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Varicose Veins Research:
2002-2006
     
Eur J Vasc Endovasc Surg. 2006 Oct 23; [Epub ahead of print]
Outcome of Ultrasound-guided Sclerotherapy for Varicose Veins: Medium-term Results Assessed by Ultrasound Surveillance.
Myers KA, Jolley D, Clough A, Kirwan J.
Melbourne Vascular Ultrasound, Epworth Hospital, Melbourne, Australia.

OBJECTIVE: To estimate medium-term success after a technique for ultrasound-guided sclerotherapy for superficial chronic venous disease. DESIGN: A prospective study in a single unit with ultrasound surveillance after treatment. MATERIALS: Results after 1189 treatment sessions for 807 venous saphenous veins and related tributaries or non-saphenous tributaries in 489 patients. METHODS: Univariate life table analysis determined primary and secondary success rates. Multivariate Cox regression analysis detected covariates that affected outcome. RESULTS: Primary and secondary success rates at 36 months for all veins were 52.4% (95%CI 46-58%) and 76.8% (95%CI 71-82%). Cox regression analysis for primary success for all veins showed significantly worse results for saphenous veins compared to tributaries (HR 3.72 - 95%CI 1.9 to 7.3). Cox regression for all saphenous veins showed independently worse results for patients less than 40 years age (HR 2.16 - 95%CI 1.27-3.66), small compared to great saphenous veins (HR 1.58 - 95%CI 1.11-2.24), veins greater than 6mm diameter compared to smaller veins (HR 2.22 - 95%CI 1.40-3.50), liquid compared to foam sclerotherapy (HR 2.20 - 95%CI 1.28-3.78), lower volumes of sclerosant compared to volumes greater than 12ml (HR 0.51 - 95%CI 0.33-0.81) and highly diluted compared to concentrated sclerosant (HR 2.05 - 95%CI 1.21-3.46) with worse results using highly diluted or undiluted 3% sclerosant compared to a 1.5% concentration. There were no significant differences for primary success for saphenous veins for date of procedure, sex, side, primary or recurrent varicose veins, or commercial type of sclerosant. CONCLUSIONS: Ultrasound-guided sclerotherapy gives satisfactory results if it is accepted that treatment may need to be repeated to achieve secondary success. Results provide a basis for further research to explore factors that might affect outcome. Younger patients with larger diameter saphenous veins may warrant alternative forms of treatment, particularly for small saphenous reflux.

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Cochrane Database Syst Rev. 2006 Oct 18;(4):CD001732.
Injection sclerotherapy for varicose veins.
Tisi PV, Beverley C, Rees A.
Bedford Hospital, Department of Vascular Surgery, Kempston Road, Bedford, Bedfordshire, UK. pvtisi@rcsed.ac.uk

BACKGROUND: Injection sclerotherapy is widely used for superficial varicose veins. The treatment aims to obliterate the lumen of varicose veins or thread veins. There is limited evidence regarding its efficacy. OBJECTIVES: To determine whether sclerotherapy is effective in improving symptoms and cosmetic appearance and has an acceptable complication rate; to define rates of symptomatic or cosmetic varicose vein recurrence following sclerotherapy. SEARCH STRATEGY: We searched the Cochrane Peripheral Vascular Diseases Group trials register (April 2006), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 2, 2006), MEDLINE and EMBASE (both inception to April 2006) and reference lists of articles. Manufacturers of sclerosants were contacted for additional trial information. SELECTION CRITERIA: Randomised controlled trials (RCTs) of injection sclerotherapy versus graduated compression stockings (GCS) or 'observation', or comparing different sclerosants, doses, formulations and post-compression bandaging techniques on people with symptomatic and/or cosmetic varicose veins or thread veins were considered for inclusion in the review. DATA COLLECTION AND ANALYSIS: Data were extracted by authors and Review Group Co-ordinators independently. MAIN RESULTS: Seventeen studies were included. One study comparing sclerotherapy to GCS in pregnancy found that sclerotherapy improved symptoms and cosmetic appearance. Three studies comparing sodium tetradecyl sulphate (STD) to alternative sclerosants found no significant differences in outcome or complication rates; another study found that sclerotherapy with STD led to improved cosmetic appearance compared with polidocanol, although there was no difference in symptoms. Sclerosant plus local anaesthetic reduced the pain from injection (one study) but had no other effects. Two studies compared foam- to conventional sclerotherapy; one found no difference in failure rate or recurrent varicose veins; a second showed short-term benefit from foam in terms of elimination of venous reflux. The recanalisation rate was no different between the two treatments. One study comparing Molefoam and Sorbo pad pressure dressings found no difference in erythema or successful sclerosis. The degree and duration of elastic compression had no significant effect on varicose vein recurrence rates, cosmetic appearance or symptomatic improvement. AUTHORS' CONCLUSIONS: Evidence from RCTs suggests that the choice of sclerosant, dose, formulation (foam versus liquid), local pressure dressing, degree and length of compression have no significant effect on the efficacy of sclerotherapy for varicose veins. The evidence supports the current place of sclerotherapy in modern clinical practice, which is usually limited to treatment of recurrent varicose veins following surgery and thread veins. Surgery versus sclerotherapy is the subject of a further Cochrane Review.

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J Vasc Surg. 2006 Sep;44(3):601-5.
Endovenous ablation of the great saphenous vein may avert phlebectomy for branch varicose veins.
Welch HJ.
Department of Vascular Surgery, Lahey Clinic and Tufts University School of Medicine, MA, USA. harold.j.welch@lahey.org

BACKGROUND: Endovenous ablation of the great saphenous vein (GSV) may be performed simultaneously with stab phlebectomy of branch varicose veins or as a stand-alone procedure. A clinical approach of performing radiofrequency ablation (RFA) alone as initial treatment for varicose veins was reviewed. METHODS: Patients with duplex ultrasound-documented reflux in the GSV and CEAP clinical stage 2 to 6 were selected for RFA. Patients were examined within a week preoperatively with duplex ultrasound imaging. Patients were seen within a week postoperatively and again at 2 to 3 months to ascertain if further treatment was required. A retrospective review of the initial 184 procedures in a series from June 2002 through February 2005 was performed, allowing for a 9-month follow-up period. RESULTS: Three procedures were performed under general anesthesia and 181 with intravenous sedation and tumescent anesthesia. Postoperative duplex scans showed total occlusion or partial patency of <10 cm in 155 limbs. Seven (4.5%) had concomitant stab phlebectomy, seven subsequently had sclerotherapy, and 39 (25.2%) underwent subsequent stab phlebectomy of persistent symptomatic varicosities. In 101 limbs (65.1%), symptoms resolved and had no further therapy, and 24 limbs had a GSV that was patent for >10 cm on postoperative duplex imaging. Nine limbs had no further therapy (37.5%), eight (33.3%) had subsequent stab phlebectomy, and three had stripping of the GSV and stab phlebectomy. Four limbs had a redo RFA, four limbs had an aborted RFA procedure, and one limb was lost to follow-up. Failure of total GSV occlusion was more often associated with use of a 6F catheter. Complications were generally mild, and there was no postoperative deep vein thrombosis. CONCLUSION: Endovenous ablation of the GSV can be performed safely and effectively as the initial treatment for lower extremity varicose veins. Because most patients show clinical improvement after RFA, an algorithm of reassessment of the limb and branch varicose veins several months post-RFA allows most patients to defer stab phlebectomy.

