5 – Treatments
Thromboprophylaxis with LMWH: an evidence-based approach for clinical practice
A.C. Spyropoulos / USA
This was a key-note lecture. The author emphasized that venous thromboembolism (VTE) is a major public healthcare problem worldwide. Recent epidemiologic data indicate that there are nearly 300 000 VTE-related deaths in the USA and over 340 000 VTE-related deaths in the European Union, with approximately 60 000 fatal postoperative VTE events (1,2). In Asia, venographic studies reveal that the range of incidence of asymptomatic DVT is similar to that found in Western studies (3). The recently completed AIDA study conducted in Asia (including China, South Korea, Taiwan, Thailand, Malaysia, and the Philippines) found a 25%, 42%, and 58% incidence of venographic DVT in patients undergoing total hip replacement, hip fracture surgery, and total knee replacement surgery, respectively (4). These rates are similar to venographic rates of DVT found in earlier Western studies in patients undergoing major orthopedic surgery prior to the systematic use of thromboprophylaxis.
Patients undergoing major orthopedic surgery and major general surgery over the age of 40 years are at high risk of VTE, with fatal pulmonary embolism (PE) occurring in up to 7.5% of patients after hip fracture surgery (5). Patients with cancer undergoing surgery are another high-risk group, as this group has a threefold greater risk of fatal PE compared with patients without cancer undergoing similar procedures (5).
The current global consensus guidelines from the American College of Chest Physicians (ACCP) and the International Consensus Statement (ICS) guidelines recommend the use of low-molecular-weight heparin (LMWH), unfractionated heparin (UFH), vitamin K antagonists (VKA), and fondaparinux, depending on the type of surgery (5,6). Aspirin as monotherapy is discouraged in VTE prevention due to limited efficacy. In orthopedic surgery, LMWH is more effective than UFH in reducing DVT and PE, whereas the ICS guidelines state that parenteral therapies are preferred for in-hospital prophylaxis over oral anticoagulant therapy. In general surgery, LMWHs are as effective and safe as UFH, with the advantages of oncedaily dosing and less risk of heparin-induced thrombocytopenia (7). The guidelines also recommend extended out-of-hospital thromboprophylaxis with LMWH in patients undergoing major surgery for cancer (5,6). Lastly, while mechanical methods such as intermittent pneumatic compression and elastic stockings can reduce the risk of DVT, they have not been shown to reduce the risk of PE (8).
The use of LMWH has become the standard of care of thromboprophylaxis in the orthopedic and general surgical patient due to an excellent efficacy and safety profile. Despite effective means of thromboprophylaxis and the advent of evidencebased guidelines, recent registries highlight the fact the many surgical patients continue to receive suboptimal thromboprophylaxis (9).
1. Heit J et al. Blood. 2005;106.
2. Cohen AT 5th Annual Eur Fed Intern Med. 2005.
3. Leizorovicz A et al. J Thromb Haemost. 2004;3(1):28-34.
4. Piovella F et al. J Thromb Haemost. 2005;3(12):2664-2670.
5. Geertz WH et al. . 2004;126suppl3:338S-400S.
6. Nicolaides AN et al. Int Angiol. 2006;25:101-161.
7. Martel N et al. Blood. 2005;106(8):2710-2715.
8. Urbankova J et al. J Thromb Haemost. 2005;94:1181-1185.
9. Friedman R et al. J Thromb Haemost. 2003;1suppl1:1436.
Deep vein thrombosis in thrombophilia. Clinical tendency to and necessity for anticoagulant therapy.
Y. Watanabe, H. Shigematsu, Y. Obitsu, N. Koizumi, S. Makimura, H. Sato /Japan
Among 208 patients with DVT, 19 (9.1%) had thrombophilia: 9 (4.3% of all DVT patients) with protein S (PS) deficiency, 5 (2.4%) with protein C (PC) deficiency, 4 (1.9%) with antithrombin III (ATIII) deficiency, and 1 (0.5%) with antiliphospholipid antibody syndrome. Five patients with thrombophilia had a family history of DVT. The initial onset of DVT occurred significantly earlier in patients with thrombophilia (average 41.4 years old) than in the other patients (average 58.3 years old) (P<0.05). The authors concluded that confirmation of thrombophilia is necessary in all cases of DVT. Patients with confirmed thrombophilia need anticoagulant therapy, which should be lifelong.
Prevention of venous thromboembolism after varicose vein surgery
J.P. Fletcher / Australia
J. P. Fletcher reported 4 cases (1.4%) of venous thromboembolism (VTE) diagnosed by Doppler ultrasound in 257 patients after varicose vein surgery. Although there is a lack of data and further work is needed, he defined three categories of risk of VTE after varicose vein surgery: low risk (operation <45 minutes, age <60 years and no other risk factors like obesity, immobility, congestive cardiac failure or infectious disease; operation >45 minutes, age <40 years and no other risk factors), moderate risk (operation >45 minutes, age 40-60 years and no other risk factors; operation <45 minutes, age >60 years and no other risk factors; operation <45 minutes, age 40-60 years, history of VTE, estrogen therapy, other risk factors), and high risk (operation >45 minutes, age >60 years and no other risk factors; operation >45 minutes, age 40-60 years, cancer, history of VTE or other risk factors; thrombophilia).
In his opinion, low-risk patients for varicose vein surgery must use graduated compression stockings in addition to early walking and adequate hydration. Prophylactic LDUH or LMWH is recommended in moderate-risk patients, and in high-risk patients, LDUH or LMWH should be continued for 7-10 days postoperatively.
Finally, Fletcher concluded that most patients undergoing varicose vein surgery are at low or moderate risk of developing VTE.
Subclavian and axillary vein thrombosis treated by catheter-directed thrombolysis therapy with urokinase: report of three cases
N. Ushida /Japan
The author presented three consecutive cases of successful treatment DVT of the upper extremity. Catheter-directed thrombolysis with urokinase (240 000 IU/day) and unfractionated heparin (10 000 U/day) were administered for 3 to 5 days. Full resolution of the thrombus was achieved in all cases. Warfarin was administered to all patients.
Efficacy of catheter-directed thrombolysis for acute deep vein thrombosis
T. Hattori, H. Haeda, H. Umezawa, H. Goshima, T. Nakamura, H. Kobayashi, A. Takasaka, H. Kawachi, N. Negishi /Japan
Thirty patients with DVT (18 patients with iliac DVT, 4 patients with femoral vein DVT, and 8 patients with inferior vena cava DVT) underwent catheter-directed thrombolysis after implantation of a temporary IVC filter. Thrombolysis with urokinase (500 000 IU/day) was carried out for 2 to 5 days. In 19 patients there was complete thrombus resolution. Stenting for persistent stenosis was performed in 5 cases. There was one patient with early re-thrombosis treated with repeat thrombolysis.
