increasing number of studies have reported the effects of different types of endovenous ablation in patients with small saphenous varicose veins. The purpose of this systematic review is to summarize the results of existing studies on endovenous ablation for the treatment of small saphenous varicose veins, compare its role and efficacy, and provide insights into the future development of endovenous ablation for treating small saphenous varicose veins. A systematic review of literature published from January 1, 2002 to January 1, 2022 was conducted from PubMed, Embase, and China Academic Journals full-text databases. The pre-determined inclusion criteria were clinical literature of endovenous ablation for treating small saphenous varicose veins. Keywords included "ablation", "small saphenous vein", "lesser saphenous vein", "short saphenous vein", "xiaoyinjingmai" and "xiaorong". Of the 506 articles screened, 33 articles were included in this review: 19 articles were related to endovenous laser ablation, five were related to mechanochemical ablation, seven were related to radiofrequency ablation, and two were related to both endovenous laser ablation and radiofrequency ablation. The anatomical success rate of endovenous laser ablation, radiofrequency ablation, and mechanochemical ablation were 94.3%, 96.0%, and 88.1%, respectively, and the heterogeneities were all moderate. Most of the current studies are of a low-quality level of research. Hence, long-term follow-up studies and large-scale randomized controlled trials are required to obtain high-quality evidence. Although the gold standard for the treatment of small saphenous vein insufficiency remains unclear, endovenous ablation is still the recommended method.
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Affiliation(s)
- Junjie Tan
- Zhuhai Hospital affiliated with Jinan University (Zhuhai People's Hospital), Xiangzhou District, Zhuhai City, Guangdong Province, China
| | - Yanhui Chen
- Second Clinical Medical College of Jinan University (Shenzhen People's Hospital), Shenzhen City, Guangdong Province, China
| | - Jianwen Huang
- Zhuhai Hospital affiliated with Jinan University (Zhuhai People's Hospital), Xiangzhou District, Zhuhai City, Guangdong Province, China
- Zhuhai Interventional Medical Centre, Zhuhai Hospital affiliated with Jinan University (Zhuhai People's Hospital), Xiangzhou District, Zhuhai City, Guangdong Province, China
| | - Weiguo Xu
- Zhuhai Hospital affiliated with Jinan University (Zhuhai People's Hospital), Xiangzhou District, Zhuhai City, Guangdong Province, China
- Zhuhai Interventional Medical Centre, Zhuhai Hospital affiliated with Jinan University (Zhuhai People's Hospital), Xiangzhou District, Zhuhai City, Guangdong Province, China
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Karnabatidis D, Papageorgiou C, Kitrou P, Spiliopoulos S. One-year duplex ultrasound-assessed closure outcomes of percutaneous endovenous microwave ablation for the treatment of varicose veins of the lower limbs. Vascular 2023; 31:1011-1016. [PMID: 35549952 DOI: 10.1177/17085381221099115] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE This study aims to investigate the safety and efficacy of a new device using microwave technology for the endovenous ablation of the great saphenous vein (GSV) causing symptomatic lower limb varicose veins (LLVV). MATERIALS AND METHODS This prospective, single-arm, single-center, cohort study investigated the safety and effectiveness of endovenous microwave ablation for the treatment of symptomatic LLVV. Enrollment period was set between January and December 2020. Primary safety endpoint was the occurrence of procedure-related complications and primary efficacy endpoint was anatomical success defined as the duplex ultrasound (DUS)-proven GSV occlusion at 1 year follow-up. Secondary endpoints included 1-year clinical success (CEAP classification improvement), repeat procedures rate due to GSV recanalization, and pain assessment at 24 h post treatment. RESULTS In total, 50 patients (42 female; mean age: 62 ± 12 years) with 64 limbs were treated. No procedure-related complications were noted. Technical success was 95.3% (61/64 GSVs), as three cases of GSV recanalization were detected. Clinical success was 100%, as in all cases symptoms improvement by at least one grade according to CEAP classification, was achieved. Mean CEAP grade significantly improved from 3.3 ± 0.72 (median: 3) at baseline to 1.8 ± 0.85 (median: 2) at 1-year (p < 0.0001). There were no repeat procedures due to GSC recanalization. The median 24-h VAS value was 2 (mean: 1.9 ± 1.4). CONCLUSIONS Endovenous microwave ablation was safe and effective for the treatment of varicose veins, achieving high 1-year GSV occlusion rates.
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Affiliation(s)
- Dimitris Karnabatidis
- Department of Interventional Radiology, School of Medicine, Patras University Hospital, Greece
| | - Christos Papageorgiou
- Department of Interventional Radiology, School of Medicine, Patras University Hospital, Greece
| | - Panagiotis Kitrou
- Department of Interventional Radiology, School of Medicine, Patras University Hospital, Greece
| | - Stavros Spiliopoulos
- Department of Radiology, Interventional Radiology Unit, School of Medicine, National and Kapodistrian University of Athens, Greece
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Bontinis V, Bontinis A, Koutsoumpelis A, Chorti A, Rafailidis V, Giannopoulos A, Ktenidis K. A network meta-analysis on the efficacy and safety of thermal and nonthermal endovenous ablation treatments. J Vasc Surg Venous Lymphat Disord 2023; 11:854-865.e5. [PMID: 37030442 DOI: 10.1016/j.jvsv.2023.03.011] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 03/08/2023] [Accepted: 03/08/2023] [Indexed: 04/10/2023]
Abstract
OBJECTIVE We assessed the mid-term efficacy and safety of thermal and nonthermal endovenous ablation for the treatment of lower limb superficial venous insufficiency. METHODS We performed a systematic review in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) statement and a Bayesian network meta-analysis. The primary end points were great saphenous vein (GSV) closure and venous clinical severity score (VCSS) improvement. A meta-regression using GSV diameter as a covariate was undertaken for the two primary end points. RESULTS We included 14 studies and 4177 patients, with a mean follow-up of 25.7 months. Radiofrequency ablation (RFA; odds ratio [OR], 3.99; 95% confidence interval [CI], 1.82-10.53), cyanoacrylate ablation (CAC; OR, 3.09; 95% CI, 1.35-8.37), and endovenous laser ablation (EVLA; OR, 2.72; 95% CI, 1.23-7.38) displayed increased odds for GSV closure compared with mechanochemical ablation (MOCA). MOCA inferiority compared with RFA (mean difference [MD], 0.96; 95% CI, 0.71-1.20), EVLA (MD, 0.94; 95% CI, 0.61-1.24), and CAC (MD, 0.89; 95% CI, 0.65-1.15) was also depicted regarding VCSS improvement. EVLA resulted in an increased risk of postoperative paresthesia compared with MOCA (risk ratio [RR], 9.61; 95% CI, 2.32-62.29), CAC (RR, 7.90; 95% CI, 2.44-38.16), and RFA (RR, 6.96; 95% CI, 2.31-28.04). Although the overall analysis identified nonstatistically significant differences for Aberdeen varicose vein questionnaire score improvement, thrombophlebitis, ecchymosis, and pain, further investigation revealed an increase pain profile for EVLA at 1470 nm compared with RFA (MD, 3.22; 95% CI, 0.93-5.47) and CAC (MD, 3.04; 95% CI, 1.05-4.97). A sensitivity analysis displayed a persistent underperformance of MOCA compared with RFA (OR, 4.33; 95% CI, 1.15-55.54) for GSV closure and both RFA (MD, 0.99; 95% CI, 0.22-1.77) and CAC (MD, 0.84; 95% CI, 0.08-1.65) regarding VCCS improvement. Although no regression model reached statistical significance, the GSV closure regression model revealed a trend for considerably decreased efficacy for both CAC and MOCA with larger GSV diameters compared with RFA and EVLA. CONCLUSIONS Although our analysis has produced skepticism regarding the efficacy of MOCA in the mid-term period for VCSS improvement and GSV closure rates, CAC showed equivalent results compared with both RFA and EVLA. Additionally, CAC displayed a decreased risk of postprocedural paresthesia and pigmentation and induration compared with EVLA. Also, both RFA and CAC had an improved pain profile compared with EVLA 1470 nm. The potential underperformance of nonthermal, nontumescent ablation modalities in ablating large GSVs necessitates further research.
