Experience of using scleroobliteration in venous angiodysplasia (results of 12-month follow-up)

AIM: To evaluate the results of using the minimally-invasive technique of scleroobliteration in patients with venous malformations. MATERIALS AND METHODS: From 2006 to 2020, 41 interventions were performed for venous-cavernous angiomatosis of various localization through scleroobliteration. Nineteen patients (46.3%) underwent complex treatment, which included a combination of this minimally-invasive technique with other surgical interventions (resection of angiomatous tissues, laser coagulation, and radiofrequency obliteration). RESULTS: Clinical improvement was achieved in 38 (92.7%) patients. According to the data of ultrasound control, 25 patients (61%) experienced no blood flow in the obliteration zone, and there was regression of the initial symptoms within 1 year of observation following intervention. The results of treatment were better due to the local spread of the angiomatous process. With diffuse forms, it was not possible to achieve a positive effect in 3 patients (11.1%). CONCLUSION: Scleroobliteration can provide a positive result in the treatment of patients with venous-cavernous angiodysplasia, both as an independent method and in combination with other minimally-invasive techniques.

Radiofrequency obliteration in treatment of venous angiodysplasia

Aim. This study aimed to investigate potential use of radiofrequency obliteration (RFO) of angiomatous tissues in patients with venous malformations. Materials and Methods. A single-center study retrospectively involved 42 clinical cases [57.1% of men (n=24), aged 18-44 years; 42.8% of women (n=18) aged 18-56 years] of venous angiodysplasia, with a total of 46 interventions using RFO. Clinical manifestations of the disease were primarily characterized by pain syndrome (71.4%), cosmetic defect (100%), and edema syndrome (95.2%). Results. Clinical improvement was possibly achieved with the reduction of the intensity of manifestations of angiomatous processes in 37 patients (88.1%). Stable and partial obliterations of caverns in the zone of exposure to radiofrequency were recorded in 37 (88.0%) and 5 (12.0%) patients, respectively. In caverns with small diameter, obliteration was achieved in 100% of the cases. Postoperative complications included bleeding (2.4%), burns in the zone of electrode introduction (2.4%), lymphorrhea (2.4%), and hypesthesia (2.4%). With this, according to the results of duplex scanning performed on control visits, no significant disease progression was observed. In the same patient, several complications could occur. All complications regressed within a month and required no treatment in hospital conditions. Conclusion. RFO showed advantage as a minimally invasive treatment method of venous angiodysplasias. Results suggest that RFO can be recommended for use in patients with 1 cm depth of lesion with caverns of medium and large diameter as an independent treatment method and in combination with standard resection methods.

Endovenous obliteration in the combined treatment of chronic venous diseases

The modern approach to the treatment of chronic venous insufficiency and varicose veins utilizes physical techniques for endovasal obliteration. It is characterized by significantly fewer side effects and opens new possibilities for the treatment of patients with varicose disease. Purpose: To evaluate the effectiveness of radiofrequency obliteration of varicose veins and puncture laser obliteration of perforant veins in the combined treatment of patients with varicose disease (VD). Material and methods. Outcomes of treatment of 528 patients with VD in the pool of the great saphenous vein (GSV) or small saphenous vein (SSV) have been analyzed. These patients had the combined treatment, which included radiofrequency obliteration of GSV and SSV trunk and / or Giacomini vein. Of these, 335 patients had also ECHO Foam-Form sclero-obliteration of GSV and SSV inflows and perforant veins on the thigh and / or ankle. In 266 patients, their treatment was combined with miniphlebectomy of GSV and SSV inflows and perforant veins on the thigh and / or ankle; and in 55 patients – with puncture laser obliteration of perforant veins. Results. The assessment of curative outcomes have has shown that postoperative pain intensity (VAS) was 3.1 + 0.5. Transient paresthesias were seen in 14 (3.4%) cases. Local ecchymoses – in 18 (4.3%) cases. Consequences of tumescent anesthesia: local ecchymoses and hyposthesia passed after 3–5 days. Skin pigmentation was noted in 1 case and lasted up to 3 months. Thrombosis was registered in 2 cases as a parietal thrombus in the great saphenous vein at the level of the middle third of the thigh; and in 2 cases as a thrombotic clot prolapse.