Both presentations confirmed the benefits and efficacy of early thrombolytic therapy of DVT of the upper and lower extremities.
Inferior vena cava filters in the management of pulmonary thromboembolism: overview and personal experience
S. Kalva / USA
The three unquestionable indications for inferior vena cava (IVC) filter insertion are the coexistence of an acute venous thromboembolism (VTE) and 1) a formal contraindication to anticoagulant therapy, 2) a complication of anticoagulant therapy, or 3) recurrent VTE despite well-conducted anticoagulant therapy. The author reported a series of 3438 patients who had an IVC filter since 1973 at the Massachusetts General Hospital. Some patients had a filter for indications other than those mentioned above: added protection in patients with compromised cardiopulmonary reserve, patients who underwent catheter-directed thrombolysis of proximal DVT, or patients noncompliant with anticoagulant therapy. Finally, it was sometimes used as VTE prophylaxis in high-risk patients, mainly those with major trauma or pelvic/long bone fractures.
Although no conclusions can be drawn regarding filter indications on the basis of the report, because almost all available filters were used over time in this institution, it provides interesting data on safety. Before 1998, the overall prevalence of post-filter PE was 5.6%, and that of IVC thrombosis 3.1% among 1753 patients. More recent filters seem to be safer, with a 3.1% post-filter PE risk and no risk of symptomatic IVC thrombosis among 751 patients. Finally, patients in whom a retrievable filter was inserted experienced a 0.7% risk of post-filter PE, without IVC thrombosis. Overall retrieval success rate was 78%. However, the post-filter risk of PE in those patients should be interpreted with caution, because prophylaxis was the indication for IVC filter in two- thirds of patients receiving retrievable filters, as compared with 30% of those who received other types of filter.
Process of thrombus regression among different venous segments after deep vein thrombosis
Y. Hosoi, M. Nunokawa, N. Takahashi, N. Takahashi, H. Kubota, T. Fujiki, K. Tonari, H. Endo, H. Tsuchiya, S. Kenichi / Japan
The authors studied the differences among venous segments and degree of resolution within 12 months after an episode of DVT. Eighty-eight limbs of 81 patients with acute DVT were evaluated and treated with i.v. unfractionated heparin followed by oral warfarin. In calf veins, total recanalization was observed in 71% of cases at 3 months and in 87% at 6 months. For popliteal veins, total recanalization was seen in 45% of cases at 3 months and in 66% at 6 months. In contrast, the regression process was relatively slow in the femoral and iliac veins. It was concluded that calf veins show more rapid recanalization than proximal veins.
Effect of leg exercises on popliteal venous blood flow during prolonged immobility of seated subjects:
implications for prevention of travel-related deep vein thrombosis
J.P. Fletcher, K. Hitos, M. Cannon, S. Cannon, S. Garth / Australia
The aim of this study was to determine the most effective form of exercise in preventing venous stasis in the lower limb veins of seated young healthy subjects. Four interventions were compared: 1) control: sitting without exercise; 2) exercising as recommended by airline companies; 3) foot exercises against moderate resistances; or 4) foot exercises against strong resistances. The outcome was the popliteal volume flow, as calculated from the popliteal vein velocity and crosssectional area. A single examiner performed all the tests, blinded to the exercise group.
In the control group, a 40% decrease in blood flow was observed after 90 minutes. The decrease was more marked in those who were sleeping and in those whose feet were not flat on the floor. Airline recommended exercises were beneficial but did not return venous flow back to baseline. The more vigorous the exercises, the greater improvement was observed in venous flow during the 90-minute period. In the group with foot exercises against strong resistances, there was a 20% increase of popliteal flow compared with baseline flow. During question time, Prof Fletcher indicated that the response is variable and the effect of exercise lasts approximately 15 to 30 min. These findings might form the basis for future exercise recommendations for airline passengers.
Anything new in air travel–related venous thromboembolism?
B. Eklof / Sweden
In view of the growing evidence of an association between air travel and an increased risk of VTE, the World Health Organization decided in March 2001 to promote investigations whose objectives were 1) to confirm and evaluate the magnitude of the thrombotic risk in travelers, 2) to examine whether or not specific risk factors linked to air travel exist, and 3) to determine which preventive measures should be taken.
Whereas the absolute risk of VTE in Dutch pilots was lower than in the overall Dutch population, an epidemiological study conducted among airline employees found a 3.5-fold increased risk of VTE during the 4-week post-flight period (incidence 4.0 per 1000 person-years of exposure) as compared with other periods (incidence 1.2 per 1000 person-years). Studies on specific air travel–related risk factors yielded conflicting results. Whereas some coagulation markers (thrombin generation, thrombin-antithrombin complex, but not factor VIIa, VIIIc or APCsr) were found to be higher in healthy volunteers after an 8 hour-flight as compared with control subjects exposed to a movie marathon, another study did not find any effect on coagulation of 8-hour exposure to mild hypobaric hypoxia in a hypobaric chamber. Unfortunately, no funding has yet been found for interventional studies on prevention. Meanwhile, the author proposed a risk stratification based on risk factors and history of VTE. General measures alone could be recommended to low-risk patients (abundant fluid intake, no alcohol, no sleeping pill abuse, leg exercises). Medium-risk patients (mainly those with VTE risk factors) should wear compression stockings, whereas a single LMWH injection should be considered in high-risk patients (that is, those with a personal history of VTE, an active malignancy, or recent major surgery).
With the participation of A.I. Shimanko / Russia, G. Serpieri / Italy, R.K. Miyake / Brazil, M. Kielar / Poland
This session consisted of a number a presentations from several countries, dealing with the value of different techniques of sclerotherapy or laser therapy in the treatment of telangiectasias.
R.K. Miyake (Brazil) presented data on 191 patients treated with an Nd:YAG 1064 nm laser followed by dextrose sclerotherapy, both used with a forced air-cooling device. The VeinViewer TM was used to guide laser light. In 86% of patients, there was partial or total improvement. No allergic, systemic reactions or skin burns were observed. In conclusion, the author suggested ambulatory phlebectomy to complete treatment of those with unsatisfactory outcome.
H. Kielar (Poland) reported the use of electro-optical synergy technology (ELOS) which consolidates diode 915 nm laser and radiofrequency (RF) simultaneously during one exposure. ELOS was used to treat 150 women (mean age 41.4 years). The medical evaluation was very good (total decline of spider nevi), good (“shadows” of spider nevi), acceptable (better local appearance after 1-3 exposures), poor (no visible changes after one exposure). After one exposure, 62% of patients showed a good and very good effect, 11% acceptable, and 28% poor. After the last exposure, effects were good and very good in 72% of cases, and poor in 28%. No photodermatoses, skin irritation, residual lesions were observed. In conclusion, ELOS was safe, effective and had a very low complication rate.
