A systematic review and meta-analysis of treatment modalities for anterior accessory saphenous vein insufficiency

Objective To investigate and compare the outcomes of the available treatment modalities for anterior accessory saphenous vein (AASV) incompetence. Methods A systematic literature search was performed in MEDLINE, Embase, and the Cochrane Library. Studies reporting the outcomes of patients who were treated for primary AASV incompetence were included. The methodologic quality of the articles was assessed using the Methodological Index for Non-Randomized Studies (MINORS). A random-effects model was used to estimate anatomic success, defined as AASV occlusion. The secondary outcomes were pain during and after treatment, venous clinical severity score, quality of life, esthetic result, time to return to daily activities, and complications. Results The search identified 860 articles, of which 16 met the inclusion criteria. A total of 609 AASVs were reported. The included studies were of poor or moderate quality according to MINORS score. The pooled anatomic success rates were 91.8% after endovenous laser ablation and radiofrequency ablation (EVLA, RFA, 11 studies), 93.6% after cyanoacrylate closure (3 studies), and 79.8% after sclerotherapy (2 studies). The non-pooled anatomic success rate was 97.9% after phlebectomy and 82% after CHIVA. Paresthesia was seen after EVLA in 0.7% of patients (6 studies). Phlebitis was seen in 2.6% of patients after RFA (2 studies), 27% after sclerotherapy (1 study), and 12% after the phlebectomy (1 study). Deep venous thrombosis and skin burn did not occur. Conclusion Treatment of AASV incompetence is safe and effective. Despite limited evidence, occlusion of the AASV can be achieved with endovenous thermal ablation and cyanoacrylate. There does not appear to be a benefit of EVLA compared to RFA regarding treatment efficacy. Phlebectomy shows promising results if the saphenofemoral junction is competent. Lower results are seen after sclerotherapy and CHIVA. However, studies with sufficient sample sizes of solely treatment of AASV incompetence are needed to draw firm conclusions.

Improvement of dynamic venous function after thermal ablation with steam vein occlusion – 6-weeks and 1-year follow-up after 167 treatments

BACKGROUND: In this paper, the method of steam vein occlusion for the treatment of the great/small saphenous vein (GSV/SSV) was analyzed in terms of a therapeutic influence on the dynamic parameters of global vein function, its effects on subjective symptoms based on chronic venous insufficiency (CVI) and the side effects of the steam vein sclerosis (SVS). It has been questioned whether the effects of this method lead to a recommendation for routine clinical practice. METHODS: The venous drainage and the venous refilling time (T0) of the leg treated were determined by photoplethysmography (Elcat, Wolfratshausen, Germany) before, six weeks and one year after the intervention to examine the effects on global venous function. Further changes of clinical symptoms and findings were assessed by the Venous Clinical Severity Score (VCSS), preoperatively and after one year, and the complication rate at 6-week follow-up was monitored. RESULTS: The SVS was performed on 167 veins (GSV: 124; SSV: 43) in a total of 156 patients. Eight patients (5.1%) did not attend the 6-week follow-up, while 29 patients (18.6%) were lost in the 1-year follow-up. Patients were suffering from symptoms such as leg pain and leg edema, which resulted in a VCSS of 9.4 (cumulated mean score of all patients) preoperatively. The T0 was reduced to mean values of 20.6 s (GSV cohort) and 21 s (SSV cohort). The VCSS improved to 6.0 after one year. This correlated with the hemodynamic parameters. The T0 increased in the GSV cohort after six weeks to 31.8 s, p < 0.001, and showed a nonsignificant improvement to 32.2 s, p = 0.509, in the 1-year check. The T0 also increased in the SSV cohort significantly after 6 weeks to 30.1 s, p < 0.001, and showed a nonsignificant reduction after one year, p = 0.289. A total of 71%of the GSV and 69.8%of the SSV of the patients involved no complications following the treatment. Light complications (grade 1) occurred (reddening, hematoma, hyperpigmentation) in the majority: 24.2%of the GSV and 18.6%of the SSV. We noticed one grade 3 complication with thrombosis in the SSV cohort, which led to a pulmonary embolism. Forty-seven complete questionnaires were analyzed (responder rate: 28.1%); 40.4%of the patients had light complaints after the treatment, such as pain, warmth or local pressure sensations (Fig. 7); 63%of those patients noticed only slight pain at a maximum of 3 out of 10. The majority (91%) would recommend this procedure. CONCLUSION: The SVS revealed endoluminal catheter-based intervention to abolish venous reflux of the G/SSV as safe. As one therapeutic target is to eliminate venous reflux, effectiveness of a method cannot be based on sonographic data alone; one must further assess patients’ symptoms and dynamic venous function. This data shows an improvement of patients’ symptoms which correlated well with the improvement of the venous function in digital photoplethysmography. The SVS can be recommended as a catheter-based treatment in the future.