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Affiliation(s)
- Vangelis Bontinis
- Department of Vascular Surgery, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Alkis Bontinis
- Department of Vascular Surgery, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Andreas Koutsoumpelis
- Department of Vascular Surgery, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Angeliki Chorti
- Department of Surgery, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasileios Rafailidis
- Department of Radiology, School of Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Argirios Giannopoulos
- Department of Vascular Surgery, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Kiriakos Ktenidis
- Department of Vascular Surgery, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Bochnakova T, Kaufman C. Combined Management of Wound Ulcers With Focus on Interventional Techniques. Tech Vasc Interv Radiol 2023; 26:100896. [PMID: 37865447 DOI: 10.1016/j.tvir.2023.100896] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
This review provides a summary of current practice patterns in managing venous ulcers. The authors will describe the workup for venous ulcers, including differentiation of symptoms, physical examination, and imaging to guide the most effective treatment course for each patient. An overview of conservative management and minimally invasive treatment options for venous ulcers will be provided with a specific focus on periulcer foam sclerotherapy to aid in preventing ulcer recurrence and promoting healing. We will give interventional troubleshooting techniques for challenging patient presentations.
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Affiliation(s)
- Teodora Bochnakova
- Vascular and Interventional Radiology, Dotter Interventional Institute, Oregon Health and Science University, OHSU Hospital, Portland, OR.
| | - Claire Kaufman
- Vascular and Interventional Radiology, Dotter Interventional Institute, Oregon Health and Science University, OHSU Hospital, Portland, OR
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Hwang JH, Park SW, Min J, Yang WY, Kwon YW, Hwang JJ, Kim JS, Lee SA, Chee HK. Endovenous radiofrequency ablation using a new bipolar electrode in a canine model: a new endovenous radiofrequency electrode. Ann Surg Treat Res 2023; 104:164-169. [PMID: 36910561 PMCID: PMC9998961 DOI: 10.4174/astr.2023.104.3.164] [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] [Received: 08/02/2022] [Revised: 11/30/2022] [Accepted: 12/19/2022] [Indexed: 03/09/2023] Open
Abstract
Purpose This study aimed to determine the effectiveness and safety of a newly developed endovenous radiofrequency (RF) catheter compared with that of the existing RF catheter in a canine model. Methods Seven dogs underwent ablation using 1 control catheter (ClosureFAST, CF; Covidien) and 1 experimental catheter (VENISTAR, VS; STARmed Co., Ltd.) in the femoral and cephalic veins. The ablated vein was evaluated macroscopically (2,3,5-triphenyltetrazolium chloride staining, TTC), microscopically (hematoxylin and eosin staining), and ultrasonographically. Vessel injury score was used to evaluate the ablating effect objectively. Veins from 1 dog were evaluated on the day of ablation, while in the remaining 6 dogs, the ablated veins were evaluated 2 weeks later. Results A total of 23 veins (CF, 11 veins; VS, 12 veins) were ablated in 7 dogs. Non-TTC-stained vein wall areas were identified in all ablated veins. No significant difference was observed in the mean vessel injury score (2.54 ± 1.16 vs. 2.42 ± 1.13, P = 0.656) and the mean vessel wall thickness (0.32 ± 0.03 mm vs. 0.31 ± 0.05 mm, P = 0.212) between CF and VS. There was no blood flow in all veins ablated with VS, whereas there was remaining blood flow in 1 vein ablated with CF. Perivenous complication was not observed. Conclusion Endovenous RF ablation using a newly developed VS RF catheter seems to provide comparable occlusion rate and degree of vein wall injury without perivenous adverse events compared to the most commonly used RF catheter (CF).
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Affiliation(s)
- Jin Ho Hwang
- Department of Radiology, Konkuk University School of Medicine, Seoul, Korea
| | - Sang Woo Park
- Department of Radiology, Konkuk University School of Medicine, Seoul, Korea
| | - Jeeyoung Min
- Department of Radiology, Konkuk University School of Medicine, Seoul, Korea
| | - Woo Young Yang
- Department of Radiology, Konkuk University School of Medicine, Seoul, Korea.,Department of Radiology, Seoul Sun Vascular Pain Center, Seoul, Korea
| | - Yong Wonn Kwon
- Department of Radiology, Konkuk University School of Medicine, Seoul, Korea.,Department of Radiology, Cheil Orthopedic Hospital, Seoul, Korea
| | - Jae Joon Hwang
- Department of Thoracic and Cardiovascular Surgery, Konkuk University School of Medicine, Seoul, Korea
| | - Jun Seok Kim
- Department of Thoracic and Cardiovascular Surgery, Konkuk University School of Medicine, Seoul, Korea
| | - Song Am Lee
- Department of Thoracic and Cardiovascular Surgery, Konkuk University School of Medicine, Seoul, Korea
| | - Hyun Keun Chee
- Department of Thoracic and Cardiovascular Surgery, Konkuk University School of Medicine, Seoul, Korea
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Yang J, Chung S, Srivatsa S. Prospective randomized trial of antithrombotic strategies following great saphenous vein ablation using injectable polidocanol endovenous microfoam (Varithena). J Vasc Surg Venous Lymphat Disord 2022; 11:488-497.e4. [PMID: 36592692 DOI: 10.1016/j.jvsv.2022.12.008] [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] [Received: 07/20/2022] [Revised: 12/06/2022] [Accepted: 12/18/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Postablation deep vein thrombosis (DVT) represents a potentially serious complication after Varithena polidocanol endovenous microfoam (PEM) ablation. The following primary outcomes were assessed: whether (1) adjunctive apixaban anticoagulation or (2) mechanical deep venous system (DVS) saline flushing could decrease saphenofemoral junction (SFJ) thrombus extension (postablation superficial thrombus extension [PASTE]) and/or DVT compared with compression alone, after great saphenous vein (GSV) PEM ablation. METHODS Varithena 1% PEM ablation patients were randomized to (1) SFJ compression, (2) compression and DVS saline flushing, or (3) compression, DVS saline flushing, and 5 days of postprocedural 5 mg oral apixaban anticoagulation twice daily. Duplex imaging was obtained 7 to 10 days after PEM ablation and PASTE/DVT incidence (primary end point) was compared between groups at this time point. RESULTS We treated 304 limbs in 257 patients with PEM. Overall, 103 limbs received SFJ compression (group C, 33.8%), 101 received compression and deep venous flushing (group D, 32.9%), and 100 received compression, deep flush, and anticoagulation (group A, 33.2%). Mean ultrasound follow-up time was 9.7 days (all patients) with a primary GSV closure rate of 92.4%. SFJ PASTE (II-IV) occurred in 0.9%, 1.0%, and 0% (groups C, D, and A, respectively). DVT occurred in 16.7%, 14.7%, and 1.98% (groups C, D, and A; χ2, P = .002). Patients in group A receiving apixaban anticoagulation had a significant reduction in DVT compared with patients in group C (1.98% vs 16.7%, χ2; P < .001); likewise, patients in group A had a significantly decreased DVT occurrence compared with group D (14.7% vs 1.98%; χ2, P = .00162), whereas patients in groups C and D were not statistically different (16.7% vs 14.7%; χ2, P = .60). CONCLUSIONS (1) Neither adjunctive DVS flushing nor anticoagulation decreased clinically relevant SFJ PASTE (II-IV) incidence, which remained similarly low across all groups and ranged between 0% and 1%, regardless of adjunctive DVS flushing or anticoagulation. This rate was significantly lower than prior reports (2.3%-4.1%). (2) DVS flushing had no influence on the rate of DVT. Observed PEM-induced DVT incidence using SFJ compression alone or compression with DVS flushing (16.7% and 14.7%, respectively) was significantly higher than prior reports (2.5%-9.6%). This finding may relate to the greater extent of AK/BK GSV territory treated in the present study. (3) Five days of postprocedural oral apixaban anticoagulation, 5 mg given twice daily, significantly decreased DVT occurrence to 1.98%, compared with nonanticoagulated patients (16.7%). This finding is comparable with the DVT rates reported after endovenous thermal ablation (0.7-1.7%). (4) Postprocedural apixaban anticoagulation may have a significant preventive role in decreasing DVT occurrence after PEM ablation.