Morphological changes in deep veins of the lower limbs before and after stripping surgery—measurement of venous crosssectional areas by color Doppler ultrasonography
H. Tanaka, Y. Ishihara, A. Hakamata / Japan
Two groups of the patients were examined: a control group (40 normal limbs/20 healthy volunteers) and a varicose vein group (116 limbs with superficial varicoses/82 patients). Cross-sectional areas of deep veins were measured using a color duplex scan. Measurement was performed in 4 venous segments: common femoral vein (CFV) above and below the saphenofemoral junction, superficial femoral vein (SFV) above the knee, and the popliteal vein (PV). Investigation was performed in the standing and supine positions before and after surgery. The cross-sectional area of the PV was significantly increased in the standing position before surgery, compared with post-surgery (P<0.0001). In the standing position, the cross-sectional areas of the CFV and SFV in the varicose vein group were larger than in the control group (P<0.001). After surgery, the difference in the crosssectional areas of the CFV and SFV between varicose vein patients and the control group became smaller. The authors concluded that measurement of the crosssectional area of the deep veins could be useful for evaluation of the degree of restoration of venous hemodynamics.
Should complete stripping to the ankle be used to treat primary varicose veins caused by long saphenous vein insufficiency?
H. Uncu /Turkey
GSV stripping from groin to ankle was done in 96 patients (102 limbs). Common postoperative complaints were pain (79.1%) and cosmetic problems (37.5%).
There were small temporary complications: hematomas (19.6%), edema (10.8%), local inflammation (13.7%), bruising (11.8%), calf deep vein thrombosis (2%). Median follow-up time was 3.4 years after surgery. All complaints due to varicose veins were resolved. Permanent paresthesia was found in two patients (2%). The author concluded that total stripping of the GSV is an appropriate technique for surgical treatment of the GSV insufficiency.
Prediction of long-term neurological symptoms after stripping operations by objective assessments of saphenous nerve injury
D. Akagi, H. Arita, T. Komiyama, S. Ishii, K. Shigematsu, H. Nagawa, T. Miyata /Japan
In contrast to the above presentation, in this study 18 patients (27 limbs) were investigated after inversion stripping of the GSV. Quantitative sensory function was determined by current perception threshold (CPT) measurements using a Neurometer® (Neuroton, Inc., USA). Neurological symptoms (pain, anesthesia, paresthesia) were found in 13 limbs (48%), 10 (77%) of which showed a 20% increase in CPT over the preoperative value. In contrast, only one of 14 asymptomatic limbs showed a CPT increase over 20%. So, CPT evaluation could be a good objective method for estimation of neurological symptoms after venous surgery. The discrepancy between these 2 presentations indicates that the prevalence of neurological symptoms depends not only the method of stripping but also on the methods used to investigate postsurgical complications.
Maturation of the treatment of the refluxing great saphenous vein: the role of open surgery
M.C. Dalsing / USA
The author presented his personal experience in the evolution of treatment of varicose veins. Initially, open surgery was the procedure usually used, but varicose vein recurrence was too high (25% at 5 years) with a saphenous nerve injury incidence of 4% to 8%. To reduce this incidence, the author changed his strategy. He stripped the great saphenous vein (GSV) from groin to knee and then, with a small stripper head, stripped the calf GSV. With this maneuver he decreased the bulk of the vein pulled through the distal tunnel, but varicose vein recurrence at five years continued to be high. For this reason, and with the introduction of new therapies, principally endovenous treatment with radiofrequency and laser or sclerotherapy, the author changed his philosophy and offered the patients the new technologies. In the second part of his presentation, the author reviewed the results of the new technologies as published. The most studied procedure is radiofrequency ablation, for which the risk of varicose vein recurrence is 30% at 5 years, with less saphenous nerve injury. Laser ablation is less studied, the incidence of nerve injury is very low, under 1%, but the varicose vein recurrence is similar to that of other techniques (10% at two years). Foam sclerotherapy needs to be repeated several times to obtain good results. In all of these therapies, patient satisfaction, analyzed by quality of life questionnaires, has been very high. Probably in the future, open surgery will be reserved for specific cases where less invasive therapies cannot resolve the varicose vein problems.
It was concluded that minimally invasive procedures are currently as effective as open surgery, appear to cause less trauma to vulnerable nerves, and are preferred by most patients. More long-term results are needed.
Mechanical inhibition of neovascularization to prevent recurrence of varicose veins
R.A. Van Rij, G. Hill, R. Christie, G.T. Jones, M. Amer, I. Thomson, R. Pettigrew, S. Packer / New Zealand
Recurrence of varicose veins following surgery can be attributed in large part to neovascular reconnection at the saphenofemoral junction. The reasons for this pathological process are not well understood and it seems that the surgical technique has a small influence on the intensification of this process. The results of the latest investigations show that neovascularization is dependent on the individual patient’s predisposition and is related to the activity of specific markers such as EphB4, NRP2 and COUP II. The process of new vein formation after varicose surgery is totally different than angiogenesis in ischemic tissues. Ultrasound and histological investigation focused on the top of ligated saphenofemoral junction additionally covered by a patch (PTFE or silicon) revealed two ways of new vessel formation. The main one is from the site of ligated SFJ (below the patch), and the other is from the site of the scar proximal to the patch. The frequency of occurrence using ultrasound was estimated as 15% to 20% of all operations, even when there are no visible changes in the groin region. Thus the main problem is how to stop the neoangiogenesis after varicose vein surgery: modify surgical technique, use only the endovascular procedure, which eliminates the angiogenesis related to scarring, or use angiogenesis inhibitors?
Saphenectomy without crossectomy, an alternative solution to endovenous techniques: short-term results
M. Lefebvre-Vilardebo / France
In this study, 285 great saphenous vein (GSV) trunks were removed without high ligation. The indication was dilatation and incompetence of the thigh GSV. Contraindication was incompetent saphenofemoral junction (SFJ). All operations were performed under femoral nerve blockade and tumescent anesthesia. A special flexible stripper was used in combination with microphlebectomy hooks. Postoperative ultrasound investigation demonstrated that the residual SFJ was completely patent, with good drainage through the tributaries in 199 cases (87.7%). 22 SFJs were partially patent. Total occlusive thrombosis was found in 6 SFJs. Parietal thrombosis of the SFJ without penetration into the CFV was found in 20.6% of cases. These thrombi completely resolved without any treatment over 1 to 3 months. Thus surgical avulsion of the GSV without high ligation has all the advantages of the endovenous techniques. Longer follow-up investigations are needed for high ligation-free stripping of the GSV.
Does closing the cribriform fascia contain postoperative neovascularization at the saphenofemoral junction?