Comparative analysis of short-term outcomes after surgical treatment of varicose disease with endovasal laser obliteration and short stripping

The purpose of this study was to compare outcomes (within six months) after short stripping (SS) and endovenous laser obliteration (EVLO) in patients with varicose veins when analyzing ultrasound findings, postoperative complications, level of postoperative pain, clinical manifestations, and duration of rehabilitation after the intervention. Patients with varicose veins of lower extremities and insufficiency of large saphenous vein valves had either EVLO or SS with miniflebectomy. All patients were examined before surgery and then in 5 days, 10 days and in 1, 3 and 6 months after it. The patients also had clinical examination, ultrasound duplex scanning of their lower extremity veins; Venous Clinical Severity Score (VCSS) was also used for the trial. Pain was assessed during the first 10 days after the surgery using a 10-point pain assessment scale. 156 patients (177 lower extremities) were followed-up for 6 months. As the results of our study showed, endovenous laser obliteration and short stripping were equally effective in eliminating the reflux of the great saphenous vein (GSV). After 6 months of follow-up, the reflux along the medial inflow was noted in one case in SS group; partial GSV recanalization was noted in one case in EVLO group in 3 months, in 3 cases – in 6 months. Besides, despite LMH preventive doses one patient from EVLO group had EHIT II deep vein thrombosis. The obtained outcomes have demonstrated that EVLO and SS have similar effectiveness and safety. No difference has been found between these two types of treatment, except more pronounced postoperative pain and bruising in SS group. Performed care was equally safe and effective in eliminating GSV reflux, in relieving symptoms and eliminating varicose veins as well as in improving the quality of life. Long-term outcomes, especially the rate of relapses depending on the type of intervention, are to be investigated in future trials.

Comparison of Non-Tumescent n-Butyl Cyanoacrylate and Endovenous Laser Therapy in Saphenous Vein Ablation

Objective: Ablation of N-butyl cyanoacrylate (NBCA) and endovenous laser ablation (EVLA) are two important techniques used in the treatment of venous insufficiency. The aim of this study is to compare the results of EVLA and NBCA methods in the treatment of saphenous vein insufficiency. Method: 739 patients with saphenous vein insufficiency who were followed up between 2013 and 2018 and treated with NBCA (350 patients) and EVLA (389 patients) applications were included in the study. Pre-procedure, during, post-procedure and follow-up data of the patients were collected and compared retrospectively. Results: In the group using NBCA technique; mean age was 46.09±6.12 years, mean age was 48.08±6.11 years in the EVLA technique group. The mean ablated vein length was 32.97-65.83 cm in the NBCA group and 30.65-67.25 cm in the EVLA group. The mean procedure time was 7 minutes in the NBCA group and 18 minutes in the EVLA group. The 12-month total occlusion rates in the NBCA and EVLA groups were 98.8% and 97.6%, respectively. In both the NBCA and EVLA groups, the post-procedure Venous Clinical Severity Score (VCSS) was significantly reduced with no difference between the groups. When NBCA treatment was compared with EVLA treatment, it was seen that there may be fewer side effects after NBCA treatment. Conclusion: When the treatment success rates, application times, complication rates and venous clinical severity scoring results in the data obtained in our study were evaluated, it was thought that the NBCA method was as successful and reliable as the EVLA method. In conclusion; It has been suggested that the vascular closure system with NBCA is a fast and effective treatment method in the treatment of saphenous vein insufficiency, as it does not require tumescent anesthesia, does not require compression stockings, and does not have the risk of paresthesia, burn scars or pigmentation.

Internal Perivenous Compression for venous insufficiency at the Saphenofemoral Junction: Early and Midterm Results and Operative Pain

Objectives To assess the postoperative pain and midterm results of patients undergoing internal perivenous compression with internal compression therapy (ICT) for venous insufficiency at the saphenofemoral junction (SFJ) Materials and Methods Patients managed with ICT between April and October 2019 for grade 4 venous reflux at the SFJ were retrospectively evaluated. The venous clinical severity score (VCSS) was calculated preoperatively and 1, 3, and 6 months postoperatively. Postoperative pain was assessed with the visual analog scale (VAS). Control Doppler ultrasound imaging was performed 6 months postoperatively. Results Forty-five patients [14 (31%) males and 31 (69%) females; mean age, 47 ± 13 years] were included. The median preoperative VCSS was 7 (5–8.5). The median VCSS at 1, 3, and 6 months postoperatively was 6 (4–7.5), 4 (3–5.5), and 3 (2–4), respectively, and these values were significantly lower than the preoperative score (p = 0,001, p < 0.001, and p < 0.001, respectively). The postoperative VAS score was 0 in 6 patients (13%), 1 in 17 patients (38%), 2 in 6 patients (13%), 3 in 15 patients (33%), and 4 in 1 patient (2%). At 6 months, reflux was absent in 9 (20%), grade 1 in 20 (44%), and grade 2 in 16 (36%) patients. A vena saphena magna diameter of >6.7 mm predicted grade >1 reflux at 6 months [87.5%, with an area under the curve of 0.78 (p < 0.001)]. No complications occurred. Conclusion ICT alleviated symptoms and reduced reflux grade in patients with venous insufficiency at the SFJ. This therapy can be applied with satisfactory patient comfort.