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Affiliation(s)
- Jady Yang
- Heart, Artery, and Vein Center of Fresno, Fresno, CA
| | - Steve Chung
- Department of Mathematics, California State University, Fresno, CA
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Cher BAY, Brown CS, Obi AT, Wakefield TW, Henke PK, Osborne NH. Women benefit from endovenous ablation with fewer complications: Analysis of the Vascular Quality Initiative Varicose Vein Registry. J Vasc Surg Venous Lymphat Disord 2022; 10:1229-1237.e2. [PMID: 35933108 DOI: 10.1016/j.jvsv.2022.05.013] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 04/25/2022] [Accepted: 05/10/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To evaluate the association between gender and long-term clinician-reported and patient-reported outcomes after endovenous ablation procedures. METHODS This retrospective cohort study of prospectively collected data from the Vascular Quality Initiative's Varicose Vein Registry included patients undergoing endovenous ablation procedures on truncal veins with or without treatment of perforating veins between 2015 and 2019. A univariate analysis included comparisons of preprocedural, postprocedural, and periprocedural change in Venous Clinical Severity Score (VCSS) and total symptom score by gender. Rates of complications including deep vein thrombosis, endovenous heat-induced thrombosis, leg pigmentation, blistering, paresthesia, incisional infection, and any postprocedural complications were reported by gender. Multivariable analysis leveraged linear regression to examine how gender affected the relationships between patient characteristics, complication rates, and periprocedural change in VCSS score and total symptom score. RESULTS Of 9743 patients who met the inclusion criteria, 3090 (31.7%) were men and 6653 (68.2%) were women. The perioperative change in VCSS score was greater for men than women (average -4.46 for men vs -4.13 for women; P < .0001). Perioperative change in total symptom score was greater for women than for men (average -10.64 for women vs -9.64 for men; P < .0001). Women had lower incidence of any leg complication (6.1% vs 8.6%; P = .001) endovenous heat-induced thrombosis (1.1% vs 2.2%; P = .002), and infection (0.4% vs 0.7%; P = .001). In multivariable analysis, among patients with a body mass index of more than 40, presence of deep reflux, and preoperative Clinical, Etiologic, Anatomic, and Physiologic classification of 2, women had a greater periprocedural change in VCSS score than men. CONCLUSIONS Women benefited from endovenous ablation similarly as men, with a lower incidence of postprocedural complications. Gender may be useful for patient selection and counseling for endovenous ablation, with particular usefulness among patients with a high body mass index, presence of deep reflux, and preoperative Clinical, Etiologic, Anatomic, and Physiologic classification of 2.
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Affiliation(s)
- Benjamin A Y Cher
- Section of Vascular Surgery, Department of General Surgery, University of Michigan Medical School, Ann Arbor, MI.
| | - Craig S Brown
- Section of Vascular Surgery, Department of General Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Andrea T Obi
- Section of Vascular Surgery, Department of General Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Thomas W Wakefield
- Section of Vascular Surgery, Department of General Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Peter K Henke
- Section of Vascular Surgery, Department of General Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Nicholas H Osborne
- Section of Vascular Surgery, Department of General Surgery, University of Michigan Medical School, Ann Arbor, MI
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Nellis JM, Obi AT, Powell CA, Wakefield TW. Treatment and contemporary outcomes associated with adjunct tourniquet use during phlebectomy of complex, voluminous truncular varicosities. J Vasc Surg Venous Lymphat Disord 2022; 10:1208-1214. [PMID: 35872142 DOI: 10.1016/j.jvsv.2022.05.010] [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] [Received: 04/01/2022] [Revised: 05/12/2022] [Accepted: 05/19/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Phlebectomy of large voluminous varicose veins comes with a risk of substantial blood loss. The purpose of the present study was to investigate the outcomes associated with the use of an adjunct tourniquet during varicose vein surgery of complex and large truncular varicosities. METHODS The prospectively collected registry data included anatomic and outcomes details for patients who presented with complex and large truncular varicosities with a CEAP clinical class of C2, or higher (indicating more serious venous disease) from December 2014 to December 2021. Of all patients, those treated with an adjunct tourniquet for large complex varicosities (largest diameter varicosity ≥1 cm by visual inspection) were selected for analysis. The venous clinical severity scores (VCSSs) and patient-reported outcomes (PROs) were obtained. Additional parameters, including operative time, tourniquet time, and blood loss, were obtained retrospectively via a review of the medical records. Univariate descriptive statistics of the demographic and procedural data were performed pre- and postoperatively, with comparisons performed using the Student two-tailed t test. RESULTS The data from 19 patients (22 limbs; 7 women and 12 men) were analyzed. Of the 22 limbs, 11 (50%) had advanced venous disease of C4 or higher preoperatively. A review of the preoperative duplex ultrasound scans confirmed the presence of large varicosities (average, 1.0 ± 0.54 cm; n = 18). All the limbs were treated using radiofrequency ablation of axial reflux and phlebectomy (a combination of powered and stab) under tourniquet control (82%) or phlebectomy under tourniquet control alone (18%). The average tourniquet time was 40 ± 12 minutes, with a median blood loss of 50 mL (interquartile range, 30-100 mL). The average follow-up was 332 ± 422 days after 19 procedures for 16 patients (2 patients moved out of state during the immediate postoperative period and 1 patient was lost to follow-up). Of the patients who completed >3 months of follow-up, 14 limbs experienced improvement in the CEAP class, 5 limbs had no change, and 3 were limbs of patients who moved or were lost to follow-up. The VCSSs significantly improved (8.8 ± 2.8 vs 3.9 ± 1.9; P < .0001). The PROs also improved significantly (16.1 ± 5.0 vs 2.2 ± 2.3; P < .0001). CONCLUSIONS Tourniquet use in the treatment of varicosities has only been described in the setting of high ligation and stripping. Our data suggest that in the modern era of minimally invasive endovenous treatment of axial reflux and phlebectomy, adjunct tourniquet use during the treatment of large complex varicosities can result in significant improvements in the VCSSs and PROs, with minimal blood loss.
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Affiliation(s)
| | - Andrea T Obi
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Chloe A Powell
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Thomas W Wakefield
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI.
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Lam YL, Alozai T, Schreve MA, de Smet AAEA, Vahl AC, Nagtzaam I, Lawson JA, Nieman FHM, Wittens CHA. A multicenter, randomized, dose-finding study of mechanochemical ablation using ClariVein and liquid polidocanol for great saphenous vein incompetence. J Vasc Surg Venous Lymphat Disord 2021; 10:856-864.e2. [PMID: 34781008 DOI: 10.1016/j.jvsv.2021.10.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 10/31/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND The purpose of the present study was to identify the ideal polidocanol (POL) concentration for mechanochemical ablation (MOCA) of the great saphenous vein (GSV) using the ClariVein system (Merit Medical, South Jordan, Utah). METHODS We performed a multicenter, randomized, controlled, single-blind trial with a follow-up period of 6 months. Patients with symptomatic primary truncal GSV incompetence were randomized to MOCA + 2% POL liquid (2% group) or MOCA + 3% POL liquid (3% group). The primary outcome was technical success (TS), defined as an open part of the treated vein segment of ≤10 cm in length. The secondary outcomes were alternative TS, defined as ≥85% occlusion of the treated vein segment, postoperative pain, venous clinical severity scores, Aberdeen varicose vein questionnaire scores, and short-form 36-item health survey questionnaire scores, and complications. RESULTS From 2012 to 2018, 364 patients (375 limbs) were included, of which, 189 limbs were randomly allocated to the 2% group and 186 to the 3% group. The TS rate at 6 months was 69.8% in the 2% group vs 78.0% in the 3% group (P = .027). A higher overall TS rate was seen in GSVs of ≤5.9 mm compared with GSVs >5.9 mm (84.3% vs 59.5%, respectively; P < .001). The alternative TS rate at 6 months was 61.4% in the 2% group and 67.7% in the 3% group (P = .028). The venous clinical severity scores, Aberdeen varicose vein questionnaire scores, and most short-form 36-item health survey questionnaire domains had improved in both groups (P < .002). Postprocedural pain was low. Two pulmonary embolisms and two deep vein thromboses were seen. Superficial venous thrombosis had occurred more often in the 3% group (18 vs 8 in the 2% group; P = .033). CONCLUSIONS The results from the present study showed a higher success rate for MOCA with 3% POL liquid than for MOCA with 2% POL liquid at 6 months of follow-up. However, the difference in quality of life was not significant. Long-term follow-up studies are required to investigate whether these results will be sustained in the future.
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Affiliation(s)
- Yee Lai Lam
- Department of Dermatology, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - Tamana Alozai
- Department of Surgery, Northwest Clinics, Alkmaar, The Netherlands
| | | | - André A E A de Smet
- Department of Vascular Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - Anco C Vahl
- Department of Vascular Surgery, OLVG, East Location, Amsterdam, The Netherlands
| | - Ivo Nagtzaam
- Department of Dermatology, Maastricht University Medical Center, Maastricht, The Netherlands
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Apruzzi L, Bilman V, Ardita V, Favia N, Saracino C, Chiesa R, Baccellieri D. Comparison of mechanochemical ablation versus ligation and stripping for the treatment of incompetent small saphenous vein. Phlebology 2021; 37:48-54. [PMID: 34505545 DOI: 10.1177/02683555211045191] [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: 11/17/2022]
Abstract
OBJECTIVE to compare the outcomes of mechanochemical ablation (MOCA) versus saphenopopliteal junction ligation and stripping (OS) for symptomatic small saphenous vein (SSV) insufficiency. METHODS This is a retrospective study including symptomatic SSV patients treated with MOCA using the ClariVein catheter (Merit Medical, South Jordan, Utah, USA) or OS from 2015 to 2019. RESULTS A total of 60 limbs (73.3% women, mean age 54.7 ± 14.4 years) were treated with MOCA and 58 limbs (63.8% women, mean age 54 ± 11.6 years) with OS. At 18 months follow-up, recurrence rates were 7.5% (4/53) for MOCA vs. 5.7% (3/52) for the OS group. MOCA group was associated with less pain at first postoperative day, and an early return to work (MOCA 3.5 ± 2.3 days vs. OS 14.2 ± 3.8 days, p < .0001). No cases of leg paresthesia/dysesthesia were observed in the MOCA group, while two patients (3.4%) presented neurological symptoms after OS treatment. CONCLUSION MOCA and OS are both safe and effective techniques for symptomatic SSV insufficiency. MOCA group demonstrated to be associated with less postoperative pain and early return to work compared to OS.