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J Vasc Surg. 2006 Sep;44(3):572-9.
Chronic venous leg ulcers benefit from surgery: long-term results from 173 legs.
Obermayer A, Gostl K, Walli G, Benesch T.
Surgical Department, Wachauklinikum Melk, Melk, Austria. alfred.obermayer@gmx.at

OBJECTIVE: The purpose of this retrospective study was to present 7 years of data from operations of currently active, chronic venous leg ulcers (CEAP: C6), focusing on the short- and long-term effects of healing and recurrence and considering concomitant risk factors. METHODS: Between January 1997 and March 2004, 173 patients (239 legs) with a currently active, chronic venous leg ulcer were surgically treated. The surgical procedures included two main steps: (1) the surgical interruption of reflux in the superficial and perforating veins to reduce venous hypertension in the entire leg and/or the affected area and (2) the surgical procedure involving the ulcer. A total of 123 patients (173 legs) who came to the follow-up were examined. The follow-up period ranged from 3 months to 7 years. The data collection integrated a preoperative examination that included medical history and clinical diagnoses and incorporated measurements such as body mass index, ankle-brachial pressure index, and the neutral position method at the follow-up. The function of the veins was measured with duplex ultrasonography. Finally, the data were analyzed by using various statistical methods, including Kaplan-Meier analysis, Cox regression analysis, and paired t tests. RESULTS: Initially, ulcer healing occurred in 87% of the cases (151 legs). A total of 13% (22 legs) of the venous ulcers never healed, and recurrent venous ulcers occurred in 5% (9 legs). The Kaplan-Meier analyses of ulcer healing showed a healing rate of 85% in 6 months for all legs. The mean time of healing was 1.5 months. Furthermore, the Kaplan-Meier analyses of ulcer recurrence showed a 1.7% rate of recurrence in 6 months for all legs. The 5-year ulcer recurrence rate was 4.6%. The mean time of recurrence was 70.4 months. CONCLUSIONS: On the basis of the results from the 7 years of data from functional surgery of venous leg ulcers and as a result of the outcomes of our study, we recommend surgical treatment of venous leg ulcers at any stage. We therefore conclude that surgery is indicated before an ulcer is intractable to treatment. In general, our findings are based on the understanding and identification of the causes and symptoms of venous ulceration and illustrate that standard surgical methods can be applied for the therapy of venous leg ulcers at any stage.

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Med J Aust. 2006 Aug 21;185(4):199-202.
Treatment of varicose veins by endovenous laser therapy: assessment of results by ultrasound surveillance.
Myers K, Fris R, Jolley D.
Epworth Hospital, Melbourne, Victoria, Australia. kamyers@bigpond.net.au

OBJECTIVE: To assess the efficacy of endovenous laser therapy (EVLT) for treating varicose veins with saphenous reflux. DESIGN: A trial of treatment, with results assessed by ultrasound surveillance. SETTING: Outpatient clinics with sonographer and nursing support. MAIN OUTCOME MEASURES: Control of reflux; occlusion or obliteration of the saphenous veins assessed by ultrasound. RESULTS: EVLT was used to treat 404 veins in 308 patients. Univariate life table analysis showed primary success in 80% (95% CI, 69%-87%) and secondary success after further treatment of recurrent saphenous vein reflux by ultrasound-guided sclerotherapy in 88% (95% CI, 78%-95%) at 3 years. On multivariate Cox regression analysis, none of the covariates studied were associated with ultrasound failure. CONCLUSIONS: Early results indicate that EVLT effectively controlled saphenous reflux. Its advantages are that it is performed as an outpatient procedure under local anaesthesia with immediate mobilisation, causes minimal disruption of activities, and avoids surgical trauma.

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Am Surg. 2006 Aug;72(8):672-5; discussion 675-6.
Endovenous laser ablation of saphenous vein is an effective treatment modality for lower extremity varicose veins.
Kavuturu S, Girishkumar H, Ehrlich F.
Department of Surgery, Bronx Lebanon Hospital Center, Bronx, New York 10457, USA.

We present our first experiences with the use of a new minimally invasive treatment of lower extremity varicose veins. We studied the occlusion rates of the great saphenous vein (GSV) with laser ablation, its failure rates, and its complications. Sixty-six limbs in 62 consecutive patients were treated and followed-up for 1 year. All of the patients had incompetent GSV proven by means of duplex scanning. The GSV segment from 2 cm distal to the sapheno-femoral junction to just above the knee was ablated by using laser energy. In addition, all patients had stab avulsions of the varicose veins of the leg with Crochet hooks. All patients were followed postoperatively on the 3rd day, 1 month, 3 months, and 1 year after surgery. All patients were treated as day-case surgeries. Among 62 patients studied, 46 patients were women (74%) and 16 were men (26%). The median age of the patients was 53 years (range 28-69 years). Median operation time was 65 min (range 40-140 min). Successful treatment (total obliteration of the GSV on duplex) was accomplished in 64 of 66 limbs (97%). In two cases, recanalization of the lower one-third of the treated segment of the GSV was noted after 3 months. There were no instances of neuropathy or skin burn. Endovenous laser ablation of varicose veins is effective in inducing thrombotic vessel occlusion and is associated with only minor adverse effects. The procedure seems to be a promising alternative for surgical stripping of the GSV.

