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Latest Research on Varicose Veins
     
Br J Surg. 2008 Mar;95(3):294-301.
Randomized clinical trial comparing endovenous laser ablation with surgery for the treatment of primary great saphenous varicose veins.
Darwood RJ, Theivacumar N, Dellagrammaticas D, Mavor AI, Gough MJ.
Leeds Vascular Surgical Institute, The General Infirmary at Leeds, Great George Street, Leeds LS1 3EX, UK. rosie_darwood@btinternet.com

BACKGROUND: Endovenous laser ablation (EVLA) is a minimally invasive technique for treating varicose veins due to truncal vein incompetence. This randomized trial compared EVLA with conventional surgery in patients with primary saphenofemoral and great saphenous vein (GSV) reflux. METHODS: Consecutive consenting patients with symptomatic varicose veins were randomized to EVLA 1 (stepwise laser withdrawal), EVLA 2 (continuous laser withdrawal) or surgery (saphenofemoral ligation, GSV stripping, multiple phlebectomies). Principal outcome measures were abolition of GSV reflux and improvement in Aberdeen Varicose Vein Symptom Score (AVVSS) 3 months after treatment. RESULTS: GSV reflux was abolished in 41 of 42 legs treated with EVLA 1, 26 of 29 following EVLA 2 and 28 of 32 after surgery (P = 0.227). The median (interquartile range, i.q.r.) AVVSS improvement was similar: 9.38 (4.54-14.93) with EVLA 1, 10.26 (5.03-15.03) after EVLA 2 and 8.36 (4.54-13.21) following surgery (P = 0.694). Return to normal activity (median (i.q.r.) 2 (0-7) versus 7 (2-26) days; P = 0.001) and work (4 (2-7) versus 17 (7.25-33.25) days; P = 0.005) was quicker after EVLA by either method. CONCLUSION: Abolition of reflux and improvement in disease-specific quality of life was comparable following both EVLA and surgery. The earlier return to normal activity following EVLA may confer important socioeconomic advantages. Registration number: ISRCTN99270116 (http://www.controlled-trials.com). 2008 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

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Eur J Vasc Endovasc Surg. 2008 Feb 27 [Epub ahead of print]
Mid Term Results of Ultrasound Guided Foam Sclerotherapy for Complicated and Uncomplicated Varicose Veins.
O'Hare JL, Parkin D, Vandenbroeck CP, Earnshaw JJ.
Gloucestershire Royal Hospital, Great Western Road, Gloucester GL1 3NN, UK.

OBJECTIVE: The aim was to describe the results of starting a foam sclerotherapy service, focussing on patients with complicated venous disease. METHODS: Consecutive patients undergoing ultrasound-guided foam sclerotherapy for truncal varicose veins underwent clinical and hand-held Doppler assessment at 2 weeks and venous duplex imaging at 6 months. RESULTS: One hundred and eighty-five truncal veins were treated in 165 patients. A high proportion of veins were complicated (109 CEAP classes 4-6, 76 CEAP 1-3). Ninety-one percent (168) had a single treatment session. After 2 weeks, ninety-three percent (136/147) of the truncal veins appeared occluded on hand-held Doppler examination. Ten percent (15/147) of patients had remaining visible varicosities in the lower leg. After six months, the truncal vein remained occluded in 74% (68/92), was partially occluded in 10% (9/92) and fully patent in 16% (15/92). There was no significant difference in occlusion rates between: primary (45/
60-75%) and recurrent (23/32-72%) veins; CEAP 2-3 (22/30-73%) and CEAP 4-6 (46/62-74%) veins; veins with diameter<7mm (29/38-76%) or >/=7mm (13/23-57%). No patient had evidence of deep vein thrombosis, though nine (10%) had new segmental deep venous reflux compared with pre-treatment scans. CONCLUSION: Foam sclerotherapy was equally effective for complicated and uncomplicated varicose veins.

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Eur J Vasc Endovasc Surg. 2008 Feb 27 [Epub ahead of print]
Obesity and Impaired Venous Function.
van Rij AM, De Alwis CS, Jiang P, Christie RA, Hill GB, Dutton SJ, Thomson IA.
Department of Surgery, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.

OBJECTIVES: The clinical severity of venous disease is often worse in obese patients. The objectives of this study were to compare lower limb venous physiology assessed by air plethysmography in a large group of obese and normal-weight patients; to consider the effect of posture on these measures and on foot vein pressure in a smaller cohort. METHODS: Venous function was assessed using air plethysmography and duplex scanning in 934 consecutive patients presenting for assessment of venous disease. These were grouped into obese or non-obese categories. A smaller group of twenty patients with a range of body weights were randomly selected from a database of patients with varicose veins. Foot vein pressures and femoral vein diameter were measured standing, sitting, lying and ambulating. RESULTS: Venous disease was more clinically severe in the obese limbs (CEAP C5&6 non-obese group 20.5%, obese group 35.4%, p<0.001 chi(2)). Venous reflux was worse in the obese but measures of muscle pump function were better. Residual volumes and fractions were better in the obese (mean residual volume, non-obese 60 SD 36, obese 50 SD 42, p<0.001 t test). In the smaller study group weight correlated with the diameter of the superficial femoral vein (r=0.50), ambulatory venous pressure (r=0.45), venous filling index (r=0.49) and the ejection volume (r=0.38, p<0.05). The foot venous pressure was significantly greater in the obese in all positions. CONCLUSION: The CEAP clinical stage of venous disease is more advanced in obese patients than non-obese patients with comparable anatomical patterns of venous incompetence. This may be the result of raised intra-abdominal pressure reported in previous studies, leading to greater reflux, increased vein diameter and venous pressures.