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Affiliation(s)
- Luca Apruzzi
- Vascular Surgery Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Victor Bilman
- Vascular Surgery Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Vincenzo Ardita
- Vascular Surgery Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nicola Favia
- Vascular Surgery Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Concetta Saracino
- Vascular Surgery Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Roberto Chiesa
- Vascular Surgery Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Alozai T, Huizing E, Schreve M, Mooij MC, van Vlijmen CJ, Wisselink W, Ünlü Ç. A systematic review and meta-analysis of mechanochemical endovenous ablation using Flebogrif for varicose veins: A summary of evidence. J Vasc Surg Venous Lymphat Disord 2021:S2213-333X(21)00289-4. [PMID: 34091106 DOI: 10.1016/j.jvsv.2021.05.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 05/21/2021] [Indexed: 11/22/2022]
Abstract
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.
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15
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Baccellieri D, Apruzzi L, Ardita V, Favia N, Saracino C, Carta N, Melissano G, Chiesa R. Early results of mechanochemical ablation for small saphenous vein incompetency using 2% polidocanol. J Vasc Surg Venous Lymphat Disord 2020; 9:683-690. [PMID: 32916372 DOI: 10.1016/j.jvsv.2020.09.001] [Citation(s) in RCA: 5] [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: 06/10/2020] [Accepted: 09/01/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The aim of the present study was to investigate the early results of mechanochemical ablation (MOCA) for the treatment of small saphenous vein (SSV) incompetence. METHODS We performed a single-center, retrospective analysis of a prospectively collected database of 60 patients treated with MOCA for single-axis SSV incompetence. All procedures were performed with the patient under local anesthesia using the ClariVein catheter (Merit Medical, South Jordan, Utah) combined with 2% polidocanol and, where appropriate, additional microphlebectomy. The primary study endpoint was to assess the SSV occlusion rate at the 1-, 6-, and 12-month follow-up examinations. The secondary endpoints included the Venous Clinical Severity Score, quality of life (QoL) assessment, periprocedural pain, and further complications after the intervention and during the follow-up period. Patient QoL was assessed using the Aberdeen Varicose Vein Questionnaire. Pain was measured using a 100-mm visual analog scale. RESULTS Technical success was achieved in 100% of the cases. The mean visual analog scale score on the first postoperative day was 15 mm. No major events were recorded. No neurological complications or deep vein thrombosis were observed. Minor complications included ecchymosis in 3.3% of cases (2 of 60), transient phlebitis of the SSV in 5% of cases (3 of 60), and itching in 3.3% of cases (2 of 60). At the 1-, 6-, and 12-month follow-up examinations, the occlusion rate was 100% (60 of 60), 98.3% (57 of 58), and 92.6% (50 of 54). The median Venous Clinical Severity Score had significantly decreased from 5 (interquartile range [IQR], 3-6) at baseline to 2 (IQR, 1-4) at the 1-month follow-up (P < .001), 1 (IQR, 1-2) at the 6-month follow-up (P < .001) and 1 (IQR, 0-1) at the 12-month follow-up (P < .001). The mean Aberdeen Varicose Vein Questionnaire score had improved from the baseline score of 25 ± 14.61 to 15.81 ± 13.76 at the 1-month follow-up (P < .001), to 9.81 ± 7.42 at the 6-month follow-up (P < .001) and 4.73 ± 3.32 at the 12-month follow-up (P < .001). CONCLUSIONS The results of our study have shown that MOCA is a feasible, safe, and painless procedure for the treatment of SSV incompetence with an occlusion rate of 92.6% at the 12-month examination. No sural nerve injuries or other major complications were observed. The procedure also provided good clinical results and positive effects on patient QoL.
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Affiliation(s)
| | - Luca Apruzzi
- Vascular Surgery Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Vincenzo Ardita
- Vascular Surgery Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nicola Favia
- Vascular Surgery Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Concetta Saracino
- Vascular Surgery Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Niccolò Carta
- Vascular Surgery Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Germano Melissano
- Vascular Surgery Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy; Division of Vascular Surgery, "Vita-Salute San Raffaele" University, Milan, Italy
| | - Roberto Chiesa
- Vascular Surgery Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
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16
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Obi AT, Afridi S, Lurie F. Management and treatment outcomes of patients undergoing endovenous ablation are significantly different between Intersocietal Accreditation Commission-accredited and nonaccredited vein centers. J Vasc Surg Venous Lymphat Disord 2020; 9:346-351. [PMID: 32721587 DOI: 10.1016/j.jvsv.2020.07.007] [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] [Received: 04/27/2020] [Accepted: 07/09/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The Intersocietal Accreditation Commission of vein centers was instituted in 2014, yet data regarding impact of accreditation on patients undergoing superficial vein interventions are lacking. This study was undertaken to identify differences in patient outcomes and utilization index as a measure of appropriate use in accredited compared with nonaccredited centers. METHODS This study was performed with a matched control design using prospectively collected data from two major U.S.-based venous registries: the Society for Vascular Surgery Vascular Quality Initiative Varicose Vein Registry and the American Vein & Lymphatic Society PRO Venous Registry. RESULTS A total of 39,001 patients treated between 2015 and 2018 in 192 centers were included in the study. The Vascular Quality Initiative Varicose Vein Registry provided information on 19,810 (50.8%) patients, and the American Vein & Lymphatic Society PRO Venous Registry provided information on 19,191 (49.2%) patients. Accredited centers were significantly more likely to treat patients with advanced venous disease as characterized by trophic skin changes (C4-C6, 38.1% vs 25.2%; P < .001). Percentage of patients treated 2 standard deviations above the Medicare-reported mean (3.4 utilization index) was significantly higher among patients treated at nonaccredited centers (3.3% vs 0.1%; P < .001). Venous Clinical Severity Score of those who were assessed between 1 month and 1 year after ablation decreased by 4.98 ± 4.01 in nonaccredited centers compared with 5.61 ± 3.64 in accredited centers (P < .001). Complications were low in both cohorts (nonaccredited centers, 71 [0.4%]; accredited centers, 17 [0.1%]; P < .001). One-year clinical follow-up was higher in nonaccredited centers (76.4% vs 31.5%; P < .001). CONCLUSIONS Venous registries are a powerful tool for capturing and identifying significant variations in procedure utilization and complications in low-risk procedures. Intersocietal Accreditation Commission accreditation was associated with reduced use of endovenous therapies, slightly lower complication rates, lower 1-year follow up, and greater improvement in Venous Clinical Severity Score.
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Affiliation(s)
- Andrea T Obi
- Section of Vascular Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, Mich
| | - Sophia Afridi
- Department of Vascular Surgery, Jobst Vascular Institute, Promedica, Toledo, OH
| | - Fedor Lurie
- Section of Vascular Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, Mich; Department of Vascular Surgery, Jobst Vascular Institute, Promedica, Toledo, OH.