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Cochrane Database Syst Rev. 2006 Jul 19;3:CD001103.
Dressings for healing venous leg ulcers.
Palfreyman SJ, Nelson EA, Lochiel R, Michaels JA.
Northern General Hospital, Academic Vascular Institute, Coleridge House, Herries Road, Sheffield, South Yorkshire, UK S5 7AU. Simon.Palfreyman@sth.nhs.uk

BACKGROUND: Venous leg ulcers, sometimes called varicose or stasis ulcers, are a consequence of damage to the valves in the veins of the legs, leading to raised venous pressure. Venous ulcers are characterised by a cyclical pattern of healing and recurrence. The main treatment is the application of compression, either in the form of compression bandages or hosiery. Dressings are usually applied beneath the compression to aid healing, comfort and to control exudate. Wounds heal quicker in a moist environment and dressings are used to absorb excess fluid or retain fluid in an otherwise dry wound in order to achieve a 'moist wound environment'. There are a large number of dressing products and types available. It is unclear whether particular dressings aid healing of leg ulcers. OBJECTIVES: To assess the effectiveness of wound dressings for the treatment of venous leg ulcers. SEARCH STRATEGY: We searched the Cochrane Wounds Group Specialised Register (April 2006) and CENTRAL (issue 1, 2006) and several other electronic databases (up to April 2005). Manufacturers of dressing products were contacted for unpublished studies. SELECTION CRITERIA: Randomised controlled trials that evaluated dressings for the treatment of venous leg ulcers. There was no restriction in terms of source, date of publication or language. Ulcer healing was the primary endpoint. DATA COLLECTION AND ANALYSIS: Data from eligible studies were extracted and summarised using a data extraction sheet by two authors independently. MAIN RESULTS: 42 randomised controlled studies were identified that met the inclusion criteria. The main dressing types that were evaluated were hydrocolloids (n = 23), foams (n = 6), alginates (n = 4), hydrogel dressings (n = 6) and a group of miscellaneous dressings (n = 3). In none of the comparisons was there evidence that any one dressing type was better than others in terms of number of ulcers healed. Current evidence does not suggest that hydrocolloids are more effective than simple low adherent dressings used beneath compression (9 trials; relative risk for healing with hydrocolloid 1.09 (95% CI 0.89 to 1.34)). For other comparisons there was insufficient evidence. AUTHORS' CONCLUSIONS: The type of dressing applied beneath compression has not been shown to affect ulcer healing. For the majority of dressing types there was insufficient data to allow us to draw strong conclusions except for hydrocolloid compared with a low adherent dressing. The result of the meta-analysis indicate no significant difference in healing rates between hydrocolloid dressings and simple, low-adherent dressings when used beneath compression. Decisions regarding which dressing to apply should be based on local costs of dressings and practitioner or patient preferences.

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Br J Surg. 2006 Jul;93(7):831-5.
Endovenous laser treatment for long saphenous vein incompetence.
Sharif MA, Soong CV, Lau LL, Corvan R, Lee B, Hannon RJ.
Department of Vascular and Endovascular Surgery, Belfast City Hospital, Lisburn Road, Belfast BT9 7AB, UK. aneessharif@yahoo.co.uk

BACKGROUND: Endovenous laser treatment is a percutaneous technique used for the treatment of long saphenous vein (LSV) incompetence. This paper presents the results of an uncontrolled case series undertaken to assess the feasibility, safety and efficacy of this technique. METHODS: Some 145 incompetent LSVs in 136 patients with saphenofemoral reflux were treated with endovenous laser. The data were evaluated prospectively. Assessment was carried out at 1 week, 3 and 12 months for LSV occlusion and symptomatic relief. RESULTS: Primary procedural success was achieved in 124 (85.5 per cent) of 145 LSVs. Reasons for primary failure included failed cannulation, failure to pass the guidewire and patient discomfort. At 3 months' follow-up, 105 (89.7 per cent) of 117 veins were totally and nine (7.7 per cent) were partially occluded. At 12 months, 63 (76 per cent) of 83 veins were totally and 15 (18 per cent) were partially occluded. At this stage 73 (88 per cent) of 83 patients remained satisfied, but 26 (31 per cent) had residual or recurrent varicosities. Of these, only five required further treatment. Complications included saphenous nerve injury in one patient and superficial skin burns in a second. CONCLUSION: Endovenous laser treatment for LSV reflux is safe and can be carried out under local anaesthesia in an outpatient setting with good patient satisfaction and low complication rates. Copyright 2006 British Journal of Surgery Society Ltd.

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Ann Vasc Surg. 2006 Jun 27; [Epub ahead of print]
A Nonrandomised Controlled Trial of Endovenous Laser Therapy and Surgery in the Treatment of Varicose Veins.
Mekako AI, Hatfield J, Bryce J, Lee D, McCollum PT, Chetter I.
Academic Vascular Surgery Unit, Hull Royal Infirmary, Hull, United Kingdom.

Endovenous laser therapy (EVLT) is a minimally invasive treatment for varicose veins. This study compares early quality-of-life (QoL) outcomes following EVLT and surgery. Two nonrandomized groups were studied: an EVLT group with 70 patients, median age 49 (interquartile range [IQR] 35-58) years, and a surgery group with 62 patients, median age 49 (IQR 35-61) years. Patients were assessed prior to and at 1, 6, and 12 weeks following the procedure using the Short Form 36 (SF-36), the Aberdeen Varicose Veins Questionnaire (AVVQ), and the Venous Clinical Severity Score (VCSS). Follow-up at 1, 6, and 12 weeks was 100%, 77%, and 70% following EVLT and 100%, 85%, and 47% following surgery. SF-36 scores were significantly better in the EVLT group at 1 week (Physical Functioning, Role Physical, Bodily Pain, Vitality, and Social Functioning domains) and at 6 weeks (Physical Functioning and Role Physical). At 12 weeks, no significant differences were evident between the groups. AVVQ scores were significantly better in the EVLT group at 6 and 12 weeks. VCSS scores were significantly improved in both groups at 12 weeks. EVLT and surgery provide similar QoL improvements in patients with varicose veins. EVLT, however, removes the QoL limitations experienced by patients in the early postoperative period.

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J Endovasc Ther. 2006 Jun;13(3):357-64.
Effectiveness and safety of ultrasound-guided foam sclerotherapy for recurrent varicose veins: immediate results.
Kakkos SK, Bountouroglou DG, Azzam M, Kalodiki E, Daskalopoulos M, Geroulakos G.
Vascular Unit, Ealing Hospital and Department of Vascular Surgery, Imperial College, London, UK.

PURPOSE: To evaluate the effectiveness and safety of ultrasound-guided foam sclerotherapy in treating recurrent varicose veins. METHODS: Between July 2003 and January 2005, 38 outpatients (25 women; median age 59 years, interquartile range 53.5-66.0) with recurrent varicose veins in 45 legs were treated. Ultrasound was used to identify sites of reflux. The Tessari method was used to produce foam using 3% sodium tetradecyl sulphate; up to 6 mL of foam was injected per session under ultrasound control. Results are shown as median (interquartile range). RESULTS: A single sclerotherapy session was adequate in 26 (58%) legs. In 87% of all legs, complete elimination of both varicose veins and all reflux points was achieved. A positive association between the amount of injected foam and CEAP class (r=0.45, p=0.002) and venous clinical severity score (r=0.37, p=0.012) was found. There was a trend for more sclerotherapy sessions [median 2 (1-2)] in legs with incomplete saphenofemoral junction/ great saphenous vein (GSV) ligation or accessory GSV (n=16) to achieve varicose vein ablation versus legs with other primary sites of reflux [median 1 (1-2), p=0.12]. There were no instances of deep vein thrombosis or systemic complications; superficial thrombophlebitis occurred in 6 (8.2%) of the 73 injection sessions. Legs with proximal reflux due to previous incomplete ligation or fed by an incompetent pelvic vein experienced superficial thrombophlebitis more frequently (4/12, 33%) than legs without proximal reflux [1/33 (3%); OR 16, 95% CI 1.6-164, p=0.014]. CONCLUSION: In most patients, ultrasound-guided foam sclerotherapy is a safe treatment for recurrent varicose veins, with an excellent immediate result. However, the presence of proximal reflux may decrease the immediate results and predispose to superficial thrombophlebitis.