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J Vasc Surg. 2007 Dec;46 Suppl S:54S-67S.
Primary chronic venous disorders.
Meissner MH, Gloviczki P, Bergan J, Kistner RL, Morrison N, Pannier F, Pappas PJ, Rabe E, Raju S, Villavicencio JL.
Department of Surgery, University of Washington School of Medicine, Seattle 98195, USA. meissner@u.washington.edu

Primary chronic venous disorders, which according to the CEAP classification are those not associated with an identifiable mechanism of venous dysfunction, are among the most common in Western populations. Varicose veins without skin changes are present in about 20% of the population while active ulcers may be present in as many as 0.5%. Primary venous disorders are thought to arise from intrinsic structural and biochemical abnormalities of the vein wall. Advanced cases may be associated with skin changes and ulceration arising from extravasation of macromolecules and red blood cells leading to endothelial cell activation, leukocyte diapedesis, and altered tissue remodeling with intense collagen deposition. Laboratory evaluation of patients with primary venous disorders includes venous duplex ultrasonography performed in the upright position, occasionally supplemented with plethysmography and, when deep venous reconstruction is contemplated, ascending and descending venography. Primary venous disease is most often associated with truncal saphenous insufficiency. Although historically treated with stripping of the saphenous vein and interruption and removal of major tributary and perforating veins, a variety of endovenous techniques are now available to ablate the saphenous veins and have generally been demonstrated to be safe and less morbid than traditional procedures. Sclerotherapy also has an important role in the management of telangiectasias; primary, residual, or recurrent varicosities without connection to incompetent venous trunks; and congenital venous malformations. The introduction of ultrasound guided foam sclerotherapy has broadened potential indications to include treatment of the main saphenous trunks, varicose tributaries, and perforating veins. Surgical repair of incompetent deep venous valves has been reported to be an effective procedure in nonrandomized series, but appropriate case selection is critical to successful outcomes.

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J Vasc Surg. 2007 Dec;46(6):1242-7.
Endovenous 980-nm laser treatment of saphenous veins in a series of 500 patients.
Desmyttère J, Grard C, Wassmer B, Mordon S.
S.E.L. Angéio-Phlébo Interventionnelle, France.

BACKGROUND: In recent years, endovenous laser treatment (ELT) has been proposed to treat incompetent great saphenous veins (GSV). This study reports the long-term outcome of ELT in a series of 500 patients. METHODS: Incompetent GSV segments in 500 patients (436 women, 64 men) with a mean age of 52.6 years (range, 19 to 83 years) were treated with intraluminal ELT using a 980-nm diode laser (Pharaon, Osyris, France). The GSV diameter was measured by Duplex examination in an upright position in different GSV segments (1.5 cm below the saphenofemoral junction, crural segment, condylar segment, and sural segment). These measurements were used to determine the optimal linear endovenous energy density (LEED) for each segment. During treatment, patients were maintained in the Trendelenburg position. Patients were evaluated clinically and by duplex scanning at 1 and 8 days, 1 and 6 months, and at 1, 2, 3, and 4 years to assess treatment efficacy and adverse reactions. RESULTS: A total of 511 GSVs were treated. The mean diameter was 7.5 mm (range, 2.4 to 15.0). The LEED was tuned as a function of the initial GSV diameter measured in the orthostatic position, from 50 J/cm (3 mm) up to 120 J/cm (15 mm). At the 1-week follow-up, 9.3% of the patients reported moderate pain. In the immediate postoperative period, the closure rate was 98.0% and remained constant during the 4-year follow-up to reach 97.1%. After 1 year, a complete disappearance of the GSV or minimal residual fibrous cord was noted. Major complications have not been detected; in particular, no deep venous thrombosis. Ecchymoses were seen in 60%, transitory paresthesia was observed in 7%. There was no dyschromia, superficial burns, thrombophlebitis, or palpable indurations. Complementary phlebectomy was done in 98% of patients. Failures occurred only in large veins (saphenofemoral junction diameter >1.1 cm or for GSV truncular diameter >0.8 cm) CONCLUSION: ELT of the incompetent GSV with a 980-nm diode laser appears to be an extremely safe technique, particularly when the energy applied is calculated as a function of the GSV diameter. It is associated with only minor effects. Currently, ELT has become the method of choice for treating superficial veins and has almost replaced the treatment of traditional ligation and stripping.

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Phlebology. 2007;22(5):219-22.
Catheter-directed foam sclerotherapy of axial saphenous reflux: early results.
Kölbel T, Hinchliffe RJ, Lindblad B.
Department of Vascular Diseases, University Hospital MAS, Malmö, Sweden. tilo.kolbel@skane.se

OBJECTIVES: Foam sclerotherapy of the great saphenous vein is a relatively new and promising treatment option for patients with axial reflux. Its usefulness may be limited by low primary occlusion rates. We present a standard technique for catheter-directed foam sclerotherapy, which facilitates foam delivery precisely to its intended site of action and potentially improves occlusion rates. METHODS: A consecutive series of 53 patients were treated with foam sclerotherapy using a standard technique for foam delivery at Malmö University Hospital between September 2006 and April 2007. Patients were treated with 3% polidocanol foam through an introducer sheath, which was inserted percutaneously over a guidewire in the great saphenous vein (GSV). All successfully treated patients were examined by colour duplex one week after the procedure. RESULTS: Primary technical success with delivery of foam along the length of the GSV was achieved in 50 of 53 limbs (94%). All treated GSVs were
occluded at one week duplex. CONCLUSION: The use of an endovascular sheath inserted percutaneously over a guidewire under duplex ultrasound control is feasible in most patients and has resulted in high primary occlusion rates.

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Minerva Cardioangiol. 2007 Dec;55(6):741-53.
Effectiveness of mesoglycan in patients with previous deep venous thrombosis and chronic venous insufficiency.
Andreozzi GM.
Angiology Care Unit, University Hospital of Padua, Padua, Italy gm.andreozzi@angio-pd.it.