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17
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Brown CS, Osborne NH, Kim GY, Sutzko DC, Wakefield TW, Obi AT, Henke PK. Effect of concomitant deep venous reflux on truncal endovenous ablation outcomes in the Vascular Quality Initiative. J Vasc Surg Venous Lymphat Disord 2020; 9:361-368.e3. [PMID: 32592853 DOI: 10.1016/j.jvsv.2020.04.031] [Citation(s) in RCA: 5] [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: 03/17/2020] [Accepted: 04/14/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Few studies have investigated outcomes after truncal endovenous ablation in patients with combined deep and superficial reflux and no studies have evaluated patient-reported outcomes. METHODS We investigated the short- and long-term clinical and patient-reported outcomes among patients with and without deep venous reflux undergoing truncal endovenous ablation from 2015 to 2019 in the Vascular Quality Initiative. Preprocedural and postprocedural comparisons were performed using the t-test, χ2, or their nonparametric counterpart when appropriate. Multivariable logistic regression models were used to assess for confounding. RESULTS A total of 4881 patients were included, of which 2254 (46.2%) had combined deep and superficial reflux. The median follow-up was 336.5 days. Patients with deep reflux were less likely to be female (65.9% vs 69.9%; P = .003), more likely to be Caucasian (90.2% vs 86.5%; P = .003) and had no difference in BMI (30.6 ± 7.5 vs 30.6 ± 7.2; P = .904). Additionally, no difference was seen in rates of prior varicose vein treatments, number of pregnancies, or history of deep venous thrombosis; however, patients without deep reflux were more likely to be on anticoagulation at the time of the procedure (10.9% vs 8.1%; P < .001). Patients without deep reflux had slightly higher median preprocedural Venous Clinical Severity Score (VCSS) scores (8 [interquartile range (IQR), 6-10]) vs 7 [IQR, 6-10]; P = .005) as well as postprocedural VCSS scores (5 [IQR, 3-7] vs 4 [IQR, 2-6]; P < .001). The median change in VCSS from before to after the procedure was lower for patients without deep reflux (3 [IQR, 1.0-5.5] vs 3.5 [IQR, 1-6]; P = .006). Total symptom score was higher for patients without deep reflux both before (median, 14 [IQR, 10-19] vs median, 13.5 [IQR, 9.5-18]; P = .005) and postprocedurally (median, 4 [IQR, 1-9] vs median, 3.25 [IQR, 1-7]; P < .001), but no difference was seen in change in symptom score (median, 8 [IQR, 4-13] vs median, 9 [IQR, 4-13]; P = .172). Patients with deep reflux had substantially higher rates of complications (10.4% vs 3.0%; P < .001), with a particular increase in proximal thrombus extension (3.1% vs 1.1%; P < .001). After controlling for confounding, this estimate of effect size for any complication increased (odds ratio, 5.72; 95% confidence interval, 2.21-14.81; P < .001). CONCLUSIONS No significant difference is seen in total symptom improvement when patients undergo truncal endovenous ablation with concomitant deep venous reflux, although a greater improvement was seen in VCSS score in these patients. Patients with deep venous reflux had a significantly increased rate of complications, independent of confounding variables, and should be counseled appropriately before the decision for treatment.
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Affiliation(s)
- Craig S Brown
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich.
| | - Nicholas H Osborne
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Gloria Y Kim
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Danielle C Sutzko
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Thomas W Wakefield
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Andrea T Obi
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Peter K Henke
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
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Cho S, Park HS, Lee T, Byun SJ, Yun WS, Yang SS, Kim H, Kim WS, Joh JH, Jung IM. CASS (CyanoAcrylate closure versus Surgical Stripping for incompetent saphenous veins) study: a randomized controlled trial comparing clinical outcomes after cyanoacrylate closure and surgical stripping for the treatment of incompetent saphenous veins. Trials 2020; 21:460. [PMID: 32493398 PMCID: PMC7268719 DOI: 10.1186/s13063-020-04393-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 05/08/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Several modalities are used for the treatment of varicose veins. Open surgical treatment with ligation and stripping of the saphenous vein has been the standard of care for many years. Endovenous thermal ablation has been shown to be a safe and effective alternative with high, long-term, target-vein closure rates. Despite this, there is the possibility of thermal injury to surrounding structures. The recently introduced cyanoacrylate closure is also considered to be a good alternative and the risk of injury to surrounding structures is minimal. The purpose of this study is to demonstrate the non-inferiority of cyanoacrylate closure with the VenaSeal™ closure system compared to surgical stripping in terms of clinical outcomes for the treatment of incompetent great saphenous veins. METHODS/DESIGN This is an open-label, multicenter, prospective, randomized controlled trial evaluating the non-inferior clinical outcomes of cyanoacrylate closure compared to surgical stripping for the treatment of incompetent saphenous veins. After baseline measurements, participants will be randomly allocated into either the cyanoacrylate closure group or the surgical-stripping group. The primary endpoint of the study is the complete closure rate of the target vein in the cyanoacrylate closure group, and the absence of venous reflux or residual venous tissue after surgical stripping in the surgical-stripping group. These endpoints will be measured by Doppler ultrasound performed by qualified vascular technologists or investigators at 3 months after treatment. Secondary outcomes include perioperative pain, postoperative ecchymosis, clinical assessment (including general and disease-specific quality of life evaluations), complete closure rate, and absence of venous reflux or residual venous tissue at the 12- and 24-month follow-ups, as well as all adverse event rates during the 24-month follow-up period. DISCUSSION This multicenter randomized controlled trial is designed to show non-inferiority in terms of complete closure rate of cyanoacrylate compared to surgical stripping for the treatment of incompetent saphenous veins. TRIAL REGISTRATION Clinical Research Information Service (CRIS), ID: KCT0003203. Registered on 20 September 2018.
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Affiliation(s)
- Sungsin Cho
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, South Korea
| | - Hyung Sub Park
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Taeseung Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Seung Jae Byun
- Department of Surgery, Wonkwang University Hospital, Wonkwang University School of Medicine, Iksan, South Korea
| | - Woo-Sung Yun
- Department of Surgery, Yeungnam University Medical Center, Yeungnam University School of Medicine, Daegu, South Korea
| | - Shin-Seok Yang
- Department of Surgery, Yeungnam University Medical Center, Yeungnam University School of Medicine, Daegu, South Korea
| | - Hyangkyoung Kim
- Department of Surgery, Chung-Ang University Hospital, Chung-Ang School of Medicine, Dongjak-gu, South Korea
| | - Woo-Shik Kim
- Department of Thoracic and Cardiovascular Surgery, National Medical Center, Seoul, South Korea
| | - Jin Hyun Joh
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, South Korea
| | - In Mok Jung
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, 07061 20 Boramae-ro, Dongjak-gu, Seoul, South Korea.
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Brown CS, Obi AT, Cronenwett JL, Kabnick L, Wakefield TW, Osborne NH. Outcomes after truncal ablation with or without concomitant phlebectomy for isolated symptomatic varicose veins (C2 disease). J Vasc Surg Venous Lymphat Disord 2020; 9:369-376. [PMID: 32502731 DOI: 10.1016/j.jvsv.2020.05.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 04/03/2020] [Accepted: 05/22/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Many insurance payers are hesitating to cover interventional treatments in patients with isolated symptomatic varicose veins. In this study, we sought to determine the outcomes of patients with varicose veins who were treated with venous ablation alone or ablation plus phlebectomy using the Vascular Quality Initiative Varicose Vein Registry. METHODS Using data from the Varicose Vein Registry between January 2015 and March 2019, we investigated immediate postoperative as well as long-term clinical and patient-reported outcomes among patients with documented symptomatic C2 disease undergoing truncal endovenous ablations alone and combined ablation and phlebectomy. Preprocedural and postprocedural comparisons were performed using t-test, χ2 test, or nonparametric tests when appropriate. Multivariable ordinal logistic regression was performed on ordinal outcome variables. RESULTS Among 3375 patients with symptomatic C2 disease, 40.1% of patients (1376) underwent isolated truncal ablation and 59.9% (1999) underwent ablation and phlebectomy. Complications overall were low (8.6%) and varied between 8.4% and 8.7% in patients undergoing ablation alone and ablation plus phlebectomy, respectively (P = .820). The most common complication noted was paresthesia, 3.4% overall, which occurred more commonly after ablation and phlebectomy (4.5%) than after ablation alone (1.3%; P < .001). An improvement in Venous Clinical Severity Score (VCSS) was experienced by 87.4% of patients; median change in VCSS was 4 points (interquartile range [IQR], 2-5 points), with an improvement of 3 points among patients undergoing ablation alone (IQR, 1-5 points) and 5 points among patients undergoing ablation and phlebectomy (IQR, 3-5 points; P < .001). An improvement in overall symptoms was experienced by 94.4% of patients (median improvement, 11 points; (maximum, 30 points), with more significant decreases among patients undergoing ablation and phlebectomy (median, 12 points; IQR, 8-17 points) compared with ablation alone (median, 9 points; IQR, 5-13 points; P < .001). CONCLUSIONS Among patients with isolated symptomatic varicose veins (C2 disease), ablation and ablation with phlebectomy are safe and effective in improving both patient-reported outcomes and clinical severity (VCSS). Given these data, payers should continue to cover these treatments.