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Semin Vasc Surg. 2006 Jun;19(2):109-15.
Endovascular treatment of varicose veins.
Stirling M, Shortell CK.
Division of Vascular Surgery, Duke University Medical Center, Durham, NC 27710, USA.

Within the past 5 years, radiofrequency ablation and endovenous laser treatment have been introduced as important new endovenous ablative techniques for the minimally invasive treatment of superficial venous reflux and varicose veins. Although sclerotherapy has been a well-established technique for spider telangectasia, recent reports have documented that administration of aerated or foamed sclerosants provides an excellent cost-effective option for treatment of varicose veins. This report reviews the indications for these minimally invasive techniques, the technical aspects of these approaches, and describes in detail the short and long-term success rates. To date, results of minimally invasive therapies are equivalent to or surpass those of surgical vein stripping, while offering dramatically reduced recovery time and complication rates.

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Cir Esp. 2006 Jun;79(6):370-4.
[Classical surgery versus 3-S saphenectomy in the treatment of lower extremity varices]
[Article in Spanish]
Arenas-Ricart J, Selles-Dechent R, Ballester-Ibanez C, Perez-Monreal J, Gonzalez-Vila S, Ruiz-del Castillo J.
Servicio de Cirugia General, Hospital Arnau de Vilanova, Valencia, Espana.

INTRODUCTION: The rate of recurrence requiring redo surgery after primary surgical treatment of varicose veins is between 20 and 30%. Several techniques to reduce the high rate of recurrence after stripping have been designed over the years, especially reticulated recurrences at the sapheno-femoral junction. The aim of this study was to compare the recurrence rates of varices after treatment with two surgical techniques: stripping and 3-S saphenectomy. PATIENTS AND METHOD: One hundred patients with leg varicose veins were randomly assigned to two groups. Group I consisted of 50 patients who underwent classical surgery (ligature and section at the sapheno-femoral junction and collateral veins, with saphenectomy). Group II consisted of 50 patients who underwent the 3-S saphenectomy technique (sclerosis injection at the sapheno-femoral junction with microfoam through a catheter, with saphenectomy and distal phlebectomies). The rate and type of recurrences were evaluated through echo-Doppler 12 months after the procedure. RESULTS: Overall recurrence: group I: 78%, group II: 44% (P< .05). Trunk recurrence: group I 12%, group II 16% (P=NS). Collateral recurrence: group I 16%, group II 6% (P=NS). Perforator vein recurrence: group I 18%, group II 18% (P=NS). Reticulated recurrence: group I 32%, group II 4% (P=.002). CONCLUSIONS: The 3-S saphenectomy technique decreases the overall rate of recurrence, particularly reticulated type recurrences. We recommend avoidance of surgery of the branches at the sapheno-femoral junction.

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Br J Surg. 2006 May 31; [Epub ahead of print]
Ultrasound-guided foam sclerotherapy for the treatment of varicose veins.
Darke SG, Baker SJ.
Vascular Surgery Department, Royal Bournemouth Hospital, Castle Lane East, Bournemouth BH7 7DW, UK.

BACKGROUND:: The aim was to assess the early efficacy and complications of ultrasound-guided foam sclerotherapy (UGFS) in a cohort of patients with varicose veins. METHODS:: Of 192 consecutive patients referred with varicose veins over 15 months, only 11 chose surgery; the rest underwent UGFS treatment. Polidocanol was foamed 1 : 3 with air. Under ultrasound control via butterfly or Seldinger cannulation, 1 per cent foam was injected into superficial veins and 3 per cent foam into saphenous trunks, up to a total volume of 14 ml. Outcome was defined as complete when occlusion of the saphenous trunk and/or over 85 per cent of the varicosities was achieved, and partial closure when less. RESULTS:: In 163 legs, complete occlusion occurred after one intervention, a further 32 after a second, and one after a third (overall 91 per cent). Of the remainder, all other legs achieved partial occlusion after up to three interventions, apart from two legs with great saphenous vein (GSV) incompetence, which failed. All 23 legs with small saphenous veins had complete occlusion after one intervention compared with 64 of 97 legs with GSV incompetence (P < 0.010). Occlusion rates were also higher when the GSV was cannulated directly: 56 of 70 versus 8 of 27 (P < 0.001). CONCLUSIONS:: UGFS achieved early complete occlusion safely in over 90 per cent of legs with varicose veins. Copyright (c) 2006 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

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J Endovasc Ther. 2006 Apr;13(2):244-8.
Endovenous ablation of incompetent saphenous veins: a large single-center experience.
Ravi R, Rodriguez-Lopez JA, Trayler EA, Barrett DA, Ramaiah V, Diethrich EB.
Department of Cardiovascular and Endovascular Surgery, Arizona Heart Institute and Arizona Heart Hospital, Phoenix, Arizona 85006, USA. rravi@azheart.com

PURPOSE: To evaluate the effectiveness of endovenous treatment of symptomatic varicose veins using the endovenous laser (EVL) or radiofrequency (RF) energy over a >3-year follow-up. METHODS: From February 2002 to August 2005, 981 consecutive patients (770 women; mean age 51 years, range 15-90) with symptomatic varicose veins in 1250 lower limbs underwent endovenous ablation of 1149 great saphenous veins (GSV) and 101 small saphenous veins (SSV) under tumescent anesthesia without intravenous sedation or regional anesthesia. There were 990 GSV and 101 SSV procedures using EVL; 159 GSVs were treated with RF energy. An ultrasound evaluation was performed within 2 weeks of the procedure to evaluate occlusion of the vein, wall thickness, and clot extension into the deep venous system. Follow-up from the first 200 procedures in the series included clinical evaluation and duplex ultrasound scanning at 6 and 12 months and annually thereafter. RESULTS: Of the 1149 GSVs treated, 39 (3.4%) recanalizations were seen in 33 of the EVL and 6 of the RF procedures for inadequate treatment as judged by ultrasound. There were 9 (9.0%) failures among the 101 SSVs treated with EVL. Overall, both EVL and RF procedures were well tolerated, with only minor complications. One obese patient with ulcer developed pulmonary embolus on the fourth postoperative day. There were no differences between EVL and RF in efficacy or complications. Follow-up at a mean 3 years (range 30- 42 months) in 143 treated limbs showed no neovascularization in the groin. CONCLUSION: Outcomes with EVL and RF were good, with low complication rates that may be related to the use of local tumescent anesthesia without intravenous sedation.