Experience of using solutions for tumescent anesthesia with endovenous radiofrequency obliteration: a comparative study

The incidence of varicose disease of the lower extremities throughout the world remains at a fairly high level. Given its socio-economic significance, low-impact surgical treatment methods continue to improve, as well as methods of anesthesia for them. In most cases, the mixtures used for infiltration anesthesia during endovenous surgery include lidocaine and adrenaline. The active substance of adrenaline, epinephrine hydrochloride, has a direct stimulating effect on α- and β-adrenergic receptors, and can cause serious disturbances in the cardiovascular system. It is not recommended for patients with CVD and endocrine system pathologies. Aim. minimize pain when performing tumescent anesthesia during endovenous radiofrequency obliteration of veins. Material and Methods. A comparative study was performed in which 192 patients with clinical forms of chronic C2-C6 venous disease took part. All patients using the envelope method were divided into three groups: patients of the first group (I) planned to perform RFO and miniphlebectomy using Klein mixture for tumescent anesthesia, the pH of which was 6.6, lidocaine concentration 0.04%. Patients of the second group (II) planned anesthesia using a solution, the pH of which was 7.3, the concentration of lidocaine was 0.02%. In patients of the third group (III), a solution with a pH of 7.4 was used, the concentration of lidocaine was 0.08%. The level of pain during the administration of the anesthetic was evaluated using two scales – the verbal descriptive scale of pain assessment (VASOB) and the visual analogue scale (VAS). Results. Patient groups were comparable in age, sex, clinical form of the disease. When assessing pain on a verbal descriptive scale, 50% of patients (27) in group II noted a complete absence of pain during tumescent anesthesia, in group III – 54.5% (48). Very severe pain (8 points) was noted by 4 patients from Group I, who were anesthetized by administering a Klein mixture, which constituted 8%; unbearable pain (10 points) also noted two patients from this group (4%). According to YOUR, the average pain in the first group was 3.02 ± 1.07, in the second – 1.13 ± 0.23, in the third – 0.93 ± 0.27 (p = 0.05). Pronounced pain (more than 5 cm according to YOUR) was noted only in the first group in 12 patients (24%). Conclusion. None of the test solutions completely removed pain during tumescent paravasal anesthesia. But the use of a solution with a pH of 7.3-7.4 is less painful when administered and significantly reduces pain during tumescent anesthesia, which was used in patients of groups II and III.

Results after radio frequency obliteration

SummaryRadiofrequency obliteration for the treatment of varicosis was licensed in Europe in 1998. Many papers have been published on the outcome of radiofrequency obliteration. In most cases these were case series, although prospective, randomised, controlled studies and metaanalyses as well as reviews were also published. Methods: The first review by Schmedt and Steckmeier in 2006, analysed 2333 treated extremities. This paper deliberately waives a formal metaanalysis of the study results on file. Lübke et al. published a metaanalyses of radiofrequency obliteration in 2008. It comprised eight prospective, randomised studies with 225 treated extremities. Another review was also published in 2008 by Noppeney et al. This review included 516 treated extremities from case series, and 116 treated extremities from prospective, randomised studies. It also deliberately waived the techniques of metaanalysis. The last published metaanalysis is by van den Bos et al. 2009. This analysis included 19 publications containing reports on 2514 treated extremities. Two papers on the more recent radiofrequency obliteration methods, VNUS Closure Fast® and RFITT have been published to date. Results: The overall perioperative complication rate for radiofrequency obliteration is very low. The frequency of deep vein thrombosis and/or pulmonary embolism is given as between 0 and 1.4%. Perioperative transient para- and hypaesthesia are reported most often; the frequency here is between 0 and 15.9%. Schmedt and Steckmeier give the mean closure rate for the VNUS Closure Plus® procedure as over 89%, Lübke et al. quote between 81.25 and 100%, and Noppeney et al. cite 89.1% for case series and 87.1% for the prospective, randomised studies. The closure rate in the metaanalysis by van den Bos et al. is given as between 67 and 100%. The European multicentre study reports a closure rate of 96.7% 12 months after the VNUS Closure Fast® procedure. The closure rate 12 months after RFITT is given as 97.6%. Conclusion: The study results on file show that radiofrequency obliteration has become an established therapeutic alternative to traditional vein stripping. Its major benefit is the very low level of perioperative pain symptoms.