AIM: Retrospective analysis of mesoglycan therapeutic activity in venous disorders. The clinical data have been selected from the outpatient database of the Chair of Angiology of the University of Catania (from 1988 to 1997) through a cross survey between the prescription commercial name of mesoglycan and the key words varicose veins, deep venous thrombosis (DVT), chronic venous insufficiency (CVI), post-thrombotic syndrome (PTS), venous thrombosis, venous ulcer. METHODS: Patients have been selected on the basis of definite data relative to principal diagnosis, clinical history, clinical and instrumental objective phlebological picture, posology and duration of treatment, follow-up visits in the first three years following the first observation. Group 1: 56 patients with first episode DVT; Group 2: 27 patients with recurrent DVT; Group 3: 182 patients with CVI (107 with primitive CVI and 75 with secondary CVI). The selected patients data have been included in new databases. DVT patients were evaluated for recurrence prevalence during the follow-up period (6, 12, 18, 24, 30 and 36 months). In Group 2 the recurrence prevalence in the normal follow-up period was evaluated and, in addition, the clinical chronology of the recurrence previous to observation was drawn, in order to find out the recurrence prevalence of the thrombotic episode preceding our observation. The two prevalence trends ( mesoglycan treatment and episode preceding our observation) have been compared with the Student t test. CVI patients (Group 3) were classified according to CEAP classification criteria. The effectiveness of treatment was assessed according to the changes in the scores of venous dysfunction of CEAP classification (disability score; pain; oedema; skin color change; cutaneous ulcer). The mean and standard deviation of the considered scores have been evaluated with the Student t test comparing each series with the immediately previous series and with the T0 series. The mean dose of mesoglycan was 50 mg twice per day. RESULTS: Group 1 (1(st) episode DVT): the recurrence prevalence was 3.5% at 6 months, 9% at 12 months, 12.5% at 18 months, 14.28% at 24, 30 and 36 months. At the end of the 3 follow-up years the PTS diagnosis could be performed in 10 patients (17.85%). Group 2 (recurrent DVT): the recurrence prevalence was 3.7% at 6 months, 11.11% at 12 months, 14.81% at 24 months, 18.51% at 36 months during mesoglycan treatment. In the preceding period the prevalence was 11.11% at 6 months from the preceding episode, 16.66% at 12 months, 33.33% at 24 months and 37.03% at 36 months. In the remaining 62.96% the recurrence occurred at 36 and 48 months. The comparison between the two series showed a significant difference with P < 0.0004. PTS prevalence at the end of the 3 follow-up years was 17.85% in patients with a first episode of DVT and 81.41% in patients with recurrent DVT. Group 3 (CVI): all the venous dysfunction scores showed a significant improvement during the follow-up period, both in comparison with the beginning of treatment and with the immediately preceding control visit. CONCLUSION: The results obtained in groups 1 and 2 show that mesoglycan is effective in preventing thrombotic recurrence in patients with previous DVT. The recurrence prevalence in patients with DVT at 1(st) episode was lower than the prevalence reported by the literature data (17.5% within 2 years and 24.6% within 5 years). The positive trend was also confirmed in the recurrent DVT group, although with a major prevalence (18.51%) due to a higher thrombotic risk. However, the prevalence in the treatment period is significantly lower than the previous thrombotic episode. Mesoglycan was also effective in CVI patients, with a progressive and significant improvement of disability, pain and edema, which are the pathophysiologic elements responsible for the impairment of quality of life. At the various follow-up points the mean score value significantly reduced compared to T0 and to the values of the preceding control. In conclusion mesoglycan is a useful and effective medication in the treatment of venous disorders, both in the subacute phase of DVT and in the long-term therapy for CVI, and is worth more extensive documentation, in accordance with the criteria of evidence-based medicine.

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Eur J Vasc Endovasc Surg. 2007 Nov 5 [Epub ahead of print]
Efficacy and Safety of Great Saphenous Vein Sclerotherapy Using Standardised Polidocanol Foam (ESAF): A Randomised Controlled Multicentre Clinical Trial.
Rabe E, Otto J, Schliephake D, Pannier F.
Department of Dermatology, University of Bonn, Germany.

AIM: To assess the safety and efficacy of sclerotherapy of the great saphenous vein (GSV) comparing standardised polidocanol foam to liquid polidocanol in a randomised controlled trial (RCT). METHODS: A multicentre randomised controlled clinical trial was carried out in which saphenous trunks were treated by sclerotherapy. 106 patients with primary varicose veins due to an incompetent GSV were treated with either standardised 3% polidocanol foam or 3% liquid polidocanol. The primary efficacy criterion was elimination of reflux (<0.5 sec) measured 3cm below the sapheno-femoral junction (SFJ) by duplex ultrasonography 3 months after the last injection. RESULTS: A significantly greater number of patients were successfully treated by foam sclerotherapy resulting in 69% elimination of reflux compared to 27% patients treated with liquid sclerosant. The secondary endpoints of vein occlusion, reflux time, refilling time and patient satisfaction also improved significantly more in the foam group. The mean number of treatment sessions was 1.3 in the foam group compared to 1.6 in the liquid group. Differences between study centres occurred with a mean of 96% reflux elimination in 6 centres versus 39% in 4 other centres. Centres with a high response rate injected a higher mean volume (4.3 vs. 3.6ml) in the first session in a vein with a smaller diameter (7.5mm vs. 8.4mm). No difference in adverse drug reactions was observed between treatment groups. CONCLUSIONS: Standardised 3% polidocanol foam is more efficient and equally safe compared to 3% liquid polidocanol for treatment of GSV. In comparison to other studies a relatively small volume was injected into relatively large veins.

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Am Surg. 2007 Oct;73(10):1067-70.
Light-assisted stab phlebectomy: early postoperative experience.
Vardanian AJ, Cao HL, Lawrence PF.
University of California Los Angeles, Division of Vascular Surgery, Gonda (Goldschmied) Vascular Center, Los Angeles, California, USA.

Light-assisted stab phlebectomy (LASP) is a technique that we have developed for treatment of lower extremity varicose veins. It combines powered and stab phlebectomy with minimally invasive surgical instruments to optimize intraoperative visualization of varicose veins and to remove branch veins with minimal bruising, hematoma, or pain. The early experience with this technique has not been reported. We conducted a retrospective review of all patients who underwent LASP to characterize the associated perioperative experience and to identify postoperative factors that indicated a successful outcome. From 2004 to 2006, LASP was performed on 268 limbs to remove lower extremity branch veins. The majority of patients were women (75%), and the mean age was 52 years. A group of 184 patients underwent LASP in combination with another procedure, and 49 patients underwent LASP alone. Nearly all patients had conscious sedation for anesthesia (99%); operating room time averaged 44 minutes, and blood loss averaged 88 cc. Immediate postoperative complications were infrequent, occurring in 10 per cent of patients, and included unresected or missed veins, hematoma, and cellulitis. LASP provides improved visualization of branch veins and allows varicose veins to be removed with a short operating room time and minor postoperative complications.

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Vascular. 2007 Sep-Oct;15(5):269-72.
Foam sclerotherapy for the treatment of varicose veins.
Bergan J, Cheng V.
Department of Surgery, University of California-San Diego School of Medicine, USA. jbergan@ucsd.edu

Treatment of venous insufficiency with liquid sclerotherapy is considered by some to be an unfulfilled promise. It was heralded in the first half of the last century to be a replacement for surgery, but as recurrences of varicose veins appeared in limbs treated with injection techniques, surgery reappeared and was dominant in the last half of the century. Just as saphenous stripping was proved to be superior to proximal ligation, both were replaced by use of electromagnetic energy, such as radiofrequency and laser venous ablation, as a means of taking the saphenous veins out of the circulation. Now reports of recurrent varices in 20 to 50% of operated cases are making some physicians look to alternatives in treating varicose veins. Foam sclerotherapy must be looked upon as an entirely new method of treatment. It is useful in all types of varices and is proven to be safe, simple, cheap, reliable, and repeatable.