A prospective study
M.G. de Maeseneer / Belgium
After SFJ ligation in 193 patients (235 limbs) with primary SFJ incompetence, the fossa ovale was closed with mobilized cribriform fascia. Postoperative duplex scanning was performed after 2 and 12 months. The results were compared with two historical control groups: silicone patch saphenoplasty (191 limbs) and no barrier technique (189 limbs). After one year, neovascularization was found in 6.7% cases of the closed fossa ovale with fascia cribrosa. This was comparable with the group with silicon patch saphenoplasty (5.2%). Neovascularization was more frequent (14.8%) (P<0.01) in the open fossa ovale group. Thus, the anatomical barrier formed by closing the fossa ovale after SFJ ligation reduces neovascularization.
Varicose great saphenous vein: no need to treat 50% of junctions. A series of 613 legs
M. Lefebvre-Vilardebo, P. Lemasle / France
Nowadays, new treatments of varicose veins in patients with great saphenous vein (GSV) incompetence tend to preserve the saphenofemoral junction (ultrasound-guided foam sclerotherapy, endovenous techniques, crossectomy free saphenectomy), even of the trunk (CHIVA). The question is: does saphenofemoral junction preservation influence varicose vein recurrence?
To answer this question, the author used duplex ultrasound to study 613 legs with primary varicose veins caused by an incompetent thigh GSV. Ultrasound studies specifically investigated the cause of GSV reflux, which was seen in 79.3% of junctions. Ostial valves were pathological in 53.8% of cases. Other causes of reflux were preterminal reflux in 25.5% of cases and incompetent perineal veins in 24.5%. In the rest of the cases, venous reflux was due to dystrophic changes in lymph nodes in 2% of cases, thigh perforator insufficiency in 3.1%, and the saphenopopliteal via the Giacomini vein in 2.6%. The results of this study were similar to those published by Capelli in 2004.
In conclusion, ostial valve incompetence causes only 53.8% of cases of GSV reflux. Crossectomy in the rest of cases may not be necessary. However, more data on long-term outcome are needed.
Bipolar coagulation: a new possibility of intravascular treatment of varicose veins
J. Strejcek, L. Pock, P. Fara, E. Skrivanova / Czech Republic
Bipolar radiofrequency-induced thermotherapy (RFITT), a new technique for the treatment of varicose veins, can eliminate the possibility of vein wall perforation by switching off the coagulation, when the thermal changes of the internal part of the vein are sufficient, in contrast to endovenous radiofrequency and laser closure. The authors reported good results from a limited number of experiments with RFITT in human saphenous veins obtained by stripping and rabbit saphenous and ear veins, but concluded that a clinical multicenter study must be done.
Endovenous laser ablation: does fluence make a difference? Progression and recurrence of vein disease in patients treated with endovenous laser ablation: one-year experience
T. King / USA
The author reported the use of a 980 nm laser in 240 cases and a 1320 nm laser in 195 cases. There was no statistical difference in the overall failure rate between the 980 nm (20/240) and 1320 nm (21/195) lasers. This was true for treatment of the SFJ and the SPJ. Energy delivery (J/cm2) does not appear to be as reliable a predictor of successful endovenous laser therapy (ELT) as fluence (J/cm2), and this was true for both the 980 nm and 1320 nm lasers.
The author also presented a retrospective analysis of 96 patients (112 veins) treated with ELT to evaluate progression and recurrence of vein disease at 12 months. Complete duplex ultrasound scanning was done at 1, 3, 6 and 12 months and any reflux (> 0.5 s) was noted. Incompetent perforators of the thigh (13.5%) and calf (15.2%) and anterograde-flowing branch (feeder) veins (46.8%) were a greater source of recurrence (16/112 at 1 year) in laser-treated veins than failure to close or reopening of the SFJ (21.6%) or SPJ (2.9%). The author concluded that in the first year after ELT recurrence of reflux in the treated veins is far more common than progression of new disease, although the incidence of both decreases over time.
Comparison of endovenous treatment with 980 nm laser versus conventional classic varicose vein surgery in an ethnically diverse society
M. Lakhwani, T.C. Lee / Malaysia
The results of a retrospective study of 292 cases (350 legs) comparing endovenous treatment with 980 nm laser (152 legs) versus conventional varicose vein surgery in nonhomogeneous groups (different CEAP classification) were presented. The conclusion was that more than 95% were satisfied with each of the procedures, but ELT was more widely acceptable due to its minimally invasive nature and better cosmetic results.
T. Noppeney (Germany) gave one current evaluation of endoluminal radiofrequency obliteration of the superficial venous system. He performed a meta-analysis using two major data sources: the still ongoing clinical registry and a prospective randomized trial (EVOLvES study) between RF obliteration and the high ligation and stripping of the GSV. The overall occlusion rate after RF obliteration was 87% up to 5 years postoperatively and during the follow-up period more than 80% of the treated veins could not be seen by duplex ultrasound any more. He concluded that midterm results up to 5 years are as good as those of high ligation and stripping, with clear advantages for RF obliteration regarding faster recovery and better quality of life perioperatively. Thus RF can be considered a very established and standardized procedure for treating varicose veins.
Complications of endovenous laser treatment- avoidance and treatment
F. Pannier / Germany
The author presented the results of a prospective, open, nonrandomized study of the efficacy and safety of endovenous laser treatment (ELT) in 89 limbs with GSV or SSV incompetence. Traditional small complications were found over four weeks: superficial ecchymoses (41%), moderate pain (50%), and paresthesia (10%). There were only two serious complications: 1 case of the skin burn and 1 case of arteriovenous fistula. There was no DVT or pulmonary embolism. Occlusion of the treated veins was found in 95% cases during 2-year follow-up. The author concluded that ELT is an effective, minimally invasive method for patients with GSV and SSV incompetence.
Endovenous laser ablation compared with stripping—preliminary results of an ongoing, randomized, controlled multicenter trial in Japan
T. Ogawa, S. Hoshino, S. Makimura, H. Shigematsu, N. Azuma, T. Sasajima, H. Sugawara, M. Ichiki, S. Shokoku / Japan
In this prospective, randomized, controlled, open multicenter study of 92 patients, 67 cases were analyzed. The ratio between endovenous laser treatment (ELT) and stripping was 2:1. The patients were evaluated by duplex scan, air plethysmography, CIVIQ2 quality of life score and clinical examination at 6-month follow-up. There were no significant between-group differences in the frequency of adverse postoperative events. There was significant improvement in the quality of life score in both groups of patients without significant difference in the dynamics. The authors underlined that the main significant difference between the ELT and stripping groups was the shorter hospital stay after ELT (average 1.14 vs. 2.76 in stripping group).
