XIX. Focus on varicose vein recurrence

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XIX. Focus on varicose vein recurrence

What do we need: better technology or better strategy? Varicose veins after saphenous ablation and
surgery: disease recurrence or disease progression?

Josef Rafetto (US)
Josef Rafetto presented the study showing that nonocclusion and early reopening of the great saphenous vein after endovenous laser treatment is fluence dependent, where fluence is calculated as energy (J) per surface area. Recurrence could occur due to tactical errors, as endovenous laser ablation is not a stand-alone treatment, to technical errors resulting from inadequate tumescence, inadequate injury/energy; however, neovascularization is rarely seen. Josef Rafetto explained the pattern of recurrence: (i) recanalization (10% to 50%); (ii) disease progression from the anterior accessory saphenous vein (15% to 55%); (iii) thigh perforators (18% to 38%); and (iv) neovascularization (radiofrequency ablation [17% to 25%] >>endovenous laser ablation). Opportunities to minimize recurrences include not preparing thermal ablation as a stand-alone treatment, looking at patients vein by vein, and developing a strategy to deliver appropriate energy and educate patients.

In a review article, an update on the currently available nonthermal ablative options in the management of superficial venous disease showed a consistent closure rate >9% at 2 years. If mechanochemical ablation is performed, tactical errors include performing it as a stand-alone treatment or using it for large veins and technical errors include pullback speed and chemical features. Neovascularization was not reported. When using endovenous adhesives, a tactical error is to use glue as stand-alone treatment and technical errors are provider-dependent and related to the volume delivered. Neovascularization was not reported. The same applies for ambulant phlebectomy, which is often not a stand-alone procedure. Technical errors are specific to both patients and operators. If foam sclerotherapy is performed, tactical errors can be due to protocol and the chemical strength of the sclerosant agent. Technical errors are inadequate training and missing provider experience.

In conclusion, recurrences vary by technique (surgical stripping vs thermal). Tactical errors may be minimized by increasing the accuracy of diagnostic testing and a more comprehensive approach. Technical errors may be minimized by training and supervision by an experienced surgeon, the use of a protocol-driven approach, and concern that each patient/leg is unique.

Standard for the investigation of the saphenous terminal and preterminal valve on duplex
Erika Mendoza (Germany)
Erika Mendoza discussed the exploration of the saphenofemoral junction in the context of recurrences. To analyze the cause of recurrences, we have to be sure about the findings prior to treatment. Recurrences depend more on the source of reflux prior to treatment, than on the technique we apply. The saphenofemoral junction consists of a common femoral vein with a valve, the great saphenous vein with valves, groin tributaries, and the common femoral artery. Flow provocation maneuvers are Valsalva/Cremona (folded-straw maneuver), manual compression calf/release, toe-elevation maneuver (Wunstorf), weight transfer maneuver (Parana), and dependency maneuver. The standard for saphenofemoral junction exploration includes a standing position and longitudinal and cross-sectional morphology. Color duplex exploration should determine the source and path of the reflux and it should be done to document the findings. At least one down-to-top and one top to- down maneuver should be performed (once Valsalva). After saphenofemoral junction exploration, information will be available on the source of reflux (from where?), the paths of retrograde flow (to where?), and the ways of drainage. Erika Mendoza presented the REVAS classification sheet. Sources of recurrence are listed as no source of reflux, pelvic or abdominal, saphenofemoral junction, thigh perforator(s), saphenopopliteal junction, popliteal perforator, gastrocnemius vein(s), and lower-leg perforator(s). The source of reflux is the saphenofemoral junction in 47% of cases and lower-leg perforator(s) in 43% of cases. There are mainly retrospective studies in the literature about varicose vein recurrence after endovenous thermal ablation. In the REVATA study, recurrent varicose veins in 164 patients after endovenous thermal ablation or radiofrequency ablation (total 2380 patients treated) were documented. Varicose vein recurrence was seen after a median of 3 years. The most common source of reflux was from incompetent perforating veins (64%), recanalization of the great saphenous vein (29%), and new anterior accessory saphenous vein reflux (24%). The recurrence of varicose veins after endovenous thermal ablation in randomized studies was 22%, the same as after high ligation and stripping. There are different mechanisms of recurrence: neovascularization after high ligation and stripping (18%), recanalization after endovenous thermal ablation (32%), and new anterior accessory saphenous vein reflux (19%). Varicose veins increase over time and they are more frequent after endovenous thermal ablation than after high ligation and stripping.