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Vascular. 2007 Sep-Oct;15(5):255-61.
Endovenous radiofrequency ablation for the treatment of varicose veins.
Dietzek AM.
Danbury Hospital Medical Arts Center, CT 06810, USA. Alan.Dietzek@danhosp.org

Chronic venous insufficiency (CVI) is the most common vascular disease and represents a significant health care problem in the United States. Reflux of the great saphenous vein is the most common cause of this condition, whose symptoms include varicose veins, leg swelling, skin discoloration, and ulceration. The traditional treatment of this condition is saphenofemoral ligation with stripping of the saphenous vein followed by varicose vein removal, if necessary. Recent advances in minimally invasive endovenous therapy have led to the development of catheter-based radiofrequency ablation (RFA) of the saphenous vein, which has gained an increasing acceptance in clinical practice. Endovenous RFA was introduced into clinical practice in Europe in 1998 and in the United States in 1999. Since then, over 250,000 procedures have been performed worldwide. Procedure safety and efficacy are well understood, with over 60 publications on the subject in the peer review literature, including four randomized trials comparing this technology with traditional vein stripping surgery. With the advent of tumescent anesthesia, the majority of RFA procedures are now performed in an office setting. This article examines the current technology using RFA in saphenous vein ablation with the Closure catheter system. Procedural techniques and clinical outcome using RFA in saphenous vein ablation are discussed. Clinical data comparing RFA versus saphenous vein stripping are also examined. Lastly, the clinical utility of a new RFA catheter, ClosureFAST, is discussed. ClosureFAST is a new generation of RFA catheter and has exhibited significant improvement in the ease of use and the procedure speed over the previous generation catheters while maintaining the favorable patient recovery profile seen with the RFA technology.

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Vascular. 2007 Sep-Oct;15(5):250-4.
Endovenous laser ablation of varicose veins: review of current technologies and clinical outcome.
Johnson CM, McLafferty RB.
Division of Vascular Surgery, Southern Illinois University, Springfield 62794-9638, USA. cjohnson@siumed.edu

Symptomatic lower extremity varicose veins represent one of the most common vascular conditions in the adult population. Associated symptoms ranged from mild conditions such as fatigue, heaviness, and itching to more serious conditions such as skin discoloration and leg ulceration. The predominant causative factor of this condition is reflux of the great saphenous vein (GSV), which is traditionally treated with surgical saphenofemoral ligation and stripping of the incompetent saphenous vein. In recent years, there have been significant advances in saphenous vein ablation using percutaneous techniques, including the endovenous laser therapy (EVLT). In this article, the authors discuss the therapeutic evolution of this technology, theoretical basis of laser energy in GSV ablation, and procedural techniques of EVLT using duplex ultrasonography. Additional discussion of procedural-related complications, such as deep vein thrombosis, skin burn, saphenous nerve injury, and phletibis, and ecchymosis, are provided. Lastly, clinical results of EVLT in GSV ablation are discussed. Current literatures support EVLT as a safe and effective treatment option for varicosities caused by GSV incompetence.

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Minerva Cardioangiol. 2007 Aug;55(4):443-58.
Radiofrequency minimally invasive endovascular treatment of lower limbs varicose veins: clinical experience and literature review.
Zan S, Contessa L, Varetto G, Barra C, Conforti M, Casella F, Rispoli P.
Unit of Vascular Surgery, S.Giovanni Battista Hospital, University of Turin, Turin, Italy pietro.rispoli@unito.it.

AIM: Varicose veins of the legs are a common condition affecting 10-15% of men and 20-25% of women in the western world. This high prevalence is responsable of high medical and social costs. Most primary varices are associated with greater saphenous vein (GSV) incompetence. A new method, radiofrequency (RF) endovenous obliteration (VNUS-Closure'' procedure), recently has been described as a less invasive and cost-saving alternative to stripping for the treatment of refluxing GSV. METHODS: Twenty-four patients with varicose veins underwent endovenous obliteration of the above knee GSV by VNUS Closure'' procedure. The vein diameters were from 5 to 10 mm. The RF catheter was inserted via percutaneos puncture or through a small skin incision. All operations were performed in local, tumescent anesthesia, under ultrasound guidance. All patients were discharged 2 h after operation. Clinical and ultrasound follow-up was performed at 1 week, and at 1, 6, 12, 24 months. RESULTS: The complete or partial occlusion of the treated segment of the GSV has been achieved in 23 cases. In only one patient persisting patency of the GSV was immediately detected after the procedure. That was successfully treated by ultrasound guided foam sclerotherapy. All patients could resume all normal activities within 3-5 days. Every patient had reduction of varicosities, leg pain, fatigue and oedema. Adverse sequelae were minimal: 2 patients had transient thigh paresthesias. We didn't report deep venous thrombosis or pulmonary embolism (mean follow-up 26.7 months, range 15-33 months). CONCLUSION: A literature review and the authors'experience reveal that, in absence of significant complications, such as deep vein thrombosis and pulmonary embolism, there are significant advantages in the RF endovascular obliteration of the GSV. In effect, the Closure'' procedure, in selected patients, offers reduced postoperative pain, shorter sick leaves, faster return to normal activities compared with vein stripping, and it appears to be cost-saving for society. The mid-term (36 months) recurrence rates after RF obliteration seem to be similar to the results of the conventional surgical management.

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Br J Surg. 2007 Aug;94(8):925-36.
Systematic review of foam sclerotherapy for varicose veins.
Jia X, Mowatt G, Burr JM, Cassar K, Cook J, Fraser C.
Health Services Research Unit, University of Aberdeen, Aberdeen, UK.

