Abstract
Comparing the effects of radial and jacketed laser tip fibers on outcome of endovenous laser ablation of lower limb truncal venous reflux
Zaki MM, Tawfick SE, Gohar KS. Ann Vasc Surg. 2023 Feb 4.
The authors investigated different laser fiber tip configurations to outcomes regarding technical success and incidence of complications. A retrospective analysis was conducted on patients with documented great saphenous vein (GSV) reflux from 2020 to 2022, comparing baseline parameters and outcome between 2 groups of laser tip fibers used; radial tip and jacketed tip. The primary endpoint was technical success. Secondary endpoints included incidence of complications in each group, and venous clinical severity score (VCSS) difference in both groups. Inclusion criteria entailed patients with primary varicose veins over the age of 18 years, free from malignancy, hematological disorders, and having documented GSV reflux of more than 0.5 seconds. All patients had endovenous laser ablation (EVLA) of the GSV, with complementary foam sclerotherapy or ambulatory phlebectomies as required. A total of 74 patients underwent EVLA (85 limbs). 54 limbs utilized the radial laser fibers, and the remaining utilized jacketed fibers. Technical success was achieved in 92.9%; 6 limbs (7.1%) had recanalization of the proximal 3 cm GSV at 1 month; 2 patients experienced hematomas; and 5 patients had superficial vein thrombosis. There was no significant association between postoperative pain, bruising, recanalization, hematoma, and superficial vein thrombosis, with different laser fiber tip configurations (p-value .95, .6, .18, 1, and 1, respectively). In addition, there was no significant difference in VCSS (p-value .14) nor technical success between groups (p-value 0.18).
The authors concluded that laser fiber tip configuration did not cause a significant difference in effectiveness regarding GSV laser outcomes. Both radial and jacketed laser fiber tips exhibit similar safety and efficacy in EVLA.
Relationship between iliofemoral venous stenting and femoropopliteal deep venous reflux
Pergamo M, Kabnick LS, Jacobowitz GR, Rockman CB, Maldonado TS, Berland TL, Blumberg S, Sadek M. J Vasc Surg Venous Lymphat Disord. 2023 Mar;11(2):346-350.
The authors’ aim of this 275-patient study was to evaluate the effects of iliac vein stenting on femoropopliteal deep venous reflux (DVR) with the hypothesis that ultrasound evidence of DVR would remain absent or would have improved after iliac vein stenting. The present study was a retrospective review of patients who had undergone iliofemoral venous stenting from 2013 to 2018. Two cohorts were established according to the preprocedural presence (group A) or absence (group B) of femoropopliteal DVR. Baseline patient variables were collected, including age, gender, CEAP (clinical, etiologic, anatomic, and pathophysiologic) class, presence of concomitant superficial or perforator reflux, deep vein thrombosis history, and additional venous interventions. The primary outcome evaluated was the persistent absence or resolution of DVR on the latest venous duplex ultrasound at follow-up. Other outcomes included the follow-up CEAP classification and the need for secondary deep venous interventions. Fifty-eight patients had presented with DVR (group A). A comparison of groups A and B revealed that group A had had a greater likelihood of prior deep vein thrombosis (p = .0001) and a higher frequency of superficial venous ablation. The remaining demographic variables did not differ significantly between the two groups. Of the 58 patients in group A, DVR had resolved at follow-up in 17 (p = .0001). When stratified by level, 7 of these 17 patients had had isolated popliteal reflux. In group B, DVR had developed at follow-up in 6 of the 217 patients. The CEAP class had improved from before intervention (C0, 1.1%; C1, 0.4%; C2, 1.8%; C3, 41.4%; C4, 24.9%; C5, 5.9%; C6, 24.5%) to the latest follow up (C0, 4.9%; C1, 1.9%; C2, 5.7%; C3, 34.2%; C4, 22.8%; C5, 17.1%; C6, 13.3%). Significant improvement had occurred in C6 disease within both groups (group A, 16 of 58 [27.6%; p = .0078]; group B, 19 of 217 [8.8%; p = .0203]).
The authors concluded that for patients who undergo iliofemoral venous stenting, DVR could improve if present initially and is unlikely to develop if not present before stenting. A cohort of patients had experienced persistent DVR and warranted further evaluation.