There are possible strategies for preventing saphenofemoral junction and anterior accessory saphenous vein recurrence, but the use of laser crossectomy and/or “prophylactic” anterior accessory saphenous vein ablation has been debated. Potential strategies for preventing recurrences due to a large tributary include combining high ligation and stripping with phlebectomies or performing endovenous thermal ablation with concomitant phlebectomies. A prospective study of the fate of venous leg perforators after varicose vein surgery has shown that, in 850 incompetent perforator treatments, 76% of limbs had new incompetent perforators after 3 years.

Erika Mendoza concluded by saying that sources of recurrent reflux are different after endovenous thermal ablation and after high ligation and stripping. Preventing recurrence remains a challenge, but is not possible in all cases.

Alarmingly high rates of groin recurrence following endovenous laser therapy
Achim Mumme (Germany)
The socioeconomic importance of groin recurrence is growing. Treatment costs per year in Germany accounts for 64 million Euros and 15% is due to varicose vein surgery. The residual stump can be seen as a technical error, but groin recurrence due to neovascularization occurs in spite of a correctly performed crossectomy. Residual stump is the main cause of groin recurrences. In the LaVaCro study (n=1090), neovascularization was rare following a correctly performed crossectomy. The time between an asymptomatic interval and clinically visible groin recurrence can be 7 to 14 years. Most of the randomized control trials with 5-year follow-ups showed higher rates (5% to 50%) of groin recurrence compared with high ligation crossectomy. In conclusion, alarmingly high rates of groin recurrence after endovenous laser ablation were documented in the last years, and an endovenous stump is the problem. A possible solution could be adjunctive crossectomy or endovenous crossectomy.

Primary saphenous stump closure – lessons learned from “0 level” saphenous ostial ablation
Juris Riss (Latvia)
Juris Riss discussed the question of whether it is a problem to close at 0 level and which method is the best (crossectomy, radiofrequency, laser, nonthermal). The distance study is a prospective, randomized single-center study comparing initial, mid-term, and long-term results after endovenous laser ablation for an insufficient great saphenous vein. Patients were randomized to two groups: (i) group 1: the distance for great saphenous vein ablation from the deep vein was 0 cm; and (ii) group 2: the distance for great saphenous vein ablation from the deep vein was 2 cm. There were no severe complications, no deep vein thrombosis, and no pulmonary embolism. However, there was more reflux in the stump and more proximal varicosity and reflux in the anterior accessory saphenous vein in group 2. Patients were equally satisfied with the treatment in both groups. There was a difference according to the venous blood flow at the groin region. Juris Riss suggested obliterating the insufficient vein as close as possible to the deep vein and he emphasized that a longer follow-up is indicated.

Does the choice of the treatment method decrease the recurrence rate?
Marlin Schul (US)
Data on recurrence is difficult due to initial treatment, definition of recurrence, method to define recurrence, and variability in follow-up. The clinical recurrence of varicose veins over 3 to 11 years has been reported to be between 26% and 62%. Pathogenesis of recurrent varicose veins can be due to residual varicose veins, true recurrent varicose veins, or new varicose veins, but the definitions vary between studies. Etiology can be related to inadequate treatment, disease progression, and neovascularization. Treatment of recurrent varicose veins is technically more difficult, as this is a debilitating and costly problem. Patient satisfaction is poorer than after primary intervention. In younger people, reflux progress from segmental to multisegmental is often tributary and nonsaphenous; however, in older people, it is saphenous and more proximal. Of the patients with reflux, 30% have chronic venous disease progression. The 13-year incidence of reflux is 12.7% to 80.9% per year. Today, we know that uncomplicated C2 progresses to C3-C6, and, over 13.4 years, there would be chronic venous disease progression in 57.8% of cases, which is about 4.3% per year. Risk factors for chronic venous disease progression include corona phlebetica, higher BMI, popliteal vein reflux. Of the patients with varicose veins, 31.9% at baseline progressed to chronic venous insufficiency. In an extended 5-year follow-up study of a randomized control study, different treatment methods in 580 limbs were compared. Secondary end points were recurrences and reoperations. There was a 38.6% recurrence after endovenous laser ablation, 18.7% after radiofrequency ablation, 34.6% after surgery, and 31.7% after ultrasound-guided foam sclerotherapy. Marlin Schul concluded that both recurrences and progression occur in chronic venous disease, which is a common problem. Chronic venous disease progression is 4.3% per year and has an identifiable risk. Secondary disease advances faster than primary disease. Technology is advanced for varicose vein treatment, but long-term follow-up is sparse to see if recurrences can be reduced. Marlin Schul finished with the questions of whether early intervention of disease will reduce recurrences and which biomarkers can predict recurrence and progression.