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Affiliation(s)
- Craig S Brown
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich.
| | - Andrea T Obi
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Jack L Cronenwett
- Section of Vascular Surgery, Department of Surgery, Dartmouth Institute and Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Lowell Kabnick
- Atlantic Health System (Morristown Medical Center), Kabnick Vein Center, Morristown, NJ
| | - Thomas W Wakefield
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Nicholas H Osborne
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
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20
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Brown CS, Osborne NH, Kim GY, Sutzko DC, Wakefield TW, Obi AT, Koleilat I. Comparison of unilateral vs bilateral and staged bilateral vs concurrent bilateral truncal endovenous ablation in the Vascular Quality Initiative. J Vasc Surg Venous Lymphat Disord 2020; 9:113-121.e3. [PMID: 32470615 DOI: 10.1016/j.jvsv.2020.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 02/25/2020] [Accepted: 05/05/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Venous insufficiency is commonly bilateral, and patients often prefer single-episode care compared with staged procedures. Few studies have investigated clinical outcomes after unilateral vs bilateral venous ablation procedures or between staged and concurrent bilateral procedures. Here, we report data from the Vascular Quality Initiative regarding truncal venous ablation for chronic venous insufficiency. METHODS Using data from the Vascular Quality Initiative, we investigated immediate postoperative as well as long-term clinical and patient-reported outcomes of patients undergoing unilateral vs bilateral truncal endovenous ablation from 2015 to 2019. We further investigated outcomes between staged bilateral and concurrent bilateral ablations. Preprocedural and postprocedural comparisons were performed using t-test, χ2 test, or their nonparametric counterpart when appropriate. Multivariable ordinal logistic regression was performed on ordinal outcome variables. RESULTS A total of 5029 patients were included, of whom 3782 (75.2%) underwent unilateral procedures. Median follow-up was 227 days (interquartile range [IQR], 55-788 days). Unilateral patients were less likely to be female (67.0% vs 70.3%; P = .031) and white (86.3% vs 91.2%; P < .001) and had lower body mass index (30.3 ± 7.3 kg/m2 vs 31.8 ± 7.6 kg/m2; P < .001) compared with patients undergoing bilateral procedures. In addition, unilateral patients had fewer prior varicose vein treatments (23.0% vs 15.7%; P < .001) and had higher median preprocedural Venous Clinical Severity Score (VCSS; 8 [IQR, 6-10] vs 7 [IQR, 5.5-9]; P < .001). No difference was seen in complications (6.9% vs 8.2%; P = .292), and systemic complications were rare in both groups. No difference was seen in VCSS improvement after treatment (median, 3 [IQR, 1-6] for unilateral; median, 3 [IQR 1-5] for bilateral; P = .055). In comparing staged with concurrent bilateral procedures, there was no difference in overall complications (7.5% vs 12.2%; P = .144). Staged bilateral patients were older (56.9 ± 13.3 years vs 54.2 ± 12.9 years; P = .002), less likely to have had prior varicose vein treatment (14.3% vs 19.8%; P = .020), and more likely to be therapeutically anticoagulated (10.8% vs 6.5%; P = .028) compared with concurrent bilateral patients. Staged patients also have higher preprocedural VCSS compared with concurrent patients (median, 8 [IQR, 6-10] vs 7 [IQR, 5.5-9]; P < .001). In multivariable analysis, there was no difference in the likelihood of VCSS improvement for concurrent compared with staged procedures (odds ratio, 0.70; 95% confidence interval, 0.40-1.24; P = .226). CONCLUSIONS Concurrent bilateral truncal endovenous ablation can be performed safely without increased morbidity compared with staged bilateral or unilateral ablations.
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Affiliation(s)
- Craig S Brown
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich.
| | - Nicholas H Osborne
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Gloria Y Kim
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Danielle C Sutzko
- Section of Vascular Surgery, Department of Surgery, University of Alabama Birmingham, Birmingham, Ala
| | - Thomas W Wakefield
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Andrea T Obi
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Issam Koleilat
- Division of Vascular Surgery, Montefiore Medical Center, Bronx, NY
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Tang TY, Yap CJQ, Chan SL, Soon SXY, Yap HY, Lee SQW, Choke ETC, Chong TT. 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. J Vasc Surg Venous Lymphat Disord 2020; 9:335-345.e2. [PMID: 32387378 DOI: 10.1016/j.jvsv.2020.03.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 02/18/2020] [Accepted: 03/29/2020] [Indexed: 01/19/2023]
Abstract
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.
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Affiliation(s)
- Tjun Yip Tang
- Department of Vascular Surgery, Singapore General Hospital, Singapore; Duke-NUS Graduate Medical School, Singapore.
| | - Charyl Jia Qi Yap
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Sze Ling Chan
- Health Services Research Center, SingHealth, Singapore
| | | | - Hao Yun Yap
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | | | | | - Tze Tec Chong
- Department of Vascular Surgery, Singapore General Hospital, Singapore; Duke-NUS Graduate Medical School, Singapore
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22
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Javier JJ, Ortiz P. Treatment of chronic venous insufficiency in Latin America. J Vasc Surg Venous Lymphat Disord 2020; 8:667-675. [PMID: 32234293 DOI: 10.1016/j.jvsv.2020.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 07/08/2019] [Accepted: 01/25/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Venous disease is common in Latin America, with an estimated 68.11% prevalence of chronic venous disease. The diverse social, political, and economic characteristics of the many nations that make up Latin America mean that different conditions affect how these diseases are diagnosed and treated, which may differ markedly from the way they are treated by the health care systems of the United States and Europe. Our goal was to review the current state of treatment of chronic venous insufficiency (CVI) in Latin America. METHODS This is a narrative review of the medical literature on the subject and synthesizes sometimes fragmentary information on CVI across a large and diverse region. RESULTS CVI represents an unmet medical need in Latin America. Conservative treatments, such as compression stockings, may be used at first, and there are nonpharmacologic and complementary and alternative medicine approaches in use. Endovenous approaches, such as endovenous thermal ablation, have largely replaced surgical interventions. In Europe and the United States, such procedures are mainly carried out in ambulatory facilities, whereas they are mainly performed in the hospital in Latin America. CONCLUSIONS Recent strong economic growth in Latin America and improvements in social security and health care suggest that innovative approaches to chronic venous disease and CVI will be implemented.
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Affiliation(s)
- Julian J Javier
- Division of Venous Disease, Naples Cardiac & Endovascular Center, Naples, Fla; Department of Venous Disease, Centro Cardiovascular Clinica Canela, La Romana, Dominican Republic.
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Abstract
At the 2019 European Venous Forum in Zurich Switzerland, a symposium entitled "State of the art: benefits of MPFF throughout CVD progression" was held to discuss the developing treatment strategies for patients at all stages of chronic venous disease (CVD). At the early stages of CVD, management should be focused on preventing disease progression through lifestyle changes and conservative treatment; treatment can also include venoactive drugs (VAD) such as micronized purified flavonoid fraction (MPFF; Daflon®), which is the most well-known and most widely prescribed VAD in Europe. As the disease progresses, patients who require interventional procedures (e.g., endovenous procedure or sclerotherapy) can also benefit from MPFF treatment in the recovery period after the procedure, as MPFF has been shown to reduce periprocedural pain and bleeding (hematoma), and to improve CVD symptoms during this period. Management of CVD in patients with venous leg ulcers (VLU) is the most challenging; in these patients, recommended adjunct therapies to be combined with standard compression therapy include VAD (MPFF) and non-VAD drugs (pentoxifylline and sulodexide) which have been shown to speed VLU healing in comparison with compression therapy alone.
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Affiliation(s)
- Andrew N Nicolaides
- Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus.
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24
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Lee V, Berland T, Jacobowitz G, Rockman C, Sadek M, Barfield M, Cayne N, Maldonado TS. Prior authorization as a utilization management tool for elective superficial venous procedures results in high administrative cost and low efficacy in reducing utilization. J Vasc Surg Venous Lymphat Disord 2020; 8:383-389.e1. [PMID: 31859243 DOI: 10.1016/j.jvsv.2019.10.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 10/13/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Prior authorization (PA) is a process used by payers for safety and cost savings purposes, but it has received criticism for being time-consuming and costly because of administrative burden. Our study evaluated efficacy of PA applied to in-office lower extremity superficial venous procedures. METHODS All in-office lower extremity venous procedures scheduled to be performed at our institution in 2017 were included in the study. Variables of interest were type of procedure, initial PA status (approved or denied), rationale for the decision, and final status after appeal. Cost analysis was performed using Centers for Medicare and Medicaid Services allowable rates to approximate billing and reimbursement data (proprietary) as well as calculated using industry averages. RESULTS For 2017, of 1959 procedures scheduled, 57.9% (n = 1134) required PA. Of these, only 6.1% (n = 69) received initial PA denial, and nearly 40% of the denials (n = 27) were overturned after appeal. Of the 42 denials that were upheld, 15 resulted in cancellations; the remainder were performed by patient self-pay (n = 11) or by the provider pro bono (n = 16). Overturned denials were a result of either submission of incomplete clinical data on initial PA request or insufficient documentation of clinical necessity. When Centers for Medicare and Medicaid Services allowable rates were applied for cost analysis, the denials resulted in <$60,000 payer savings. Administrative expenses totaled >$110,000 when industry standards were applied, which far exceeds any calculated payer savings using the same methods. The 15 denials resulting in procedure cancellations (1.3% of all PAs) could be considered a net savings to the health care system but only approximated a mere $30,000. CONCLUSIONS Our study demonstrates that PA is not a cost-effective measure for utilization management of outpatient superficial venous procedures when surgeon practices are already well aligned with insurance guidelines. For these physicians and physician groups, the administrative cost associated with the PA process exceeds the savings seen by the insurance companies.