Prevalence and risk factors of phlebosclerosis in the great saphenous vein
Tepelenis K, Papathanakos G, Kitsouli A, Barbouti A, Varvarousis DN, Kefalas AA, Anastasopoulos N, Paraskevas G, Kanavaros P. Vascular. 2023 Mar 10.
The authors aimed to estimate the prevalence and define the risk factors of phlebosclerosis of the great saphenous vein. 300 volunteers with symptoms and signs of acute or chronic venous disease or known varicose veins, thrombosis, chronic vein insufficiency, and any operation in the lower extremities were excluded; this cohort underwent duplex ultrasound. The imaging hallmarks of phlebosclerosis were described and include wall brightness, calcification, and increased wall thickness. Demographics of the volunteers (sex, age, weight, and height), Body Mass Index (BMI) and the presence of smoking, hypertension, diabetes mellitus, and dyslipidemia were recorded. 60.3% were females, and 39.7% were males. The mean age was 60 ± 13, mean BMI was 26.01 ± 4.76, 66.3% were non-smokers, and 62.3%, 81.3%, and 58.7% did not suffer from hypertension, diabetes mellitus, and dyslipidemia, respectively. The prevalence of phlebosclerosis was 2.3%. Hypertension was a risk factor for the development of phlebosclerosis (p = 0.045). Moreover, volunteers with phlebosclerosis were older than volunteers without phlebosclerosis (74.2 vs 59.11 years, p < .001). Both sexes are equally affected, while BMI, smoking, diabetes mellitus, and dyslipidemia do not contribute to the development of phlebosclerosis.
The authors concluded that prevalence of phlebosclerosis of the great saphenous vein is low. Hypertension and increased age are risk factors for the development of phlebosclerosis.
Clinical outcomes following mechanochemical ablation of superficial venous incompetence compared with endothermal ablation: meta-analysis
Lim AJM, Mohamed AH, Hitchman LH, Lathan R, Ravindhran B, Sidapra MM, Smith G, Chetter IC, Carradice D. Br J Surg. 2023 Mar 10.
The authors’ aim of this study was to compare the outcomes from randomized controlled trials (RCTs) of mechanochemical ablation (MOCA) versus endovenous thermal ablation (EVTA). MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) were accessed. Meta-analysis inclusion was restricted to RCTs comparing MOCA against EVTA. Outcomes included anatomical occlusion rate, Aberdeen Varicose Vein Questionnaire, procedural and postprocedural pain, and rates of venous thromboembolism. Four RCTs were included in the meta-analysis comprising 654 patients. At 1 year, the occlusion rate was lower after MOCA than EVTA (risk ratio 0.85, 95% c.i. 0.78 to 0.91; p < 0.001). No significant differences in procedural pain (mean difference −3.25, −14.25 to 7.74; p = 0.560) or postprocedural pain (mean difference −0.63, −2.15 to 0.89; p = 0.420). No significant differences in Aberdeen Varicose Vein Questionnaire score at 1 year (mean difference 0.06, −0.50 to 0.62; p = 0.830) or in incidence of venous thromboembolism (risk ratio 0.72, 95% c.i. 0.14 to 3.61; p = 0.690).
The authors concluded that the rate of successful anatomical occlusion after MOCA was significantly lower than that after EVTA; however, there was no difference in procedural and postprocedural pain between the two interventions. Long-term data are required to assess the impact of the reduced vein occlusion rate on clinical outcomes such as quality of life and reintervention.
Direct oral anticoagulant agents might be safe for patients undergoing endovenous radiofrequency and laser ablation
Chang H, Sadek M, Barfield ME, Rockman CB, Maldonado TS, Cayne NS, Berland TL, Garg K, Jacobowitz GR. Journal of Vascular Surgery: Venous and Lymphatic Disorders Volume 11, Issue 1, January 2023, Pages 25-30. doi.org/10.1016/j.jvsv.2022.05.011.