Endovascular Laser Therapy versus Open Surgery for the Treatment of Primary Varicose Veins of the Lower Limb

Background Venous drainage of the lower extremities is accomplished by a network of superficial veins connected to the deep veins by small perforator veins. Through a variety of pathophysiological mechanisms, weakness develops in the vein wall that results in varicosity over time. Varicosities typically form in the greater and lesser saphenous veins but also develop in branch vessels. Obstruction of the iliac veins or inferior vena cava can result in extensive varicose veins Objective s: The aim of this work is to compare the outcome of endovascular laser therapy versus open surgery in management of primary varicose veins in lower limb. Patients and Methods Type of study is a prospective, randomized, clinical study. This study was conducted on 30 patients with primary varicose veins of the lower limb, 15 patients were subjected to endovascular laser therapy for treatment of varicose veins of the lower limb (EVLA group) and 15 patients were managed by standard open surgery for treatment of varicose veins of the lower limb (surgery group). The patients were randomized selected from surgery clinic in Eldemerdash Hospital. The work was carried out in the period from June 2017 to December 2018. Results Both groups were well matched regarding age(P = 0.352) and sex (P = 0.713), type of vein diseased(P = 0.913), CEAP classification (P = 0.910) and also regarding BMI (P = 0.761). Regarding preoperative venous clinical severity score, the median(IQR) for group A (surgery group) was (5), and for group B (laser group) was (5) without statistical significant differences between both groups (P value =0.524). Many studies have shown that there was some difference in between two methods of treatment of primary varicose veins of the lower limbs open vascular surgery and endovascular laser therapy. Regarding Six weeks post-operative VCSS assessment, the VCSS score in the surgery group was statistically significantly higher (p &lt; 0.001). However, at one and two years after the intervention The VCSS scores converged and the difference between the groups was no longer statistically significant. Conclusion The presented results show that intreatment of varicose veins with both endovascular laser ablation and open surgery there was improvement in the clinical status of the patient occur after both but EVLA was more effective early which was observed by measuring venous clinical severity score. EVLA show distinct advantages over open surgery especially in post operative pain, analgesia use and time needed to return to work.

TP5.2.6 Use of objective assessment criteria to assess symptom severity and clinical effectiveness following deep venous stenting

Aims This review aimed to identify measures that assess symptom severity in patients prior to deep venous intervention, and outcomes used to evaluate its clinical effectiveness. Methods MEDLINE was searched for studies of stent placement for treatment of iliofemoral venous disease using relevant key words (April 2019). Data were extracted and validated by three authors. Results 6,356 patients with venous stents were identified from 93 studies. 1,300 patients (20%) were treated for acute thrombosis and 5,056 patients for chronic venous insufficiency (CVI), due to non-thrombotic lesions (2,200 patients, 35%) or post-thrombotic disease (2,856 patients, 45%). The Clinical-Etiological-Anatomical-Physiological classification (CEAP) was reported in 3,233/5,056 CVI patients (64%) pre-intervention (C0:2%; C1:2%; C2:7%; C3:46%; C4:21%; C5:6%; C6:16%). Stent patency was reported in all studies, with variable follow-up (six months – five years). Primary patency was 81% in 3,365 patients and secondary patency 95% in 4,700 patients at one year. 655 patients had active ulceration, of which 397 (61%) healed post-intervention. Venous Clinical Severity Score (VCSS) or revised VCSS was reported in 849 patients (13%). Average VCSS/rVCSS was eight pre-intervention and three post-intervention. Villalta scores were reported in 768 patients (12%) pre-intervention vs. 1,111 patients (17%) post-intervention. Average Villalta scores were 20 pre-intervention vs. five post-intervention. Conclusions Few studies use objective measures to quantify the clinical effectiveness of deep venous stenting; consensus is lacking on which is the most appropriate tool to use. More research is needed on ideal assessment measures to identify suitable patients for these interventions and to quantify clinical effectiveness.

Does body mass index have an effect on clinical and pain after endovenous therapy? A retrospective study

Objectives: The study aims to investigate the change in postoperative clinic, pain, and general quality of life of patients who were operated on due to chronic venous disease (CVD), according to their body mass index (BMI). Materials and methods: 150 patients (30–45 years) who were treated with cyanoacrylate embolization for CVD between January 2017 and February 2020 were analyzed retrospectively. The clinical (C) category of clinical, etiology, anatomy, and pathophysiology (CEAP) classification venous clinical severity score (VCSS) and visual analog scale (VAS) questionnaires were applied to the patients before and after the operation periodically. The patients were surveyed preoperatively and postoperatively at 1st, 6th, 12th, and 24th months. Results: The patients were divided into three groups according to their BMI. In the comparison between normal and overweight participants, venous reflux, CEAP C categories, and VAS scores were not statistically significantly different in preoperative and postoperative periods. In the comparison between normal and obese participants, CEAP C categories, VCSS, and VAS scores were statistically significantly different in postoperative periods. There was no statistically significant difference in terms of venous reflux preoperatively and postoperatively in all three groups. Conclusions: The study showed that the increase in BMI had negative effects on the CEAP C categories, pain, and quality of life independently of the venous reflux of CVD.