Randomized trial comparing endovenous laser ablation of the great saphenous vein with high ligation and stripping in patient with varicose veins: short-term results
L.H. Rasmussen, L.B. Rasmussen, M. Lawaetz, B. Lawaetz, A. Blemings, B. Eklof / Denmark
One hundred twenty-one patients (137 incompetent GSVs, CEAP C2-C4) were randomized (envelope method) into two groups for EVL or high saphenous ligation and Oesh stripping (HL/S). All procedures were performed under tumescent anesthesia. The following criteria were recorded: occlusion or absence of the GSV, complications, varicose vein severity score (VVSS), postoperative pain score, Aberdeen score, SF-36 QoL, time off work and time of normal activity and costs. There were no significant between-group differences in the frequency of the complications and adverse events. Improvements in the quality of life (SF-36 and Aberdeen scores) and in VVSS at three months were similar in the two groups. Postoperative pain score was higher in the HL/S group than in the ELT group (NS). Sick leave was 7.7 and 6.9 calendar days, while time to normal physical activity was 7.6 and 7 days in the HL/S and ELT groups, respectively (NS). The total cost of the procedures including work loss was 4053 USD per patient in the HL/S group and 4492 USD per patient in the ELT group. There were no differences between the two treatment modalities except for slightly increased postoperative pain in the HL/S group. The ELT procedure was 10% more expensive.
With the participation of P.J.S. Montemayor / Philippines, C.K. Oh, H.K. Kim / Korea, K. Wasilewski / UAE,
M. Hirokawa / Japan, J.R. Kingsley, T. King, L. Cunningham / USA
Endovenous laser treatment (ELT) is a new alternative to surgical stripping of the saphenous veins. It is performed by various specialists such as vascular surgeons and dermatologists, preferably under tumescent local anesthesia.
The 1320 nm laser is the most effective. However, a large study analyzing the data of 1000 cases showed that 98.5% and 98.1% of patients exhibited complete ablation at six-month and one-year follow-up, respectively.
ELT is rarely followed by major complications such as deep venous thrombosis, skin burns, arteriovenous fistula, or paresthesias. However, minor complications such as redness, tenderness, hematoma, superficial thrombophlebitis, skin hyperpigmentation, and prolonged pain are recorded more frequently. There are also a few reports of satisfactory short- and intermediate-term results of ELT of the small saphenous veins. A new device, the closure FAST, has been introduced to reduce the duration of the operation.
There are no available results assessing the long-term success of ELT and its effect on quality of life. Therefore, prospective, randomized, comparative (to surgery) studies should be designed and performed.
Results of treatment of superficial venous insufficiency: what do we really know?
B. Eklof / Sweden
The author reviewed the evidence concerning treatment of superficial venous insufficiency (great saphenous vein, small saphenous vein, perforators and varicose veins). In the past decade, the development of minimally invasive endovenous techniques like endolaser treatment (ELT), radiofrequency (RF), and foam sclerotherapy (FST) has changed the standard of care, which is considered to be surgical treatment with high ligation and stripping (HL/S). The advantage of RF over HL/S was demonstrated in four randomized, controlled trials (RCTs), the most significant differences being quicker patient recovery, reduction in postoperative morbidity, and improvement in quality of life.
Two RCTs comparing ELT with HL/S showed similar results apart from less bruising and swelling for ELT in one of the studies. In one RCT comparing RF with ELT, the occlusion rate was higher after RF, while the adverse event rates were the same. There are two RCTs comparing surgery with FST. In the first surgery was superior to Varisolve foam, and in the second FST combined with HL was less expensive, required less treatment time, and resulted in more rapid recovery. The author concluded that we need a large, randomized, multicenter study comparing the three endovenous methods with surgery.
Long-term results of endovenous ablation: consensus statement and illustration by 5-7 years of results at the Straub Clinic and Hospital
F. Lurie / USA
The consensus statement on Reporting Standards for Endovenous ablation (EVA) recently published by the American Venous Forum and the Society of Interventional Radiology was debated. This document emphasizes the need for standardization of terminology (recanalization, neovascularization, primary ablation, primary assisted ablation, secondary ablation) and methodology for clinical research studies in this area and major points of consensus include general information (patient population, age, gender, race, clinical indication, anatomic location of treated veins, CEAP staging, clinical severity score, study design, comorbid diseases, functional status and quality of life, pre-treatment imaging, primary reason for treatment), treatment description (pre-treatment preparation, method of vein access, intra-procedural imaging, device or chemical agent description, energy source and duration, total energy deposited, or dose of sclerosant, adjunctive techniques, anesthesia, length and diameter of vein), and post-EVA evaluation (complications, follow-up imaging at regular intervals, followup of clinical status, quality of life assessment, uniform duration of follow-up, need for additional procedures, costs/cost effectiveness, primary outcomes) required and recommended.
Endovenous laser treatment versus surgery for incompetent great saphenous veins: a prospective study
S. Jianu, E. Ursuleanu / Romania
A total of 546 patients were enrolled in a prospective study comparing endovenous laser treatment (ELT) versus surgery (high ligation and stripping, HL/S) for incompetent great saphenous veins. ELT (810 nm laser) was used in 264 patients and HL/S in 282, under local anesthesia in all cases. In the ELT group the vein occlusion rate was 91% at 18 months, morbidity rate was 4%, and 2 patients required further crossectomy. In the surgical group, 2 patients required further surgery and the morbidity rate was 10%. It was concluded that ELT is associated with fewer complications than surgery and requires less recovery time, and that the rate of further operations is the same for the two techniques.
Endovenous laser treatment of saphenous vein reflux: mid-term results
S. Shokoku / Japan
Mid-term follow-up results were presented for endovenous laser treatment (ELT) of great saphenous vein (GSV) reflux (131 patients) caused by saphenofemoral junction incompetence and small saphenous vein (SSV) reflux (27 patients) caused by saphenopopliteal junction incompetence. Occlusion rate was 100% immediately and 96.6% after 1 year, with most cases of recanalization concerning the SSV, due to low energy delivery.
Four-year results after ELVes for saphenous varicose veins
H.C. Wenzel / Germany
A single-center, retrospective, four-year study of ELVeS (980 nm diode laser) for saphenous varicose veins (62 GSV and 12 SSV) found an occlusion index of about 96%, 91% satisfaction, and no significant side effects.
Venous stasis ulcers successfully treated with endovenous saphenous vein ablation: the first reported series
J.R. Kingsley, J.H. Isobe, S.A. Tadros / USA
This is the first reported series with results concerning venous stasis ulcers successfully treated with endovenous saphenous vein ablation. There were 75 patients with venous stasis ulcers of the medial or lateral malleolus who underwent 82 saphenous vein ablation operations. Seventy-four procedures were performed on the GSV and the remainder on the SSV. Twenty-two percent of patients also underwent high ligation, 61% micro-phlebectomy, and 40% ultrasound-guided FST. Seventy-three patients were treated with a 1320 nm laser, 7 with radiofrequency, and 2 with a 940 nm diode laser. The ulcer healing rate was 93% within one to six months and the author concluded than this may be a good option for patients suffering from venous stasis ulcers and saphenous vein reflux.