Studies assessing the effect of the use of anticoagulant agents on endovenous thermal ablation (ETA) have been limited to patients taking warfarin. The authors aim to assess the efficacy and safety of ETA for patients taking direct oral anticoagulants (DOACs). They performed a retrospective review to identify patients who had undergone radiofrequency ablation or endovenous laser ablation with 1470-nm diode laser fibers for symptomatic great or small saphenous venous reflux. The patients were dichotomized into those who had received a therapeutic dose of DOACs periprocedurally and those who had not (control group). They studied the incidence of deep vein thrombosis (DVT), endothermal heat-induced thrombosis (EHIT), and bleeding periprocedurally. Of the 301 patients (382 procedures), 69 patients (87 procedures) had received DOACs and 232 control patients (295 procedures) had not received DOACs. The patients receiving DOACs were more often older (mean age, 65 years vs 55 years; p < .001) and male (70% vs 37%; p < .001), with a higher prevalence of venous thromboembolism and more severe CEAP (clinical, etiologic, anatomic, and pathophysiologic) classification (5 or 6), than were the control patients. Those receiving DOACs were more likely to have had a history of DVT (44% vs 6%; p < .001), pulmonary embolism (13% vs 0%; p < .001), and phlebitis (32% vs 15%; p < .001). Procedurally, radiofrequency ablation had been used more frequently in the control group (92% vs 84%; p = .029), with longer segments of treated veins (mean, 38 mm vs 35 mm, respectively; p = .028). No major or minor bleeding events nor any EHIT had occurred in either group. Two patients in the control group (0.7%) developed DVT; however, no DVT was observed in those in the DOAC group (p = .441). At 9 months, the treated vein had remained ablated after 94.4% of procedures for patients receiving DOACs and 98.4% of the control group (p = .163).
The authors found that DOAC usage was not associated with an increased risk of vein recanalization (hazard ratio, 5.76; 95% confidence interval, 0.57-58.64; p = .139). The periprocedural use of DOACs did not adversely affect the efficacy of endovenous ablation to ≥9 months. Furthermore, DOAC use did not confer an additional risk of bleeding, DVT, or EHIT periprocedurally. The authors conclude that DOACs may be safely continued without affecting the efficacy and durability of ETA.
Review of malpractice litigation in the diagnosis and treatment of venous and lymphatic disease
Choinski K, Sanon O, Sacknovitz Y, Ilonzo N, Ting W, Koleilat I, Phair J. Annals of Vascular Surgery Volume 88, January 2023, Pages 274-282. doi.org/10.1016/j.avsg.2022.07.002.
This group of authors investigated common reasons for litigation, medical specialties involved, patient injuries, and case outcomes in malpractice litigation involving venous and lymphatic disease. Litigation cases entered into the Westlaw were analyzed. Search terms included relevant words and phrases related to nonthrombotic venous, thoracic outlet syndrome, and lymphatic disease and treatment. Data on physician specialty, malpractice claims, and patient injuries jury outcomes, amount awarded to the plaintiff, and jury fees were collected and compared for each category. A total of 144 cases were identified. Forty one cases involved varicose veins, 11 spider veins, 35 thoracic outlet syndrome (TOS), 17 other venous diseases, and 40 lymphatic diseases. Physician defendants were frequently vascular surgeons (23%) and general surgeons (15%). The majority of litigation claims involved “post-procedure complication” (77%), “lack of informed consent” (25%), “failure to diagnose & treat” (15%), and “intraoperative complications” (13%). The most common injuries were skin damage (27.8%), nerve damage (25%), and lymphedema (24%). Patient death occurred in 6% of cases. Out of venous malpractice cases with post-procedure complications, stab phlebectomy (27%) was the most common intervention followed by foam sclerotherapy (21%), rib resection (21%), laser spider vein removal (5%), and endovenous laser ablation therapy (EVLT)(3%). Of varicose vein cases, 15% included deep vein thrombosis or pulmonary embolism as post-procedure complications. In TOS rib resections, 65% of cases referenced nerve damage and 12% involved arterial injury. For lymphatic disease cases, general surgeons were frequently identified defendants (25%). Lymphedema (93%) and lymphangitis (7%) occurred as post-procedure complications after breast, gynecologic, orthopedic, and radiation procedures. A majority of complications occurred after breast cases (40%). Verdicts overall ruled in favor of the defendant in 71% (102/144) of cases and the plaintiff in 20% (29/144) of cases. Out of cases ruled in favor of the plaintiff, 31% were lymphatics, 24% varicose veins, and 24% TOS cases. Only 8% (12/144) of cases were settled and one outcome was unknown. The mean award was $820,193 (standard deviation SD $1,226,008, Range $12,853–$6,500,000).