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Curr Treat Options Cardiovasc Med. 2006 Apr;8(2):97-103.
Current treatment of varicose veins.
Becker F.
Department of Vascular Surgery and Vascular Medicine, University Hospital Jean Minjoz, 03 Boulevard Fleming, Besancon 25030, France. francois.becker@wanadoo.fr.

Varicose veins (VVs) of the lower limbs are a common complaint that can take many forms, ranging from a nonpathologic condition to an invalidating chronic disorder. When they have not been neglected, uncomplicated VVs have often been treated by sclerotherapy or surgery, with variably successful results. Currently, the best way of assessing VVs has been to carry out routine ultrasound investigations. The approach to VVs has changed due to recent awareness of cosmetic considerations and the way they can affect quality of life, as well as the development of new treatments (ie, echo-guided sclerotherapy, foam sclerotherapy, endovascular obliteration) and ambulatory care practices. In some cases, the evolution of the disease can be disconcerting, if not entirely hopeless. However, in most cases, poor results have been obtained because of perfunctory assessment, inappropriate treatment, and lack of follow-up. The treatment of complicated VVs has been improved by combining clinical and ultrasound examinations, which make for a quick, accurate diagnosis, pointing the way to the right treatment. Venous ulcers resulting from primary saphenous vein insufficiency, which account for 50% of all venous ulcers, and recurrent venous ulcers should all be a thing of the past, apart from those associated with deep valvular insufficiency disease. The quality of care and the scientific standard of clinical studies on chronic venous insufficiency and VVs have both increased considerably. Although there is still a need to set up scales for assessing symptoms and quality of life, progress is being made in clinical studies that now meet the standards of evidence-based medicine.

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Vasa. 2006 Feb;35(1):21-6.
Recurrent varicose veins: sonography-based re-examination of 210 patients 14 years after ligation and saphenous vein stripping.
Hartmann K, Klode J, Pfister R, Toussaint M, Weingart I, Waldermann F, Hartmann M.
Phlebologische Gemeinschaftspraxis Hartmann & Partner, Freiburg, Germany. kahartmann@web.de

BACKGROUND: The objective of this study was to assess the frequency of varicose recurrence 14 years after flush ligation of the saphenofemoral (SFJ) or saphenopopliteal (SPJ) junction with additional stripping of the incompetent saphenous vein. PATIENTS AND METHODS: Our study group comprised 245 extremities of 210 patients operated upon in 1990 for either great saphenous vein (GSV) or small saphenous vein (SSV) incompetence. Limbs were assessed with Duplex ultrasound by a practitioner other than the original surgeon and relevant patient data was recorded. RESULTS: In 68.5% of re-examined limbs Duplex imaging provided no evidence for recurrent varicose veins at the former SFJ or SPJ. This included 15 legs (= 6.1%) where reflux immediately proximal to the junction but originating from adjacent veins (i.e. pudendal vein, epigastrical vein) was detected. In 31.5%, reflux from the operated SFJ or SPJ (junctional recurrence) was detected but only a minor percentage of legs (6.9%) had actually developed a clinically relevant recurrent varicosity (> 3 mm in diameter) branching out from the former junction and requiring treatment. Patients with a BMI < 30 were less likely to suffer recurrent varicose veins (no recurrence in 72.7%) than patients with a BMI > or = 30 (no recurrence in 54.5%). CONCLUSIONS: 14 years after flush ligation of the SFJ or SPJ with stripping of the incompetent saphenous vein, junctional recurrences were found in less than one-third of re-examined extremities. In the absence of surgical errors, we must assume neovascularisation as cause for these recurrences. Duplex US determined a clinically relevant recurrence (> 3 mm in diameter) in only 7% of limbs. Post-operative varices seem to develop less often after SPJ surgery than after SFJ surgery and according to our data, obesity (BMI > or = 30) constitutes a significant risk factor.

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Zentralbl Chir. 2006 Feb;131(1):45-50.
[The endovenous laser therapy of varicose veins--substantial innovation or expensive playing?]
[Article in German]
Lahl W, Hofmann B, Jelonek M, Nagel T.
St. Willehad-Hospital, Gefasschirurgische Abteilung, Ansgaristrasse 12, 26382 Wilhelmshaven. wolfgang.lahl@willehad.de

INTRODUCTION: The aim of the study was to evaluate the efficiency of the endovenous use of laser for treatment of varicose veins. In particular the influence of laser energy on the perivenous temperature, the postoperative clinical and duplex ultrasound course was taken into account. METHOD: The patients were divided into two groups. In 33 cases the laser therapy was used without perivenous liquid protection. In 30 cases a 0.9 % NaCl solution has been injected around the vein. The laser used was a 980 nm diode laser (Ceralas D 980, Biolitec AG, Bonn). The pulse-mode procedure has been applied for triggering the laser impulse (1.5 s pulse length, 1.5 s pause with a 3 mm withdrawal of the laser fibre. The laser energy was 15 watt. 20 cm distal to the saphenofemoral or saphenopopliteal junction a thermo unit measured continuously the perivenous temperature. Clinical and duplex ultrasound checks were carried out before and on the day of the operation. Further checks followed on the first and tenth day after the operation and 8 weeks and 6 months afterwards. RESULTS: The perivenous temperature prior to ELT was 31.3 degrees C, then dropping after the injection of the NaCl solution by 3.4 degrees C. During the ELT the temperature rose by 10.0 degrees C without and by 5.5 degrees C with infiltration. The rise in temperature happened only 3 cm before the tip of the laser fibre arrived at the thermo unit and fell quite rapidly. 98 % of the veins showed within the time period of 2 to 14 months an effective occlusion controlled by duplex ultrasound without refluxing segments. All operations were out-patient treatments. The patients were able to take up work after 1 to 7 days. CONCLUSION: The endovenous laser treatment is an innovative method for the treatment of varicose veins. Considering the mid-term subjective and objective outcomes this method can not only compete with the conventional surgery but has proved to be superior as regards the recurrence rate and patient's comfort. The study presented here, did not find a risk of damage to surrounding non-target tissue.