4th Bauerfeind Phlebology Award
How to utilize compression therapy after ultrasound-guided sclerotherapy with foam for the treatment of varicose saphenous veins, a randomized controlled trial
R.P.M. Ceulen / The Netherlands
This award-winning, ongoing study is designed to determine the role of compression after sclerotherapy with foam. The hypothesis is that compression decreases the extent of thrombus formation, thus decreasing the risk of recanalization and the incidence of postsclerotic pigmentation. This prospective, randomized, controlled study included 72 patients with great or small saphenous vein insufficiency divided into two groups according to venous diameter (<4 mm and >4 mm). Both groups were divided into three subgroups depending on the type of compression (no compression, compression for 1 week, compression for 4 weeks). Patients with very dark skin tone, GSV or SSV diameter greater than 1 cm, ankle/brachial index <0.7, age <18 years or >65 years, presence of obesity, malignancy, acute superficial or deep vein thrombosis were excluded. The results will be analyzed through blind assessment of photographs by 6 independent reviewers. The presence of thrombophlebitis was analyzed by means of clinical and ultrasound signs. Other variables analyzed are vein disappearance, hyperpigmentation, and neovascularization. Clinical improvement was assessed with one scale from 4 to 12 (4 poor result, 12 excellent result). Obliteration measured by duplex ultrasound, presence of venous complaints, and quality of life are analyzed too. The study will start in September 2007, the final inclusion will be in February 2008, follow-up will end in April 2008, and the results will be presented in June 2008.
Efficacy and safety of Aethoxysklerol foam in a prospective randomized multicenter trial (ESAF-Study): results of the first phase
E. Rabe, J. Otto, D. Schliephake, F. Pannier/ Germany
F. Pannier and E. Rabe described the study procedures and presented the results of the ESAF-study, a prospective, multicenter, randomized clinical trial comparing the efficacy and safety of polidocanol-foam with polidocanol-liquid for ultrasoundguided sclerotherapy of great saphenous vein (GSV) incompetence. Patients with incompetent GSV with a diameter <12 mm, a reflux >1 s (3 cm below junction) and a PPG refilling phase <25 s were included (106 patients) and were treated with up to 5 mL foam or up to 4 mL of 3% polidocanol liquid per treatment session, and up to 3 sessions were allowed. To assess the efficacy of both treatments, duplex ultrasound 3 cm below the saphenofemoral junction 3 months after the last injection was done and patients with no reflux or a reflux <0.5 s were considered as responders. The responder rate among patients treated with foam was 70%, whereas the responder rate in the liquid group was just 31%, with no differences in safety. The most successful centers injected a mean volume of 4.2 mL foam in comparison with 3.2 mL foam at the other centers. The authors concluded that ultrasound-guided foam sclerotherapy is an effective and safe technique, with better results than liquid. However, the optimum maximum volume of foam to be injected must be standardized.
The current role for sclerotherapy in the management of venous disease: the Australian perspective
G.M. Malouf / Australia
The sclerosants used included Aethoxysklerol, Fibrovein and hypertonic 20-24% saline (restricted to microslerotherapy). After different phases, sclerotherapy is now used as a follow-up to surgical or thermal truncal ablative procedures, or for microslerotherapy. Ultrasound-guided therapy using liquid or foam is used just for narrow (< 5 mm) refluxing GSV, SSV, Giacomini veins, and recurrent varicose veins. The Australian experience showed fewer allergic reactions and less severe complications for Aethoxysklerol, and stockings have been used to replace bandages for compression after sclerotherapy, and the duration of compression has fallen from 6 to 2 weeks or less.
The Japanese Polidocanol (Aethoxysklerol) clinical trial
H. Satokawa, S. Hoshino, S. Sakaguchi, C. Yamada / Japan
The first phase assessment of suitable concentration, safety and tolerability included 261 patients, none of whom developed any treatment-related systemic adverse events, with a safety limit of 2 mg/kg polidocanol. In the second phase a doubleblind test to evaluate clinical usefulness included 86 patients, and the 69.2% to 100% efficacy noted with a single use of polidocanol was greater than that of placebo.
Update on foam sclerotherapy: the 2nd European Consensus Meeting on Foam Sclerotherapy, April 28-30, 2006, Tegernsee, Germany
F.X. Breu, S. Guggenbichler, J.C. Wollmann / Germany
The authors reported the guidelines from the last consensus on foam sclerotherapy which took place in Germany in 2006. A total of 35 000 patients affected by small and large varicose veins were managed. The main topics were access location, foam volume, foam preparation, safety, and contraindications.
Access: when treating the great saphenous vein (GSV), access is by direct puncture at the proximal thigh. Long catheters can be used to access the GSV below the knee. When treating the small saphenous vein (SSV), access is at the proximal or middle part of the calf.
Foam volume: the foam volume has to be limited to no more than 10 mL. If treating large veins, a compact, viscous foam should be used: liquid/gas ratio 1/4
Foam preparation: the Tessari method is recommended in all situations.
Safety: to increase safety during treatment of the GSV, most operators use a volume per puncture and per session. Also, for injection with needles and short catheters, a minimal distance to the junctions of 8 to 10 cm should be used. Immediate compression over the injected areas should be avoided. Ultrasound monitoring of foam location should be used. Inject very viscous foam. There should be no movement of the patient or leg for 2 to 5 minutes, and no Valsalva maneuver or muscle activation.
Contraindications: a known asymptomatic patent foramen ovale is a relative contraindication. History of thromboembolism is a relative contraindication. Heparin prophylaxis is appropriate in such cases, using low concentrations and small volumes.
Ultrasound-guided foam sclerotherapy in the elderly patient: a minimally invasive treatment for chronic venous disease
C. Vandenbroeck, M. De Maeseneer, P. Van Schil / Belgium
The authors described the treatment of varicose veins with foam sclerotherapy (USGFS) in an aging population. Fifty-eight patients (15 male, 43 female, age range 70-84) were treated and examined at 14 days and 6 months using duplex ultrasound. The sclerosant used was 3% Polidocanol and the foam was created by the Tessari method. After 14 days, full obliteration was obtained in 89% of cases; 8 legs needed a second session because of only partial occlusion. No serious side effects occurred. Minor symptoms as bruising, pigmentation, or induration occurred in 28% of patients. Three patients required heparin for delayed superficial thrombophlebitis.
After 6 months, full obliteration was observed in 72% of cases. The authors conclude that an adequate understanding of chronic venous disease can lead to optimal foam sclerotherapy results in a group of patients who would otherwise be left untreated.
Ascent of foam sclerotherapy in treating venous disorders
J. Bergan / USA
Dr Bergan gave a personal overview of the changes in practice due to the advent of foam sclerotherapy, which has revolutionized the treatment of superficial venous insufficiency and nowadays is an alternative to surgery and laser obliteration.