The authors found that the majority of venous and lymphatic litigation cases involve claims of post-procedure complications. Venous complications occurred after open and endovascular treatment of varicose veins, spider vein treatment, and surgical management of TOS. Lymphedema occurred after breast, oncology, and orthopedic procedures. These cases reflect opportunities for intervention to help potentially prevent litigation.
A systematic review and meta-analysis of concomitant truncal and perforator surgery
Kiernan A, Fahey B, Boland F, Aherne T. Journal of Vascular Surgery: Venous and Lymphatic Disorders, 2023, ISSN 2213-333X. doi.org/10.1016/j.jvsv.2022.12.068.
The authors’ aim of this study is to establish the exact role of concomitant treatment in patients with chronic venous disease, since some studies have shown that concomitant treatment of truncal and perforator incompetence improves ulcer healing, yet a Cochrane review was unable to determine the potential benefits of perforator surgery in venous ulcer management due to poor quality evidence. A search of online databases including MEDLINE, Embase, and Cochrane was performed in March 2022. All studies comparing the outcomes of concomitant superficial venous plus perforator surgery with standard therapy were included. Variables assessed included ulcer healing, time to healing, and ulcer recurrence. Disease severity and quality of life (QoL), vein occlusion rates, number of IPVs on Duplex Ultrasound (DUS) post-treatment, re-intervention, and complication rates were also analysed. Data were pooled using a random effects model. The authors found seven studies (872 limbs). Ulcer healing rates were similar in each. Two studies reported no difference in mean time (days) to ulcer healing between groups. Ulcer recurrence was significantly lower in the concomitant group (3.7% vs 44%). QoL was reported in only one study. The total number of perforator veins identified at follow up DUS was significantly lower in the concomitant group (22.4% vs 89%) compared to standard therapy. There was no difference between groups for occlusion rates of treated great saphenous vein or incompetent perforators.
The authors conclude that concomitant truncal and perforator surgery is comparable to standard therapy in terms of ulcer healing, safety, and efficacy. Meta-analysis suggests that concomitant treatment could significantly reduce ulcer recurrence rates, but included studies were subject to some biases and short follow-up.
Personal factors and postoperative changes in the revised Venous Clinical Severity Score of varicose veins
Kobata T, Kasamaki Y, Kanda T. Journal of Vascular Surgery: Venous and Lymphatic Disorders Volume 11, Issue 1, January 2023, Pages 31-38. doi.org/10.1016/j.jvsv.2022.06.004.
The primary aim of this observational study was to measure the Revised Venous Clinical Severity Score (rVCSS) in patients treated for varicose veins (VVs) owing to saphenous vein reflux. Treatment was by endovenous thermal ablation (ETA) alone or by ETA and ambulatory phlebectomy (AP). A secondary aim was to determine whether participant characteristics and treatment methods affect rVCSS and how the score changes over time. The authors enrolled 44 men with 55 treated legs and 79 women with 105 treated legs (bilateral cases, 23.1%). All legs were treated by ETA, and participants were divided into three groups depending on AP treatment: E0 group (40 legs), no AP; EP1 group (101 legs), AP performed only at one site above or below the knee; and EP2 group (19 legs), AP performed both above and below the knee. The rVCSS was measured in the treated legs up to five times: preoperatively and on postoperative days (POD) 1, 7, 90, and 180. The mean age was 67.5 ± 11.24 years (range, 32–87 years). The mean preoperative rVCSS also was not different between groups. Factors associated with less improvement in the rVCSS were a high body mass index and the occurrence of endovenous heat-induced thrombosis, and factors associated with more improvement in the rVCSS were hypertension, hyperuricemia, and wearing compression stockings. The rVCSS decreased strongly at POD1 and then gradually decreased until POD180. It was not significantly different between EP1 and EP2, but it improved significantly earlier in these two groups than in the E0 group.
The authors concluded that factors associated with less improvement in the rVCSS are a high body mass index and the occurrence of endovenous heat-induced thrombosis. Hypertension, hyperuricemia, and wearing compression stockings are associated with greater improvements in the rVCSS. Patients treated with ETA and AP tend to improve earlier than patients treated by ETA alone, but all patients improve to nearly the same level within 6 months.