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J Cardiovasc Surg (Torino). 2006 Feb;47(1):9-18.
Venous disorders: treatment with sclerosant foam.
Bergan J, Pascarella L, Mekenas L.
The Vein Institute of La Jolla, La Jolla, CA, USA.
Full article: http://www.minervamedica.it/index2.t?show=R37Y2006N01A0009

AIM: Treatment of venous insufficiency has been revolutionized by introduction of less invasive endovenous procedures. Foam sclerotherapy competes with these for truly minimal less invasive care. The idea of using air and drug in combination is quite old. Orbach described an air block technique using froth in 1944 and in 1993 Cabrera proposed use of a true foam of sodium tetradecyl sulfate or polidocanol to treat varicose veins. When Tessari presented a three-way tap technique in 2000, very good microfoam could be made at a very low cost. Foam can be used in classical sclerotherapy but it is the new indications that excite interest. This report documents experience in treating severe chronic venous insufficiency (CVI), venous angiomata and varicose veins using foam sclerotherapy METHODS: This report describes initial experience in treating 332 patients: 261 patients with varicose veins, 56 patients (77 limbs) with severe CVI, 6 patients with venous angiomata and 9 patients with Klippel-Trenaunay (KT) syndrome. Patients with telangiectasias were also treated but are not a part of this report. A compounding pharmacy supplied the 1-3% polidocanol that was prescribed for each patient according to guidelines on the Food and Drug Administration (FDA) website. Foam was produced by the Tessari technique. Ultrasound guidance was used. Venous access was obtained percutaneously through varices for saphenous vein and variceal closure and through specific targeted veins for treatment of CVI, angiomata and KT syndrome. Deep venous thrombosis (DVT) surveillance was done at 1, 7, 30, and 60 days. Specific perforating vein injection was done only occasionally. Foam volumes varied from 1 to 16 mL for each treatment. RESULTS: Obliteration of varicose and saphenous veins was entirely satisfactory (2.89 treatments/limb). There was no disability down time, no need for analgesics or sedation. Trapped thrombus in large varices required evacuation and caused local pain and cutaneous staining. Treatment goals but not cure were achieved in limbs with angiomata and KT syndrome. Treatment of CVI resulted in rapid, 2-6 weeks, ulcer healing, relief of painful lipodermatosclerosis and dermatitis and some decrease in skin hyperpigmentation. There was one failure in 77 limbs treated for CVI and one case of cutaneous necrosis in one limb treated for CVI and another in a limb treated for angiomata. Other adverse events (5.4%) lasting 3 to 20 min included dry cough (4), occular migraine (2), true migraine (2), other visual disturbances (3), chest tightness (2), panic attack (2), paresthesias (2) myoclonus (1) and cutaneous necrosis (2). DVT (1.8%) was limited to gastrocnemius veins (3 cases) and posterior tibial veins (3 veins). No pulmonary emboli or lung complications occurred. CONCLUSIONS: Treatment of a variety of venous disorders can be accomplished using foam sclerotherapy with results comparable to surgery and with an acceptably low rate of adverse events. These results, however, must be confirmed by larger experience in other institutions.

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J Cardiovasc Surg (Torino). 2006 Feb;47(1):3-8.
Endovenous laser therapy and radiofrequency ablation of saphenous varicose veins.
Pannier F, Rabe E.
Dermatology Clinic and Polyclinic, Rheinischen Friedrich Wilhelms Universita, Bonn, Germany.

Radiofrequency ablation (RFA) and endovenous laser treatment (EVLT) are minimal invasive methods to treat saphenous varicose veins. The short- and mid-term results are excellent with an occlusion rate for RFA of almost 90% after 5 years and about 95% for EVLT after 2 years. Severe side effects are rare in both cases. Prospective randomised comparative studies are available for RFA and surgery showing comparable short-term results and superiority of RFA concerning short-term quality of life outcome. For laser treatment no prospective randomised comparative studies are available. Endovenous treatment is only a part of the complex treatment concept of varicose veins. Insufficient tributaries have to be treated in addition. The fact that the insufficient saphenous vein is treated without high ligation seems not to influence the short-term and mid-term recurrence rates. More prospective randomised comparative studies comparing endovenous treatment and surgery or foam sclerotherapy are necessary to decide which method is the best for which patient.

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Br J Surg. 2006 Feb;93(2):175-81. Comment in: Br J Surg. 2006 Feb;93(2):131-2.
Randomized clinical trial comparing surgery with conservative treatment for uncomplicated varicose veins.
Michaels JA, Brazier JE, Campbell WB, MacIntyre JB, Palfreyman SJ, Ratcliffe J.
Sheffield Vascular Institute, Northern General Hospital, University of Sheffield, Herries Road, Sheffield S5 7AU, UK. j.michaels@shef.ac.uk

BACKGROUND: Surgical treatment of medically uncomplicated varicose veins is common, but its clinical effectiveness remains uncertain. METHODS: A randomized clinical trial was carried out at two large acute National Health Service hospitals in different parts of the UK (Sheffield and Exeter). Some 246 patients were recruited from 536 consecutive referrals to vascular outpatient clinics with uncomplicated varicose veins suitable for surgical treatment. Conservative management, consisting of lifestyle advice, was compared with surgical treatment (flush ligation of sites of reflux, stripping of the long saphenous vein and multiple phlebectomies, as appropriate). Changes in health status were measured using the Short Form (SF) 6D and EuroQol (EQ) 5D, quality of life instruments based on SF-36 and EuroQol, complications of treatment, symptomatic measures, anatomical extent of varicose veins and patient satisfaction. RESULTS: In the first 2 years after treatment there was a significant quality of life benefit for surgery of 0.083 (95 per cent confidence interval (c.i.) 0.005 to 0.16) quality-adjusted life years (QALYs) based on the SF-6D score and 0.13 (95 per cent c.i. 0.016 to 0.25) based on the EQ-5D score. Significant benefits were also seen in symptomatic and anatomical measures. CONCLUSION: Surgical treatment provides symptomatic relief and significant improvements in quality of life in patients referred to secondary care with uncomplicated varicose veins. Copyright (c) 2006 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

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Br J Surg. 2006 Feb;93(2):169-74.
Randomized clinical trial comparing multiple stab incision phlebectomy and transilluminated powered phlebectomy for varicose veins.
Chetter IC, Mylankal KJ, Hughes H, Fitridge R.
Academic Vascular Surgical Unit, Vascular Laboratory, Hull Royal Infirmary, Alderson House, Anlaby Road, Hull HU3 2JZ, UK. ian.chetter@hey.nhs.uk