Reflux sources after surgical treatment and endovenous ablation: does accessory saphenous, big tributaries and perforator closure really work in the varicose vein recurrence prevention?
Marianne de Maeseneer (Belgium)
Marianne de Maeseneer postulated that, if clinically relevant, the superficial venous system should be treated in patients with reflux-type postthrombotic syndrome. Ablation is recommended in case of an incompetent great saphenous vein, small saphenous vein, anterior accessory saphenous veins, posterior accessory saphenous veins, and Giacomini vein, as well as to treat tributaries and use compression treatment for residual deep venous reflux. In obstructive postthrombotic syndrome ± reflux in the superficial venous system should not be treated; compression treatment is the most important. In patients with (sub)total obstruction of the femoral and/or popliteal vein, collateral circulation through the great saphenous vein is established with a large-caliber great saphenous vein, spontaneous antegrade flow, but no reflux. If there is a combination of collateral circulation and reflux, refluxing tributaries should be treated in addition to compression treatment. In case of partial obstruction of the femoral and/or popliteal vein, collateral function of the great saphenous vein should be assessed with duplex ultrasound and the role of the profund a should be evaluated. There could be ipsilateral or contralateral reflux in the great saphenous vein and varicose tributaries. In these cases, the superficial venous system should be treated by ablating the incompetent great saphenous vein (distally from the collateral circulation), treating the tributaries, and using compression treatment. The take-home message was that, in reflux-type postthrombotic syndrome, the superficial venous system may be treated in case of reflux (symptoms and clinical signs). In obstructive postthrombotic syndrome, the superficial venous system should be evaluated very carefully as well as potential collateral function. In treating obstructive postthrombotic syndrome with reflux, the superficial venous system should be treated “a la carte.”

Long term (20 years) results of preventive and venopreserving operations
Evgeny Shaydakov (Russia)
Pathogenesis of primary chronic venous disease is due to activation of the endothelium, release of inflammatory mediators, activation and recruitment of neutrophils, recruitment of T lymphocytes, and vein wall injury. Retrograde blood flow and venous hypertension on the background of congenital anomalies of the vein wall are the main links in the pathogenesis of chronic venous disease. Chronic venous disease is characterized by progressively worsening symptoms, suggesting the necessity of early treatment to prevent severe hemodynamic disturbances and skin changes.

Evgeny Shaydakov presented the results of a study on 106 patients with endothelial dysfunction, especially in C1-C2 patients. A high level of endothelemia is an indicator for the early stages of varicose transformation of superficial veins. It may be possible to predict the development of varicose veins, elaborate preventive conservative management, and perform early preventive and vein-preserving procedures. Today, the prevention of primary chronic venous disease progression consists of surgery on various tributaries, hemodynamic correction, elimination of hemodynamic overload of the deep axial veins, anti-inflammatory therapy, venotonic drugs, and risk factor elimination. Unfavorable sequelae of great saphenous vein elimination are the increased hemodynamic challenge of the deep veins, impairment in the physiologic skin blood outflow, and loss of a conduit for possible vascular interventions.

Evgeny Shaydakov discussed the preventive and vein-sparing procedures in patients with primary chronic venous disease, such as ASVAL (Ambulatory Selective Varices Ablation under Local anesthesia). He presented the types of operations in patients with initial forms of primary chronic venous disease practiced at his center; for example, preventive extravasal correction of great saphenous vein valves and mini-phlebectomies in 37% of the patients. The reported outcomes were good, and, as a result, valvular competency was achieved. Mild symptoms of venous disease after long walking or prolonged standing, which were self-limiting, did not significantly affect quality of life and did not require medical management. There were no recurrent varicose veins; ambulatory status and psychological and emotional status were improved. Outcomes were satisfactory in perforator vein incompetence with segmental varicose veins and poor in axial reflux of the great saphenous vein or small saphenous vein, which required a second surgery. Evgeny Shaydakov summarized by stating that chronic disease can be controlled, but cannot be cured. Early detection and timely treatment can reduce serious consequences of the disease. In chronic disease hemodynamic correction, anti-inflammatory therapy and prevention of neoangiogenesis are important.