Surgery for varicose veins requires anesthesia, is often associated with pain, sometimes nerve injury, and above all unacceptable varicose vein recurrence rates (30-60%). Endovenous laser therapy involves day surgery, local anesthesia, and has a high equipment cost. It produces ecchymosis, patient discomfort, and often multiple treatments are needed. Foam is made from a detergent solution. The ratio is 1 part agent to 4 parts room air. Most practitioners use ultrasound-guided saphenous vein access, some simply cannulate a varix, but both techniques involve massaging the foam into the saphenous vein and into target varicosities. A varix can be cannulated directly and the foam directed proximally, then leg elevation directs the foam distally. Groin pressure is maintained and more foam is added if necessary. Leg elevation is maintained to fix foam in the vein. Of 116 patients with varicose veins treated with foam sclerotherapy, during a mean follow-up of 24 months, 72% showed complete fibrosis of saphenous vein, 21% 2-3 mm fibrotic saphenous vein, 7% persistent reflux without varices.
The tangle of dilated venules under the ulcer are the target of treatment by foam sclerotherapy. In his personal experience of 869 patients, Dr Bergan has recorded a low rate of adverse effects (cutaneous necrosis 2 cases, DVT 3 cases, chest pain 2 cases, ocular symptoms 4 cases, dry cough 3 cases, migraine-like attack 2 cases, in total 3.2%).
In conclusion, surgery of varicose veins is nearly obsolete. Laser procedures are acceptable surgical substitutes. Sclerosant foam is effective as an endovenous procedure in obliterating dysfunctional veins. It is less expensive, painless, nondisabling, efficient, and easy to use.
Obstruction and stent placement
Long-term outcome of iliac vein stenting
S. Raju / USA
Iliac venous stenting is a minimally invasive technique indicated for iliac obstructive lesions. The procedure is percutaneous, carried out on an outpatient basis and does not constitute a contraindication for future operation.
Iliac obstructive lesions occur commonly in postthrombotic disease (PTS), in primary chronic venous disease (CVD) (for >90% of patients). They are called obstructive non-thrombotic iliac vein lesions (NIVLs) and are diagnosed by means of intravenous ultrasound (IVUS). MR imaging reveals asymptomatic NIVL in about 60% of the general population.
Iliac obstructive lesions (permissive), although silent, may become symptomatic when secondary pathologies such as reflux, infection, or trauma are superimposed. Remission of symptoms may be achieved by correction of iliac obstructive lesions alone, even when secondary pathologies are not addressed.
The author presented his experience on iliac vein stenting in 982 limbs stented over an 8-year period: 518 for primary lesions and 464 in patients with PTS. Follow-up was complete for 94% of them. Mortality (30 days) was zero. The early (30 days) thrombotic event rate was 1.5% and the late rate was 3%.
Primary chronic venous disease: cumulative primary and primary assisted patency were 79% and 100% at 6 years.
Postthrombotic disease: primary, primary assisted, and secondary patency were 57%, 80% and 86%, respectively.
In-stent restenosis was rare <5%.
Although 70% of stents were extended below the inguinal ligament, there were no stent fractures or erosions.
Complete relief of pain and swelling at 6 years was 62% and 32%, respectively, and 58% of ulcers healed and remained healed at 6 years, although residual reflux was not addressed in most of them.
In conclusion: long-term stent patency is excellent in PTS and 100% in primary chronic venous disease, resulting in excellent clinical results. In primary chronic venous disease, stenting of NIVLs results in clinical relief even when the associated reflux is left uncorrected. Therefore, iliac venous stenting is the primary choice in the management of iliac obstructions.
Follow-up results of 71 patients after stent placement for malignant obstruction of the superior vena cava
T. Nagata, S. Makutani, H. Uchida, K. Kichikawa / Japan
This was a retrospective review of a series of patients with superior vena cava syndrome (SVCS) secondary to a compression for malignancy treated by Spiral Z-Stent implantation, habitually used in the treatment of tracheobronchial and biliary system stenosis. The right femoral vein approach was used. After crossing the lesion, the hydrophilic guide was replaced by a stiffer guide. Normally it was necessary to predilate to implant the Spiral Z-Stent. After treatment, the patients were anticoagulated with heparin for two days followed by oral anticoagulation and antiplatelet therapy. The Spiral Z-Stent was chosen because of its radial tension, adaptability, and the possibility of implanting it through a smaller introducer (12Fr).
Treatment was 100% technically successful in 71 patients. Improvement in edema was obtained in 87% of cases, between the first and ninth day. The primary clinical patency rate was 88% (57/65) and the secondary rate was 95% (62/65). All the patients died, and the survival of 57 patients varied between 1 and 29 months. There was no recurrence of SVCS. Unilateral stenting was useful in the 8 patients with bilateral brachiocephalic vein thrombosis.
In conclusion, spiral Z-Stent placement seems to be effective in the treatment of malignant obstruction of SVC, with an excellent clinical patency rate.
Iliac vein compression syndrome
The results of endovascular treatment for iliac vein compression syndrome
W.-H. Kwun, H.-J. Kim, B.-Y. Suh, W.-K. Park / Korea
This is a retrospective review of a series of 31 patients with iliofemoral vein thrombosis and iliac vein compression (May-Thurner syndrome or Cockett syndrome) treated by thrombolysis with local urokinase and aspiration thrombectomy. Complete lysis was obtained in 28/31 patients, with subsequent stenting in all. All patients had clinical improvement (100%). Iliac thrombosis recurred in four cases. It seems that aggressive therapy can result in a high patency rate.
Chronic venous insufficiency and venous leg ulcer
Effectiveness of ulcer stockings
M. Neumann / The Netherlands
For medical elastic compression stockings (MECS), the three characteristics of major importance are elasticity, stiffness, and hysteresis. In this study, the Medi Ulcer Kit was administered. Effectiveness was determined in terms of capillary filtration rate (CFR) reduction, compression, and hysteresis. These parameters were measured as follows.
In the supine position, the pressure exerted by the stocking exceeded the pressure in the femoral vein, and caused significant reduction of edema by reducing CFR. In the standing position, two stockings were used: low + class II stocking = class III stocking. Two separate stockings result in increased hysteresis, which in turn leads to a higher dynamic stiffness index. Therefore they are highly effective during walking.
Limit of free skin grafting and application of free flaps for intractable venostatic crural ulcer
K. Tanaka, R. Murakami, A. Hirano / Japan
Venostatic ulcer complicates leg varices and often recurs after treatment. However, there are a few cases of intractable ulcer, for which free skin grafting is less effective. The authors presented an alternative method of ulcer reconstruction using a free flap. A free flap from the groin was transplanted in 3 patients. No ulcer has recurred as of 7-10 years after the procedure. Transplantation with good circulatory conditions and anastomosis with a deep vein may have allowed inflow of venous blood around the flap into the deep vein. Consequently, venous circulation may have improved with tissue replacement.