REVAT (Recurrent Varices After Treatment)

SummaryThe term “recurrent varicose veins” covers various entities. In the first instance, recurrent varicose veins may be the progression of the underlying disease, as there is a hereditary disposition to the condition, but we also find the phenomenon of neovascularisation, and lastly we repeatedly see recurrent varices as a result of technical or strategic surgical errors and the failure of endovenous procedures. No differentiation between these different types of recurrent varicose veins has previously been made in the literature, so that the numbers given vary between 6% and 60%. Up to the present time, few data on the progression of the underlying disease are to be found in the literature. Our own studies, on average 36 months postoperatively, demonstrated new varicose side branches that could be interpreted as progression of the underlying disease in 56.8% of the patients followed up.Several recent publications demonstrate neovascularisation as a cause of recurrence. While some authors give a figure of 24% for recurrence due to neovascularisation in patients who have had surgery, other publications regard neovascularisation as the main cause of postoperative recurrence.The data on technical or strategic surgical errors and recanalisation after endovenous procedures are also very varied. Numbers for technical errors as the cause of recurrent varicose veins following surgery range from 10.7% to more than 70%. Published recanalisation rates after endovenous laser therapy vary between 0% and 36%; the average recanalisation rate in the available prospective randomised studies on radiofrequency obliteration was 12.9%. Foam sclerotherapy has recanalisation rates between 69% and 86%, with a mean follow-up of 32.2 months.Given the different possible causes, it is extremely important, that recurrent varicose veins should be classified. The authors have developed a simple classification that can be used in routine daily practice. Recurrent varicose veins are given the acronym REVAT (recurrent varices after treatment). Generally speaking, on the one hand there is progression of the underlying disease (progression of disease = PD) and, on the other hand, varicosities after treatment as a result of technical error or failure of the method used (recurrence after treatment = RT). Progression of the underlying disease can be further subdivided into neovascularisation at the saphenofemoral or popliteal junction (progression of disease at the junction = PD-J) and new varices arising in the treated vascular territory (progression of disease at the limb = PD-L).In the case of recurrent varices after treatment we distinguish between a persisting or a new reflux at the saphenofemoral or the popliteal junction (recurrence after treatment at the junction = RT-J), untreated segments of the great or small saphenous veins or recanalisation of the trunk (recurrence after treatment at the trunk = RT-T) and untreated side branches or perforating veins (recurrence after treatment at side branches = RT-S). With the help of these abbreviations a simple formula can be generated to describe the recurrent varices, e.g. recanalisation of the left great saphenous vein (GSV) after endovenous treatment and a new varicosis in the vascular territory of the left great saphenous vein resulting from progression of the underlying disease: vascular territory left great saphenous vein = GSV-L, technical or tactical error due to recanalisation of the GSV = RT-T, progression of the underlying disease in the vascular territory of the GSV = PD-L. This generates the formula: GSV-L : RT-T, PD-L.Since there are no exact figures on the incidence of the individual causes of recurrent varicosis, a classification of recurrent varicosis is indispensable to ensure clarity in the future.