BACKGROUND: The aim was to compare early postoperative subjective outcome measures in a randomized trial of multiple stab incision phlebectomy (MSIP) and transilluminated powered phlebectomy (TIPP) for the treatment of varicose veins. METHODS: Patients having surgery for varicose veins were randomized to receive either MSIP or TIPP for local avulsion of varicose veins. Operating time, number of incisions and postoperative outcome were analysed in both groups. Quality of life (QoL) was analysed before and 1 and 6 weeks after surgery using domain-specific (Burford pain scale), disease-specific (Aberdeen Varicose Vein Questionnaire) and generic (Short Form 36 and EuroQol 5D) instruments. RESULTS: Sixty-six patients consented to participate in the trial but four withdrew before surgery, so 33 patients underwent MSIP and 29 patients had TIPP. All patients had symptomatic or complicated varicose veins. There was no significant difference between groups in the total duration of surgery or the time taken for the avulsions. The number of incisions was significantly lower with TIPP. However, skin bruising at 1 and 6 weeks, and Burford pain score at 6 weeks were significantly higher in the TIPP group (P < 0.01 for bruising and P = 0.019 for pain). TIPP also had a greater adverse impact on generic QoL, resulting in a more prolonged recovery. CONCLUSION: TIPP had the advantage of fewer surgical incisions, but was associated with more extensive bruising, prolonged pain and reduced early postoperative QoL. Copyright (c) 2006 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

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Eur J Vasc Endovasc Surg. 2006 Jan;31(1):93-100. Epub 2005 Oct 17
Ultrasound-guided Foam Sclerotherapy Combined with Sapheno-femoral Ligation Compared to Surgical Treatment of Varicose Veins: Early Results of a Randomised Controlled Trial.
Bountouroglou DG, Azzam M, Kakkos SK, Pathmarajah M, Young P, Geroulakos G.
Josef Pflug Vascular Laboratory and the Vascular Unit, Ealing Hospital, Department of Vascular Surgery, Imperial College, London, UK.

AIM: This study is a prospective randomised controlled trial comparing sapheno-femoral ligation, great saphenous stripping and multiple avulsions with sapheno-femoral ligation and ultrasound guided foam sclerotherapy to the saphenous vein. Primary end points were patient recovery period and quality of life and secondary end points frequency of complications on the two arms of the trial and the cost of the treatment. MATERIAL AND METHOD: Sixty patients with primary varicose veins due to GSV incompetence and suitable for day case surgery were randomly allocated to undergo ultrasound-guided sclerotherapy with sapheno-femoral ligation under local anaesthesia (n=30) or sapheno-femoral ligation, stripping and multiple avulsions under general anaesthesia (n=30). The study protocol included history, physical examination, assignment of CEAP class and assessment venous clinical severity score (VCSS), completion of the aberdeen vein questionnaire (AVQ) and colour duplex ultrasound. RESULTS: All treatments were completed as intended. Median time to return to normal activities was significantly reduced in the foam sclerotherapy group (2 days) compared to the surgical group (8 days) (p<0.001, Mann-Whitney). AVQ score was also significantly reduced at 3 months by 46% in the sclerotherapy group, and by 40% in the conventional surgery group (p<0.001, Wilcoxon). The time taken to complete treatment was shorter in the foam sclerotherapy plus SFJ ligation group: 45 vs. 85min (p<0.001, Mann-Whitney). The overall cost of the procedure in the sclerotherapy group ( pound672.97) was significantly less compared to conventional surgery ( pound1120.64). At 3 weeks, there was no statistical difference in the complication rate between the two groups. At 3 months, median CEAP class dropped from four pre-operatively to one following treatment in both groups and the median VCSS score dropped from five to one in group one and from seven to three in group two (p<0.001, Wilcoxon test). In group one four patients (13%) had a recanalised vein which needed further sessions of foam sclerotherapy, resulting in a short-term closure rate of 87%. CONCLUSION: Ultrasound guided sclerotherapy combined with sapheno-femoral ligation was less expensive, involved a shorter treatment time and resulted in more rapid recovery compared to sapheno-femoral ligation, saphenous stripping and phlebectomies.

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Ann Vasc Surg. 2006 Jan;20(1):30-34.
Quality of Life after Surgery for Varicose Veins and the Impact of Preoperative Duplex: Results Based on a Randomized Trial.
Blomgren L, Johansson G, Bergqvist D.
Department of Surgery, Capio St. Goran's Hospital, Stockholm, SE-112 81, Sweden, lena.blomgren@telia.com.

In a prospective randomized study, we found that the addition of a preoperative duplex scan before varicose vein (VV) surgery reduced recurrences and reoperations after 2 years. The aim of the present study was to investigate whether this correlates with an improved quality of life (QoL). We studied 293 patients scheduled for VV surgery with or without preoperative duplex. QoL was assessed preoperatively at 1 month, 1 year, and 2 years with the Short Form-36 (SF-36). Scores were compared with matched reference groups from the Swedish population. The 237 complete responders (81%) had a mean age of 47 (range 22-73) years, 169 (71%) were women, and 43 (18%) had skin changes. Both groups of VV patients scored significantly worse than the reference group in the domain Bodily Pain preoperatively (p < 0.001) and better after 1 year (p = 0.04), with no difference found after 2 years. There was no significant difference in QoL between the duplex and control groups at any time. We conclude that preoperative duplex before VV surgery did not significantly improve QoL after 2 years in spite of improved surgical results. VV surgery per se improved QoL as measured with the SF-36.

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Hautarzt. 2005 Dec 16; [Epub ahead of print]
[Sclerotherapy for varicosities.]
[Article in German]
Pannier F, Rabe E.
Klinik und Poliklinik fur Dermatologie der Rheinischen Friedrich-Wilhelms-Universitat Bonn, .

Sclerotherapy is a standard treatment for intradermal varicose veins and branch varicosities. In the treatment of insufficient saphenous veins, crossectomy and stripping used to be the methods of choice. In the last few years good results have also been reported for endovenous methods such as endovenous laser and radio frequency treatment. Sclerotherapy is more effective and even appropriate for larger saphenous veins when the sclerosing liquid is replaced by a foam agent. This cost-effective approach can be done on an outpatient basis without additional anesthesia. Prospective randomized studies are need to confirm the effectiveness.

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Eur J Vasc Endovasc Surg. 2005 Dec 13; [Epub ahead of print]
Transilluminated Powered Phlebectomy: Not Enough Advantages? Review of the Literature.
Scavee V.
Department of Thoracic and Vascular Surgery, Ottignies, Belgium.

BACKGROUND: Recently, new procedures for the treatment of varicose veins have been developed. The purpose of this review is to analyse the data available concerning the transilluminated powered phlebectomy (TIPP). DESIGN: Review of the English literature. RESULTS: The number of studies is limited. Currently, no trial has proven any significant advantage of TIPP technique when compared with conventional surgery, except for the number of surgical incisions. TIPP procedure seems to be shorter than conventional surgery, particularly for the extensive or recurrent varicose veins. CONCLUSIONS: Several questions regarding TIPP technique remain. Further randomised trials are needed to determine the benefit of this procedure.