Importance of surgical treatment in venous leg ulcers – Consensus document of the “Surgical Treatment in Venous Leg Ulcers” study group of the German Society of Phlebology
H.J. Hermanns, C. Schwahn-Schreiber, F. Waldermann / Germany
Venous leg ulcers are still a major medical problem worldwide, especially in industrialized societies. The poor results reported after have prompted further search for more effective procedures.
Scientifically well founded and successful methods of surgical treatment of venous leg ulcers are now available. The “Surgical Treatment in Venous Leg Ulcers” study group of the German Society of Phlebology evaluated the current long-term results from German vascular centers using different surgical methods. The conclusions of the conferences in Vienna 2005 (Austria) and in Berlin 2006 (Germany) were summarized as a consensus document.
Three therapeutic concepts for the treatment of venous leg ulcers are available: varicose vein surgery or endovascular techniques, methods including the fascia cruris (fasciotomy and fasciectomy), and shave therapy or other local treatments.
Varicose vein surgery and endovenous techniques are used to eliminate primary and secondary varicose veins. The indications for treatment of an incompetent perforator have recently changed. In Germany only 0.8% are managed by SEPS. Fasciotomy, indicated by a CEAP classification C4 to C6, has declined from 12.8% (2001) to 7.1% (2004).
Shave therapy is the first choice of treatment of nonhealing leg ulcers, and has given good long-term complete healing in 77.5% (Hermans) and 70.6% (Schmeller) of cases. Fasciectomy is reserved for special indications (deep transfascial necrosis and failure of shave therapy).
Fasciectomy in lateral venous leg ulcers: a nerve-sparing procedure
A. Obermayer, K. Göstl / Austria
The great medical problem after fasciectomy for nonhealing venous leg ulcer is paresthesia related to peroneal nerve injury. The results of modified fasciectomy for lateral located and nonhealing leg venous ulcer were presented. Fourteen legs (12 patients) with chronic active venous ulcers (CEAP: C6) all lateral, were surgically treated. The surgical procedure included surgical interruption of the causative reflux and fasciectomy with mesh graft transplantation. As the superficial peroneal nerve was adherent to the inflamed fascia, meticulous dissection was performed in all cases. Afterwards the superficial peroneal nerve was transposed between the musculus peroneus longus and musculus extensor digitorum longus. The intensity of pre- and postsurgical pain was measured using a visual analogue scale and the Nottingham Health profile. A median follow-up of 3 years after surgery showed significantly reduced levels of pain. The excellent outcome of healing (initial healing rate of 86% in a median 4.5 weeks) and recurrence (recurrence ratio of 0) underlines the benefits of this surgical technique. Except for two unhealed leg ulcers, there were no postsurgical complications.
Painful venous leg ulcers located on the lateral side of the lower leg benefit from surgical interruption of the pathogenetic reflux, fasciectomy combined with the sparing of the superficial peroneal nerve, and mesh graft transplantation.
Combined treatment of arterial and venous insufficiency by using the incompetent saphenous vein as graft in patients with ulcer
O. Nelzén / Sweden
Elderly patients with combined arteriovenous insufficiency are often difficult to treat and the risk of later amputation is high. The main aim of this study was to look at ulcer healing and the durability of vein grafts.
All 13 patients (14 legs) with combined arteriovenous insufficiency and ulcer underwent high ligation of the great saphenous vein (GSV) and short saphenous vein (SSV), and a bypass procedure using the incompetent saphenous vein as a graft was performed. Patients were followed up for 12 months or until the ulcer healed. Long-term follow-up was conducted through repeated telephone contact.
In-situ bypass was used in 7 legs, and the remaining 7 had reversed short bypasses. One graft occluded within 30 days and the patient had to undergo amputation. Within the first 12 months, 9/14 ulcerated limbs healed. Two patients died with patent grafts but unhealed ulcers after 5 and 6 months, respectively. One patient had successful re-do surgery with a vein patch procedure and precutaneous transluminal angioplasty (PTA) of the distal anastomosis. One had PTA + stenting of the iliac artery. The median long-term follow-up was 3.5 years (range 1.5-10). Two patients had later PTA, both combined with successful thrombolysis, and they had no remaining ulcers. At the last follow-up, 8/11 (73%) legs followed up beyond the first 12 months were healed. By intention-to-treat, 57% were successfully healed.
It appears that this combined arteriovenous treatment gave satisfactory palliation and ulcer healing for the majority of these elderly patients with a relatively short life expectancy.
Recalcitrant and recurrent leg venous ulcer after surgical treatment: long-term follow-up
K. Ziaja, G. Biolik, D. Ziaja, T. Urbanek, P. Nowakowski, M. Kasibucki, M. Glanowski / Poland
Recurrent or nonhealing leg venous ulcer is the most serious complication of chronic venous insufficiency (CVI). Conservative treatment and surgical treatment have proven unsatisfactory. Sufascial endoscopic perforator vein surgery (SEPS) is recognized as an effective method of treatment of incompetent perforator veins, but in many cases this is not a sufficient procedure. The aim of the study was to determine the efficacy of SEPS + saphenectomy and SEPS + crossectomy in patients with nonhealing or recurrent venous leg ulcers. The study was performed in 63 patients (11 men and 52 women) aged 54 years (22 to 76 +/- 4.23) who were divided into two groups:
– group I – SEPS + crossectomy – 37 patients
– group II – SEPS + saphenectomy – 26 patients
The 10-year observation period was from 1996 to the end of 2005.
Recalcitrant leg venous ulcer was observed in 10.8% of patients in the crossectomy group and in 3.8% in the saphenectomy group. Venous ulcer recurred at the same site in 21.6% of patients in the crossectomy group and in 19.2% in the saphenectomy group. Venous ulcer at a new site of the same leg was noted in 8.1% of patients in the crossectomy group and in 3.8% in the saphenectomy group. Investigation of valvular competence of the deep venous system revealed that valvular insufficiency was 3 times more frequent in the superficial femoral vein (10.8% patients) and nearly 2 times more frequent in the popliteal vein (24.3% patients) in the crossectomy group.
New calf vein thrombosis was observed in 10.8% of patients in the crossectomy group and in 3.8% of patients in the saphenectomy group. Insufficiency of the Cockett I perforator vein was 50% in both groups. On the basis of these findings, the author drew the following conclusions:
– In most patients treated by SEPS + crossectomy, there was GSV insufficiency, which was the main cause of ulcer recurrence or nonhealing.
– Valvular insufficiency of the popliteal vein is probably the second most important factor in ulcer recurrence or nonhealing.
– There is no single ideal method of treatment which eliminates all signs and symptoms of CVI and leads to permanent ulcer healing.