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25
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Jones AD, Boyle EM, Woltjer R, Jundt JP, Williams AN. Persistent type IV hypersensitivity after cyanoacrylate closure of the great saphenous vein. J Vasc Surg Cases Innov Tech 2019; 5:372-374. [PMID: 31440717 PMCID: PMC6699189 DOI: 10.1016/j.jvscit.2019.05.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 05/03/2019] [Indexed: 11/29/2022]
Abstract
The VenaSeal (Medtronic, Minneapolis, Minn) cyanoacrylate closure system is a nonthermal technique for ablating saphenous veins using a proprietary n-butyl cyanoacrylate. One possible side effect is an allergic reaction to cyanoacrylate. We report the case of a 49-year-old woman treated with cyanoacrylate closure who developed a persistent type IV hypersensitivity reaction. The patient elected to have the vein excised, and the histologic features were consistent with a type IV hypersensitivity reaction.
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Affiliation(s)
| | | | - Randy Woltjer
- Department of Pathology, Oregon Health Sciences University, Portland, Ore
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Chou JH, Chen SY, Chen YT, Hsieh CH, Huang TW, Tam KW. Optimal duration of compression stocking therapy following endovenous thermal ablation for great saphenous vein insufficiency: A meta-analysis. Int J Surg 2019; 65:113-119. [PMID: 30959134 DOI: 10.1016/j.ijsu.2019.03.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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: 01/21/2019] [Revised: 03/16/2019] [Accepted: 03/27/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND The need for patients to wear compression stockings after varicose vein surgery and the duration of compressions tocking therapy has been debated. This study isa meta-analysis of randomized controlled trials (RCTs) to determine the optimal duration of compression stocking therapy after endovenous thermal ablation (ETA) of the great saphenous vein. METHODS The PubMed, Embase, and Cochrane Library databases were searched before January 2019. Individual effect sizes were standardized, and a meta-analysis was conducted to calculate the pooled effect size by using a random effects model. The primary outcome was the severity of pain in the postoperative period. Secondary outcomes were quality of life (QoL), leg volume, bruising scores, consumptionof analgesic agents, recovery time off work, satisfaction, and the incidence rates of postoperative complications including paresthesia and phlebitis. RESULTS Five RCTsinvolving775 patients were reviewed. The long-duration (1-2 weeks) group significantly reduced postoperative pain at 1 week (mean difference [MD] 1.19; 95% confidence interval [CI]: 0.58-1.80) and recovery time off work (MD: 1.01 day, 95% CI: 0.06-1.96)when compared with the short-duration (24-48 h) group. However, the mean pain scores at 2 (0.1; 95% CI: 0-0.2) and 6 weeks postoperatively (-0.3; 95% CI: -1.09-0.49) did not differ significantly between the two groups. Moreover, the incidence rates of complication, paresthesia, and phlebitis did not differ significantly between the short-duration and long-duration groups. CONCLUSION The use of compression therapy for a long time (1-2 weeks) is better than short-term (24-48 h) use in terms of postoperative pain at 1 week and recovery off work. Hence, we recommend the prescription of 1-week compression stocking therapy after ETA in routine clinical practice. However, the available evidence is of variable quality, further well-structured RCTs with improved standardization of compression treatment, types of stockings, and target populations are warranted.
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Affiliation(s)
- Jian-Hong Chou
- School of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Shiaun-Yeu Chen
- School of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yueh-Ting Chen
- School of Medicine, Taipei Medical University, Taipei, Taiwan
| | | | - Tsai-Wei Huang
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan; Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan.
| | - Ka-Wai Tam
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan; Division of General Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan; Division of General Surgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
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Cordes J, Zimbelmann M, Merseburger AS, Kramer M, Vonthein R, Büttner H, Recke A, Kahle BK. Transient increased tumescence of the glans penis during penile erection after endovenous ablation of the great saphenous vein. J Vasc Surg Venous Lymphat Disord 2018; 7:387-391. [PMID: 30477979 DOI: 10.1016/j.jvsv.2018.06.014] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 06/21/2018] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The primary objective of our study was to investigate the impact of endovenous ablation of the great saphenous vein (GSV) on the degree of tumescence of the glans penis during penile erection as well as on global erectile function (EF). METHODS We included patients scheduled for one of three different methods of endoluminal treatment. Our questionnaire was composed of the EF domain of the International Index of Erectile Function, an additional question that has been validated for assessment of swelling (tumescence) of the glans penis, and a question on the use of erectogenic medication. RESULTS There were 62 patients enrolled in the study. Seven patients (11%) reported a postoperative enlargement of the glans penis on penile erection compared with the subjectively assessed glans tumescence before surgery. Three patients (5%) reported an increased tumescence of the glans 1 week after surgery, and four (7.4%) different patients reported the effect 3 months after surgery. Of these seven men, three had normal EF (score ≥26) at any time. One patient had mild erectile dysfunction before the operation, with an improvement to normal EF from week 1 throughout the observation in the study (3 months). CONCLUSIONS This is the first prospective study that confirms an unexpected side effect of endoluminal treatment of the GSV occurring in approximately 10% of men. It might be of interest for insufficient responders to phosphodiesterase type 5 inhibitors with varicosis of the GSV in the future.
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Affiliation(s)
| | | | | | | | - Reinhard Vonthein
- Institute of Statistics, UKSH, Lübeck, Germany; ZKS Luebeck, University of Luebck, Lübeck, Germany
| | - Hartwig Büttner
- Medical Department, Lilly Deutschland GmbH, Bad Homburg, Germany
| | - Andreas Recke
- Clinic of Dermatology Luebeck Campus, University Medical Center, Schleswig-Holstein, Lübeck, Germany
| | - Birgit K Kahle
- Clinic of Dermatology Luebeck Campus, University Medical Center, Schleswig-Holstein, Lübeck, Germany
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Abstract
Objective To evaluate the effect of endovenous ablation in patients presenting with leg swelling. Methods We identified Clinical, Etiology, Anatomy, Pathophysiology (CEAP) clinical class 3 (C3) patients undergoing endovenous ablation from 21 January 2005 to 19 March 2015 with an 810-nm or 1470-nm laser. Patients were surveyed regarding the degree of edema, use of compression stockings, and satisfaction with the procedure. Results A total of 1634 limbs were treated by endovenous ablation for incompetent saphenous veins with or without adjunctive segmental varicose vein microphlebectomy. Of these, 528 limbs were treated for CEAP C3. The average time period from the procedure date until the survey date was 1494 days (range, 562–2795 days). Ninety-two respondents accounted for 130 ablations in 128 limbs with an average venous segmental disease score of 2.7. Ninety-seven limbs (75.8%) had reduced or resolved swelling, 29 limbs (22.6%) were unchanged, and 2 limbs (1.6%) had increased swelling. The vast majority (81%) were satisfied with their decision to have the procedure. Conclusions Endovenous ablation for edema secondary to superficial venous insufficiency is effective and has high patient satisfaction. Further investigation is needed regarding risk factors for immediate failure and delayed recurrence of edema.