BACKGROUND AND METHOD:: Foam sclerotherapy is a potential treatment for varicose veins. A systematic review was undertaken to assess its safety and efficacy. RESULTS:: Sixty-nine studies were included. The median rates of serious adverse events, including pulmonary embolism and deep vein thrombosis, were less than 1 per cent. The median rate of visual disturbance was 1.4 per cent, headache 4.2 per cent, thrombophlebitis 4.7 per cent, matting/skin staining/pigmentation 17.8 per cent and pain at the site of injection 25.6 per cent. The median rate of complete occlusion of treated veins was 87.0 per cent and for recurrence or development of new veins it was 8.1 per cent. Meta-analysis for complete occlusion suggests that foam sclerotherapy is less effective than surgery (relative risk (RR) 0.86 (95 per cent confidence interval (c.i.) 0.67 to 1.10)) but more effective than liquid sclerotherapy (RR 1.39 (95 per cent c.i. 0.91 to 2.11)), although there was substantial heterogeneity between studies. CONCLUSION:: Serious adverse events associated with foam sclerotherapy are rare. There is insufficient evidence to allow a meaningful comparison of the effectiveness of this treatment with that of other minimally invasive therapies or surgery. Copyright (c) 2007 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

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Eur J Vasc Endovasc Surg. 2007 Aug;34(2):232-5. Epub 2007 May 15.
The use of foam sclerotherapy for varicose veins: a survey of the members of the vascular society of great britain and ireland.
O'Hare JL, Earnshaw JJ.
Gloucestershire Royal Hospital, UK.

OBJECTIVES: The aim was to explore the current experience and practice of vascular surgeons in the United Kingdom and Ireland regarding foam sclerotherapy for varicose veins. METHOD: A postal questionnaire was sent to 609 members of the Vascular Society of Great Britain and Ireland. RESULTS: There were 281 responses (47%). Seventy surgeons (25%) used foam sclerotherapy. Most use it selectively; few (29%) offer it to all patients. It was more likely to be used for recurrent varices (71%), in older patients (61%) and for smaller non-saphenous varices (67%). The majority of surgeons (69%) used sodium tetradecyl sulphate and up to a maximum of 10-12ml of foam. The majority used ultrasound guidance (95%), leg elevation (69%) and direct pressure over the saphenofemoral or saphenopopliteal junction during injection (63%). Eighty per cent used compression bandaging after treatment, usually for 7 days (44%). Ninety percent advised compression stockings, usually Class II (64%) for 14 days (39%). Serious complications were few, but eleven surgeons had seen a deep vein thrombosis, two had seen a patient with a stroke and one a transient ischaemic attack. CONCLUSION: Foam sclerotherapy was used by a quarter of surgeons who replied to the survey. Aspects of technique varied considerably and studies to determine optimal techniques are needed. Serious complications with the technique were rare.

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Ann Vasc Surg. 2007 Jul-Aug;21(4):535-43. Epub 2007 May 18.
Echo-sclerosis hemodynamic conservative: a new technique for varicose vein treatment.
Bernardini E, Piccioli R, De Rango P, Bisacci C, Pagliuca V, Bisacci R.
Interuniversity Center for Research and Education of Phlebology, University of Perugia, Perugia, Italy.

Treatment of venous insufficiency has been revolutionized by introduction of various less invasive procedures. The echo-sclerosis hemodynamic conservative (ESEC) technique is a completely new treatment of varicose veins that combines ultrasound-monitored sclerosis, innovative sclerotherapy findings, and hemodynamic principles. The objective of venous stasis suppression is achieved by the ESEC technique through a conservative and functional approach that preserves venous drainage and saphenous vessel integrity. The technique is efficient, simple, safe, in-office manageable, and easily repeatable, although it obviously requires training and skill. It may be considered as the primary treatment for most varicose patients. Evaluation of long-term results, with regard to comparison with other techniques, should assess cost efficacy from a lifelong point of view.

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Chirurg. 2007 Jul;78(7):620-629.
[Primary varicosis.]
[Article in German]
Noppeney T, Rewerk S, Winkler M, Nüllen H, Schmedt HC.
Zentrum für Gefäßmedizin, Obere Turnstraße 8–10, 90429, Nürnberg, Deutschland, TNoppeney.Nbg@t-online.de.

The classic varicose vein operation still represents the "gold standard" in the operative therapy of varicose veins. The results of this procedure in view of perioperative complications are very good, with the incidence of perioperative deep venous thrombosis varying between 0.05% and 0.1%. Recurrence rates between 6% and 60% are published. However, the true recurrence rate is unknown since an exact definition of recurrent varicosis is still lacking. In recurrent varices it is essential to distinguish between disease progression, including neorevascularisation, and technical errors. Endovascular procedures for elimination of the superficial venous system - radiofrequency obliteration and endovenous laser therapy - meanwhile have established themselves as alternative, minimally invasive procedures. The perioperative complication rate of endovenous procedures is very low and comparable to that of the classic operation. Good results, with occlusion rates of the treated vein around 87% to 93% up to 2 years postoperatively, have been published for both endovenous laser therapy and radiofrequency obliteration. For the latter, 5-year results were published, with occlusion of the treated vein in 87%. Results in the literature for radiofrequency are better documented than for endovenous laser treatment because there are now five prospective randomised trials for the former and most publications for endovenous laser treatment are single-center experiences. The advantage of endovenous procedures, especially radiofrequency obliteration, over the classic operation is the lower rate of perioperative pain and better quality of life. The spectrum of operative treatment methods of the superficial venous system has increased tremendously due to new technical developments. For the surgeon this implies the necessity of informing patients conscientiously about the pros and cons and available results of each procedure, and carefully weighing which methods are at the time best for the patient.

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J Vasc Surg. 2007 Jun 26; [Epub ahead of print]
Randomized trial comparing endovenous laser ablation of the great saphenous vein with high ligation and stripping in patients with varicose veins: Short-term results.
Rasmussen LH, Bjoern L, Lawaetz M, Blemings A, Lawaetz B, Eklof B.
Danish Vein Centre and Surgical Clinic.