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Affiliation(s)
- William Shutze
- 1 Texas Vascular Associates, Dallas, Texas, USA.,2 The Heart Hospital Baylor Plano, Dallas, Texas, USA
| | - Ryan Shutze
- 1 Texas Vascular Associates, Dallas, Texas, USA
| | - Paul Dhot
- 1 Texas Vascular Associates, Dallas, Texas, USA.,2 The Heart Hospital Baylor Plano, Dallas, Texas, USA
| | - Gerald O Ogola
- 3 Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas, Texas, USA
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Belramman A, Bootun R, Tang TY, Lane TRA, Davies AH. Mechanochemical ablation versus cyanoacrylate adhesive for the treatment of varicose veins: study protocol for a randomised controlled trial. Trials 2018; 19:428. [PMID: 30086774 PMCID: PMC6081848 DOI: 10.1186/s13063-018-2807-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 07/13/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Thermal ablation techniques have become the first-line treatment of truncal veins in the management of chronic venous disease (CVD). Despite excellent outcomes, these methods are often associated with pain; generally due to their use of heat and the necessity of fluid infiltration around the vein. More recently, novel non-thermal techniques, such as mechanochemical ablation (MOCA) and cyanoacrylate adhesive (CAE) have been developed to overcome these unwelcome effects. So far, the novel techniques have been found to have similar efficacy to thermal methods, yet no direct comparisons between the non-thermal treatment techniques have been conducted to date, giving rise to this study. METHODS/DESIGN This is a prospective, multicentre, randomised clinical trial, recruiting patients with truncal saphenous incompetence. Patients will be randomised to undergo either MOCA or CAE truncal ablation, followed by treatment of any varicosities. All patients will be required to wear compression stockings for 4 days post intervention. The primary outcome measure is the pain score immediately following completion of truncal ablation, measured by a 100-mm Visual Analogue Scale (VAS). The secondary outcomes are entire treatment pain scores, clinical scores, quality of life scores, occlusion rates, time to return to usual activities/work at 2 weeks, 3, 6 and 12 months. Re-intervention rate will be considered from the third month. Cost-effectiveness will be assessed for each intervention at 12 months. The study is powered to detect a mean 10-mm difference in maximum pain score. Allowing for loss to follow-up, the total target recruitment is 180 patients. DISCUSSION The study will be the first study to compare MOCA against CAE and is designed to determine which method causes less pain. Completion of this study is expected to be the end of 2019. TRIAL REGISTRATION ClinicalTrials.gov, ID: NCT03392753 . Registered on 17 November 2017.
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Affiliation(s)
- Amjad Belramman
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, 4N12A, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF UK
| | - Roshan Bootun
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, 4N12A, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF UK
- East of England Deanery, London, UK
| | - Tjun Yip Tang
- Singapore General Hospital, London, Singapore
- Sengkang General Hospital, Singapore, Republic of Singapore
| | - Tristan R. A. Lane
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, 4N12A, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF UK
- London Deanery, London, UK
- Imperial College Healthcare NHS Trust, London, UK
| | - Alun H. Davies
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, 4N12A, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF UK
- Imperial College Healthcare NHS Trust, London, UK
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Abstract
Despite recent NICE guidance there remains a definite role for surgery in the management of varicose veins. A lot of the available evidence that has driven the transformation of care towards endovenous treatments is of good quality yet published by enthusiasts. No endovenous studies have reported long term results as far out from intervention as the open studies, yet in the meta-analysis from Murad et al, the authors suggested from their results that when surgery was compared with all endoluminal ablation therapies, surgery was associated with a non-significant reduction in the risk of varicose vein recurrence (RR0.63; 95%CI 0.37--1.07). Much of the longer-term data on recurrence following open surgery for primary varicose veins dates back well over 15 years ago. This is prior to the inclusion of routine duplex assessment and sub-specialty designation. The recent Cochrane review (13 randomised controlled studies, 3081 patients). The overall conclusion was that UGFS, EVLT and RFA were at least as effective as surgery in the treatment of the LSV. This meta-analysis did not include the CLASS (Comparison of LAser, Surgery and foam Sclerotherapy as a treatment for varicose veins) trial in which measures of clinical success were similar among the groups. Only 48% of the patients screened were eligible for the CLASS study and of these, only 24% of the eligible patients agreed to take part in the study. Similarly in the study by Carradice out of a total of 772 patients assessed for suitability, 442 did not meet the inclusion criteria. There is no doubt that endovenous surgery will increasingly become first line treatment for patients with symptomatic superficial venous reflux specifically in patients with SSV reflux. However, given the device related limitations with endothermal techniques specifically with regard to adverse anatomical features allied to the poorer results of UGFS within the treatment of LSV reflux, there is without doubt still a role for more traditional open surgical techniques that can be delivered with good short and long term outcomes and still being delivered in a cost effective manner.
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Affiliation(s)
| | - David C Berridge
- Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, UK
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Belyaev AN, Chabushkin AN, Khrushchalina SA, Kuznetsova OA, Lyapin AA, Romanov KN, Ryabochkina PA. Investigation of endovenous laser ablation of varicose veins in vitro using 1.885-μm laser radiation. Lasers Med Sci 2016; 31:503-10. [PMID: 26873497 DOI: 10.1007/s10103-016-1877-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 01/14/2016] [Indexed: 10/22/2022]
Abstract
This paper presents the results of endovenous laser ablation (EVLA) of varicose veins in vitro using radiation of a solid-state laser based on the crystal LiYF4:Tm, with a wavelength of 1.885 μm and power output of around 3 W. An experimental series with saline solution and red blood cell (RBC) suspension in the venous lumen was performed to identify the impact of a heated carbonized layer precipitated on the fiber end face versus the efficiency of EVLA. Results of these experiments confirmed that the presence of a heated carbonized layer on the fiber end face increases the efficiency of EVLA.
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Balint IB, Bali O, Vargovics E, Simon E, Vizsy L. The Histological Changes of the Great Saphenous Vein at 2 Years after Cryosclerosis. Vasc Specialist Int 2015. [PMID: 26217627 PMCID: PMC4480296 DOI: 10.5758/vsi.2014.30.3.102] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Cryosclerosis was developed at the end of the last decade. It is the endovenous cryoablation of the great saphenous vein and has been forgotten before the era of the endovenous ablation techniques began. The caused histomorphological changes of the vein weren’t described before, especially, years after the procedure. A 31-year-old female patient underwent cryosclerosis 2 years ago. Because of the recanalization of the great saphenous vein and recurrent varicosity, high ligation, cryostripping and phlebectomy of varices were performed. During surgery, a saphenous vein piece was harvested to investigate the histomorphological effect of cryosclerosis. Histological findings verified that recanalization had occurred, the vein wall had undergone remodeling, and the picro-sirius red stain showed collagen deposition in the whole vein wall. Cryosclerosis seems to result in the remodeling of the vein wall.
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Affiliation(s)
- Istvan Bence Balint
- Department of Surgery, Kanizsai Dorottya Hospital, Hospital of Nagykanizsa, Nagykanizsa, Hungary
| | - Ottilia Bali
- Department of Pathology, Kanizsai Dorottya Hospital, Hospital of Nagykanizsa, Nagykanizsa, Hungary
| | - Eszter Vargovics
- Department of Radiology, Kanizsai Dorottya Hospital, Hospital of Nagykanizsa, Nagykanizsa, Hungary
| | - Eva Simon
- Department of Surgery, Kanizsai Dorottya Hospital, Hospital of Nagykanizsa, Nagykanizsa, Hungary
| | - Laszlo Vizsy
- Department of Surgery, Kanizsai Dorottya Hospital, Hospital of Nagykanizsa, Nagykanizsa, Hungary
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Kapoor A, Kapoor A, Mahajan G. Endovenous ablation of saphenofemoral insufficiency: analysis of 100 patients using RF closure fast technique. Indian J Surg 2010; 72:458-62. [PMID: 22131655 DOI: 10.1007/s12262-010-0160-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [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: 11/19/2009] [Accepted: 06/18/2010] [Indexed: 10/18/2022] Open
Abstract
Chronic venous insufficiency is a common problem leading to varicose veins of lower limbs which was traditionally being treated with ligation and stripping. Endovenous ablation is an attractive alternative minimally invasive technique to treat such patients. We analysed the results of 100 consecutive patients treated with Radiofrequency based endovenous ablation using Closure Fast Catheter. Retrospective analysis of 100 consecutive patients with chronic venous insufficiency treated at our institution was done. All patients were classified pre and post procedure based on clinical, etiologic, anatomic and pathophyslogical classification, Venous clinical severity and Venous disablitity scores alongwith color doppler examination with follow up done at 2 weeks, 3 months and one year for any disease recurrence or residual symptoms. 97 of the 100 patients treated at 3 months and at 1 year showed good reduction of venous clinical severity and Venous disability scores to 0. Doppler showed complete closure of saphenofemoral junction and long saphenous vein at 2 weeks with no recanalisation at one year. No thrombus formation was observed. Minor complications like ecchymosis was seen in 9 patients and thrombophlebitis in 4 patients. Endovenous ablation using radiofrequency with Closure Fast technique showed improved short and long term results in patients with venous insufficiency with 100% closure seen on doppler studies along with lesser complications and no thrombus formation due shortened procedure time and improved catheter design.
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Affiliation(s)
- Atul Kapoor
- Department of Interventional Radiology, Department of Ultrasound Imaging, Advanced Diagnostics and Institute of Imaging, 17/8 Kennedy Avenue Amritsar, 143001 Punjab, India
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