BACKGROUND: Endovenous laser (EVL) ablation of the great saphenous vein (GSV) is thought to minimize postoperative morbidity and reduce work loss compared with high ligation and stripping (HL/S). However, the procedures have not previously been compared in a randomized trial with parallel groups where both treatments were performed in tumescent anesthesia on an out-patient basis. METHODS: Patients with varicose veins due to GSV insufficiency were randomized to either EVL (980 nm) or HL/S in tumescent anesthesia. Miniphlebectomies were also performed. Patients were examined preoperatively and at 12 days, and 1, 3, and 6 months postoperatively. Sick leave, time to normal physical activity, pain score, use of analgesics, Aberdeen score, Medical Outcomes Study Short Form-36 quality-of-life score, Venous Clinical Severity Score (VCSS), and complication rates were investigated. The total cost of the procedures, including lost wages and equipment, was calculated. Cost calculations were based on the standard fee for HL/S with the addition of laser equipment and the standard salary and productivity level in Denmark. RESULTS: A follow-up of 6 months was achieved in 121 patients (137 legs). The groups were well matched for patient and GSV characteristics. Two HL/S procedures failed, and three GSVs recanalized in the EVL group. The groups experienced similar improvement in quality-of-life scores and VCSS score at 3 months. Only one patient in the HL/S group had a major complication, a wound infection that was treated successfully with antibiotics. The HL/S and EVL groups did not differ in mean time to resume normal physical activity (7.7 vs 6.9 calendar days) and work (7.6 vs 7.0 calendar days). Postoperative pain and bruising was higher in the HL/S group, but no difference in the use of analgesics was recorded. The total cost of the procedures, including lost wages, was euro3084 ($3948 US) in the HL/S and euro3396 ($4347 US) in the EVL group. CONCLUSIONS: This study suggests that the short-term efficacy and safety of EVL and HL/S are similar. Except for slightly increased postoperative pain and bruising in the HL/S group, no differences were found between the two treatment modalities. The treatments were equally safe and efficient in eliminating GSV reflux, alleviating symptoms and signs of GSV varicosities, and improving quality of life. Long-term outcomes, particularly with respect to recurrence rates, shall be investigated in future studies, including the continuation of the present.

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J Wound Care. 2007 May;16(5):227-30.
Use of topical corticosteroids on chronic leg ulcers.
Hofman D, Moore K, Cooper R, Eagle M, Cooper S.
Leg Ulcer Clinic, Department of Dermatology, Churchill Hospital, Oxford, UK. deborah.hofman@orh.nhs.uk

OBJECTIVE: Topical corticosteroids are widely used in the management of chronic wounds, yet there is little evidence to support this. This pilot study aimed to identify current practice by three specialist nurses and to assess the efficacy of topical corticosteroids. METHOD: Data on healing, pain relief, exudate reduction and control of hypergranulation tissue were collected on 34 patients whose wounds were treated with topical corticosteroids prospectively in three centres over a three-month period. RESULTS: Twenty-seven patients (79%) benefited from the application of topical corticosteroid either in terms of healing, pain relief, exudate reduction or the control of hypergranulation tissue. Two wounds deteriorated and treatment was immediately withdrawn. CONCLUSION: Suppression of inflammation plays an important role in healing and pain relief. Applying topical corticosteroids to the wound can accelerate healing and reduce pain in certain cases. However, careful monitoring is essential as there is a risk of sensitisation with prolonged use as well as a potential increased risk of infection.

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Eur J Vasc Endovasc Surg. 2007 May 16; [Epub ahead of print]
Randomised Trial of Polytetrafluoroethylene Patch Insertion for Recurrent Great Saphenous Varicose Veins.
Winterborn RJ, Earnshaw JJ.
Department of Surgery, Southmead Hospital, Southmead Road, Westbury-on-Trym, Bristol, BS10 5NB, UK.

OBJECTIVES: The aim of this study was to assess the possible value of a polytetrafluoroethylene (PTFE) patch in the treatment of recurrent varicose veins. METHODS: Thirty-one patients (40 legs) with recurrent saphenofemoral junction incompetence were randomised to redo saphenofemoral ligation and great saphenous vein stripping with, or without the insertion of a PTFE patch over the ligated junction. Patients underwent assessment preoperatively, and at 6 weeks, 1 year and 2 years postoperatively with clinical examination, duplex imaging and completion of the Aberdeen Varicose Vein Symptom Severity Score (AVVSSS). RESULTS: A total of 27 patients (32 legs) attended for assessment at 6 weeks, 25 patients (30 legs) at 1 year and 27 patients (32 legs) at 2 years. At 6 weeks, seven legs (22%) had an area of cutaneous numbness; all but one had resolved by 1 year. Four legs (13%) developed a groin infection, which required antibiotics, 2 had a groin haematoma and four had a seroma, all of which resolved spontaneously. The overall complication rate was 35% (11 legs), with no statistically significant difference between the groups. Four of 16 legs without a patch and five of 16 legs with a patch developed neovascularisation at the saphenofemoral junction on duplex imaging by two years postoperatively. Two cases of neovascularisation in the patch group and one in the no patch group directly resulted in clinical recurrence (p=1.0). There was an improvement in patients' AVVSSS two years postoperatively (p<0.03), that was similar in both groups. CONCLUSIONS: In this study, insertion of a PTFE patch did not affect the rate of perioperative complications and it did not appear to contain neovascularisation.

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Curr Treat Options Cardiovasc Med. 2007 Apr;9(2):115-26.
Treatment of chronic venous insufficiency.
Rathbun SW, Kirkpatrick AC.
Department of Medicine, Cardiovascular Section, University of Oklahoma Health Sciences Center, 920 Stanton L. Young Boulevard, WP 3120, Oklahoma City, OK 73104, USA. suman-rathbun@ouhsc.edu.

Chronic venous insufficiency (CVI) results from venous hypertension secondary to superficial or deep venous valvular reflux. Treatment modalities are aimed at reducing venous valvular reflux, thereby inhibiting the ensuing pathologic inflammatory process. Compression therapy using pumps, bandaging, and/or graded compression stockings is the mainstay of treatment for CVI. Compression therapy has been shown to be effective in reducing venous hypertension retarding the development of inflammation and pathologic skin changes. Pharmacologic agents such as diuretics and topical steroid creams reduce swelling and pain short term but offer no long-term treatment advantage. Herbal supplements may reduce the inflammatory response to venous hypertension, but are not licensed by the US Food and Drug Administration, and vary in their efficacy, quality, and safety. However, several randomized controlled trials using the herbal horse chestnut seed extract containing aescin have shown short-term improvement in signs and symptoms of CVI. Endovascular and surgical techniques aimed at treatment of primary and secondary venous valvular reflux have been shown to improve venous hemodynamics promoting healing of venous ulcers and improving quality of life. The newer endovascular treatments of varicose veins using laser, radiofrequency ablation, and chemical foam sclerotherapy show some promise.

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Eur J Vasc Endovasc Surg. 2007 Feb 28; [Epub ahead of print]
Embolisation of Symptomatic Pelvic Veins in Women Presenting with Non-saphenous Varicose Veins of Pelvic Origin—Three-year Follow-up.
Creton D, Hennequin L, Kohler F, Allaert FA.
E.C. Ambroise Pare. Rue Ambroise Pare. 54100 F-Nancy, France.

AIM: To evaluate the clinical results of embolisation of symptomatic, incompetent pelvic veins in women presenting with perineal veins. PATIENTS AND METHODS: Twenty-four women presenting with non-saphenous perineal varicose veins and who experienced pelvic vein syndrome were treated. Symptoms was scored on a visual analogue scale assessing dyspareunia, pelvic and lower limb pain. Lower limb varices were investigated by duplex ultrasonography. Pelvic veins were studied by pelvic vein angiography with simultaneous embolisation of incompetent veins. Ovarian and internal iliac veins were systematically embolised when incompetent. Follow-up assessment of symptoms and varices was carried out at 1, 2 and 3 years. RESULTS: All patients presented with perineal veins, 2 with sciatic vein incompetence and 2 with a perforator of the thigh or buttock. Pelvic venous angiography was performed via right femoral access in 87% of the cases and confirmed the presence of incompetent ovarian and internal iliac veins. The mean number of coils used per vein was 6 and all were successfully embolised. No serious complications were encountered. The mean clinical improvement score was 80%, 77%, 80% and 76% at respectively 45 days, 1, 2 and 3-year follow-up. CONCLUSION: In women of reproductive age, non-saphenous varicose veins associated with pelvic venous incompetence (PVI) should undergo pelvic vein investigation. In this clinical series we achieved a satisfactory improvement in symptoms after 3 years following treatment of incompetent pelvic veins.

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Eur J Vasc Endovasc Surg. 2007 Feb 1; [Epub ahead of print]
Recurrent Varicose Veins Following Surgical Treatment: Our Experience with Five Years Follow-up.
Allegra C, Antignani PL, Carlizza A.
Department of Angiology, S. Giovanni Hospital, Rome, Italy.

OBJECTIVE: To report the 5 year outcome of varicose veins surgery and to establish the factors determining recurrence. STUDY DESIGN: Prospective observational study. MATERIALS AND METHODS: This study reports the outcome in 1326 patients treated in a day surgery centre of an institutional referral centre. Patients were investigated clinically and by colour flow duplex scanning before operation. Treatments used included flush ligation of the sapheno-femoral junction (SFJ) and the sapheno-popliteal junction (SPJ). Incompetence of the great saphenous vein (GSV) and small saphenous vein (SSV) were managed by stripping of these veins. Perforating vein ligation and hook phlebectomy were also used. Patients were evaluated 3 weeks and 5 years following treatment by clinical examination and duplex ultrasonography. RESULTS: 412 patients were excluded from the study because they failed to attend for follow-up or did not wear elastic stockings post-operatively. No residual saphenous truncal reflux was found at the initial assessment 3 weeks following surgery. After 5 years, recurrence of varicose veins occurred in 332 patients out of 1326 (25 %). Recurrences arose at the sapheno-femoral junction in 109 out of 862 patients (13%), at the sapheno-popliteal junction in 39 out of 132 patients (30%), in both saphenous regions 38 out of 107 patients (36%) and in 146 out of 225 subjects (65 %) with secondary varicose veins. CONCLUSION: Varicose veins recurred despite technically correct surgery confirmed on post-operative duplex ultrasonography. The likelihood of recurrence increased in the presence of SSV reflux, perforating vein incompetence and post-thrombotic deep vein incompetence.

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Herz. 2007 Jan;32(1):18-25.
[Varicose veins: disfigurement or disease?]
[Article in German]
Bohler K.
Universitatsklinik fur Dermatologie, Abteilung fur Allgemeine Dermatologie, Medizinische Universitat Wien, Wien, Osterreich.

According to one's subjective appraisal varicose veins will be perceived as more or less disfiguring. About 60% of the population suffer from only minor variants of varicose veins which bear no risk to health. A certain percentage will develop progressive disease with the venous ulcer representing the worst variant of chronic venous insufficiency. As long as there is no progressive disease, therapeutic modalities also account for a superior cosmetic appearance. Endoluminal procedures in particular meet with the claim for a superior treatment result with respect to cosmetic outcome without diminution of efficiency. In case of progressive venous insufficiency appearance is of inferior importance. About 70% of venous ulcers are due to primary varicose veins. Surgery of all accessible superficial refluxing veins is important to prevent recurrence. Compression treatment is highly effective in preventing chronic venous insufficiency and in venous ulcer treatment. About 60% of venous ulcers heal within a 24-week treatment period.

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Cochrane Database Syst Rev. 2007 Jan 24;(1):CD001066.
Interventions for varicose veins and leg oedema in pregnancy.
Bamigboye A, Smyth R.

BACKGROUND: Pregnancy is presumed to be a major contributory factor in the increased incidence of varicose veins in women, which can in turn lead to venous insufficiency and leg oedema. The most common symptom of varicose veins and oedema is the substantial pain experienced, as well as night cramps, numbness, tingling, the legs may feel heavy, achy, and possibly be unsightly. Treatment of varicose veins are usually divided into three main groups: surgery, pharmacological and non-pharmacological treatments. Treatments of leg oedema comprise mostly of symptom reduction rather than cure and use pharmacological and non-pharmacological approaches. OBJECTIVES: To assess any form of intervention used to relieve the symptoms associated with varicose veins and leg oedema in pregnancy. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (October 2006). SELECTION CRITERIA: Randomised trials of treatments for varicose veins or leg oedema, or both, in pregnancy. DATA COLLECTION AND ANALYSIS: Both review authors independently assessed trials for eligibility, methodological quality and extracted all data. MAIN RESULTS: Three trials, involving 159 women, were included.Varicose veinsOne trial, involving 69 women, reported that rutoside significantly reduced the symptoms associated with varicose veins (relative risk (RR) 1.89, 95% confidence interval (CI) 1.11 to 3.22). There were no significant differences in side-effects (RR 0.86, 95% CI 0.13 to 5.79) or incidence of deep vein thrombosis (RR 0.17, 95% CI 0.01 to 3.49).OedemaOne trial, involving 35 women, reported no significant difference in lower leg volume when compression stockings were compared against rest (weighted mean difference -258.80, 95% CI -566.91 to 49.31). Another trial, involving 55 women, compared reflexology with rest. Reflexology significantly reduced the symptoms associated with oedema (reduction in symptoms: RR 9.09, 95% CI 1.41 to 58.54). There was no evidence of significant difference in the women's satisfaction and acceptability with either intervention (RR 6.00, 95% CI 0.92 to 39.11). AUTHORS' CONCLUSIONS: Rutosides appear to help relieve the symptoms of varicose veins in late pregnancy. However, this finding is based on one small study (69 women) and there are not enough data presented in the study to assess its safety in pregnancy. It therefore cannot be routinely recommended. Reflexology appears to help improve symptoms for women with leg oedema, but again this is based on one small study (43 women). External compression stockings do not appear to have any advantages in reducing oedema.

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Eur J Vasc Endovasc Surg. 2007 Jan 13; [Epub ahead of print]
Initial Experience in Endovenous Laser Ablation (EVLA) of Varicose Veins Due to Small Saphenous Vein Reflux.
Theivacumar NS, Beale RJ, Mavor AI, Gough MJ.
Leeds Vascular Institute, The General Infirmary at Leeds, Great George Street, Leeds, LS1 3EX, UK.

OBJECTIVE: Conventional surgery for varicose veins due to small saphenous reflux is associated with high recurrence rates (up to 50%), many resulting from inadequate surgery. This prospective audit examines the safety and efficacy of EVLA in the treatment of this. METHOD: 65 patients (68 limbs) with varicosities due to primary or recurrent sapheno-popliteal junction (SPJ) and small saphenous vein (SSV) reflux underwent out-patient EVLA (810nm diode laser). The SSV was ablated from mid-calf to the SPJ. Symptomatic improvement (Aberdeen Varicose Vein Severity Score [AVVSS]), time to return to normal activity, post-EVLA analgesic requirements, and complications were recorded. RESULTS: Duplex ultrasound follow-up (median 6-months) confirmed abolition of SPJ/SSV reflux in all limbs following a median total laser energy delivery of 1131J (IQR 928-1364) at an energy density of 66.3 Joules/cm (IQR 54.2-71.6). AVVSS improved from 15.4 (IQR 11.8-19.7) to 4.6 (IQR 3.2-6.7) at three months (p<0.001). Median analgesia requirement was 3 days (23% [15/65] patients required none) and the median time to normal activity was 0 (0-4) days (65% [42/65] returning to normal daily activity immediately). There were no instances of skin burns or DVT but 3 patients (4.4%) developed transient cutaneous numbness (sural nerve). 98% (64/65) patients would undergo EVLT again. CONCLUSIONS: EVLA abolished SPJ/SSV reflux in all limbs. This is likely to be more effective than conventional surgery, although long-term follow up is required. Data from a randomised control trial would be desirable.

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Eur J Vasc Endovasc Surg. 2007 Jan 12; [Epub ahead of print]
Foam Sclerotherapy Combined with Surgical Treatment for Recurrent Varicose Veins: Short Term Results.
Creton D, Uhl JF.
Denis Creton, EC A Pare, rue A Pare, 54100 F-Nancy, France.

OBJECTIVE: To study the short term results of combined peroperative foam sclerotherapy (PFS) and surgical treatment for recurrent varicose veins. METHODS: PFS was used to treat 129 limbs with recurrent varices: 100 great saphenous (GSV), 29 small saphenous veins (SSV). Foam was prepared with 1% polidocanol mixed with 4 times its volume of air. The 100 GSVs comprised 28 trunks directly connected with the femoral vein, 28 connected to a lymph node venous network, 11 associated with perforators and 33 isolated trunks. The 29 SSVs comprised 4 trunks directly connected to the popliteal vein, 7 isolated trunks, 15 popliteal perforators and 3 recanalisations after SSV stripping. All operations included phlebectomies. In twenty limbs re-ligation of the SFJ and 4 SPJs was carried out. All were performed under local anaesthesia in an ambulatory setting. Patients were assessed clinically and by colour duplex ultrasound after 3 and 40 days follow-up. RESULTS: 120 patients (93%) showed complete obliteration of saphenous trunks, junctions and varices. The 9 incomplete obliterations were 3 venous recanalisations in the SSV compartment and 6 perforators (4 popliteal and 2 femoral). Two asymptomatic deep venous thromboses were detected by colour duplex 3 days after operation. CONCLUSION: PFS facilitates surgical treatment of recurrent varicose veins. There is a small risk of post-operative deep vein thrombosis.

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J Vasc Surg. 2006 Nov;44(5):1118-25.
A systematic review of randomized controlled trials of wound dressings for chronic venous ulcer.
O'Donnell TF Jr, Lau J.
Vascular Service and the Center for Wound Healing, Tufts-New England Medical Center, Boston, MA 02111, USA. todonnell@tufts-nemc.org

OBJECTIVE: To determine whether more "modern" complex wound dressings further improve the healing of venous ulcers over that with simple wound dressings, we conducted a systematic review of randomized controlled trials (RCTs) of wound dressing trials that were published from October 1, 1997, through September 1, 2005. METHODS: We searched MEDLINE, CINAHL, and the Cochrane Controlled Trials Registry Database to identify RCTs. Criteria for ultimate selection included treatment with compression and an objective outcome describing the proportion of wounds healed. Twenty RCTs were identified that satisfied these criteria and were classified into three wound dressing classes: semiocclusive/occlusive group (n = 8), growth factor group (n = 7), and human skin equivalent group (n = 5). RESULTS: Assessment of study design quality for the 20 RCTs showed a low percentage (<49%) of RCTs that incorporated at least 3 of 7 indicators of trial quality, but it seemed better in the 5 RCTs that showed significance for ulcer healing; 4 of the studies used at least 6 of the 7 characteristics of adequate study design. Five (25%) of the 20 RCTs had a statistically significantly improved proportion of ulcers healed in the experimental dressing group over control values: zinc oxide paste bandage (79% vs 56%) and Tegasorb (59% vs 15%) in the semiocclusive/occlusive group and perilesional injection of granulocyte-macrophage colony-stimulating factor (57% vs 19%) and porcine collagen derived from small-intestine submucosa (Oasis; 55% vs 34%) in the growth factor group. In the sole significant RCT from the human skin equivalent group, Apligraf (63%) was superior to Tegapore (48%). Four of these five studies also showed an improved time to complete healing by Kaplan-Meier estimate. CONCLUSIONS: Certain wound dressings can improve both the proportion of ulcers healed and the time to healing over that achieved with adequate compression and a simple wound dressing. The selection of a specific dressing, however, will depend on the dressing characteristics for ease of application, patient comfort, wound drainage absorption, and expense.
  

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