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Dermatol Surg. 2005 Dec;31(12):1685-94.
Comparison of Endovenous Treatment with an 810 nm Laser versus Conventional Stripping of the Great Saphenous Vein in Patients with Primary Varicose Veins.
Furtado de Medeiros CA, Luccas GC.

background: Patients with varicose veins seek medical assistance for many reasons, including esthetic ones. The development of suitable and more flexible instruments, along with less invasive techniques, enables the establishment of new therapeutic procedures. objective: To compare endovenous great saphenous vein photocoagulation with an 810 nm diode laser and the conventional stripping operation in the same patient. methods: Twenty patients selected for operative treatment of primary great saphenous vein insufficiency on duplex scanning were assigned to a bilateral random comparison. In all cases, both techniques were performed, one on each lower limb. Clinically, evaluation was assessed on the seventh, thirtieth, and sixtieth postoperative days. Patients underwent examination with duplex ultrasonography and air plethysmography during the follow-up. results: Patients who received endovenous photocoagulation presented with the same pain but fewer swellings and less bruising than the stripping side. Most patients indicated that the limb operated on by laser received more benefits than the other. There was only one recanalization and no adverse effects. The venous filling time showed better hemodynamics in both techniques. conclusion: The endovenous great saphenous vein photocoagulation is safe and well tolerated and presents results comparable to those of conventional stripping.

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Br J Surg. 2005 Oct;92(10):1189-94.
Systematic review of endovenous laser treatment for varicose veins.
Mundy L, Merlin TL, Fitridge RA, Hiller JE.
Department of Public Health, University of Adelaide, Adelaide, South Australia, Australia.

BACKGROUND: The safety and effectiveness of endovenous laser treatment (EVLT) for varicose veins are not yet fully evaluated. METHODS: Medical bibliographic databases, the internet and reference lists were searched from January 1966 to September 2004. Only case series were available for inclusion in the review. RESULTS:: Thirteen studies met the inclusion criteria. Self-limiting features, such as pain, ecchymosis, induration and phlebitis, were commonly encountered after treatment. Deep vein thrombosis and incorrect placement of the laser in vessels were uncommon adverse events. No study has yet assessed the effectiveness of laser therapy in comparison to saphenofemoral junction ligation with saphenous vein stripping. Occlusion of the saphenous vein and abolition of venous reflux occurred in 87.9-100 per cent of limbs, with low rates of re-treatment and recanalization. CONCLUSION: From the low-level evidence available it seems that EVLT benefits most patients in the short term, but rates of recanalization, re-treatment, occlusion and reflux may alter with longer follow-up. The lack of such data, in addition to the small numbers of patients in the available studies, demonstrates the need for a randomized clinical trial of EVLT versus conventional surgery.

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Br J Surg. 2005 Sep 20;92(10):1189-1194 [Epub ahead of print]
Systematic review of endovenous laser treatment for varicose veins.
Mundy L, Merlin TL, Fitridge RA, Hiller JE.
Department of Public Health, University of Adelaide, Adelaide, South Australia, Australia.

BACKGROUND:: The safety and effectiveness of endovenous laser treatment (EVLT) for varicose veins are not yet fully evaluated. METHODS:: Medical bibliographic databases, the internet and reference lists were searched from January 1966 to September 2004. Only case series were available for inclusion in the review. RESULTS:: Thirteen studies met the inclusion criteria. Self-limiting features, such as pain, ecchymosis, induration and phlebitis, were commonly encountered after treatment. Deep vein thrombosis and incorrect placement of the laser in vessels were uncommon adverse events. No study has yet assessed the effectiveness of laser therapy in comparison to saphenofemoral junction ligation with saphenous vein stripping. Occlusion of the saphenous vein and abolition of venous reflux occurred in 87.9-100 per cent of limbs, with low rates of re-treatment and recanalization. CONCLUSION:: From the low-level evidence available it seems that EVLT benefits most patients in the short term, but rates of recanalization, re-treatment, occlusion and reflux may alter with longer follow-up. The lack of such data, in addition to the small numbers of patients in the available studies, demonstrates the need for a randomized clinical trial of EVLT versus conventional surgery. Copyright (c) 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

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J Vasc Surg. 2005 Sep;42(3):494-500.
Endovenous laser treatment combined with a surgical strategy for treatment of venous insufficiency in lower extremity:
A report of 208 cases.
Huang Y, Jiang M, Li W, Lu X, Huang X, Lu M.
Department of Vascular Surgery, Ninth People's Hospital, affiliated to Shanghai Second Medical University.

BACKGROUND: We assessed the safety and efficacy of endovenous laser treatment (EVLT) of the saphenous vein combined with a surgical strategy for treatment of deep venous insufficiency in the lower extremity. METHODS: Two hundred thirty venous insufficiencies of the lower limbs in 208 consecutive patients (93 men and 115 women; mean age, 54.15 years) were treated with EVLT combined with surgical strategies. All patients were symptomatic. There were 84 limbs (36.5%) in C(2), 25 (10.9%) in C(3), 109 (47.7%) in C(4), 1 (0.4%) in C(5), and 9 (3.9%) in C(6) (CEAP), and Klippel-Trenaunay syndrome was present in 2 limbs. A total of 119 (51.7%) had perforator vein incompetence. Four therapeutic methods were included in this series according to symptoms, CEAP classification, and venous reflux. Simple EVLT was performed for 15 patients with only great saphenous vein (GSV) incompetence or Klippel-Trenaunay syndrome in 19 lower limbs. EVLT combined with high ligation of the GSV and open ligation of perforators was performed for 5 patients with GSV and perforator incompetence in 5 lower limbs. EVLT was combined with high ligation of the GSV for 76 patients with GSV incompetence in 94 lower limbs. EVLT was combined with external banding of the first femoral venous valve and high ligation of the GSV for 112 patients with primary deep venous insufficiency in 112 lower limbs. All patients were followed up on an outpatient basis for physical examinations and postoperative complaints, and duplex ultrasonography was performed 2 weeks, 6 months, and 1 year after operation. RESULTS: All patients tolerated the procedure well and returned to normal daily activities immediately, achieving a 100% immediate clinical success rate. Spot skin burn injuries occurred in 2 patients (1.0%). Paresthesia in the gaiter area was noted in 15 patients (7.2%). No postprocedural symptomatic deep venous thrombosis or pulmonary embolism occurred. Three patients had local recurrent varicose veins in the calf (1.4%) during a 2- to 27-month follow-up (mean, 6.12 months). Postoperative clinical classes were significantly improved between 2 weeks and 24 months (P = .0001 at 2 weeks and 3 to 18 months; P = .0055 at 24 months compared with before operation), especially in preoperative C(2) to C(3) stage patients, who achieved complete amelioration. CONCLUSIONS: EVLT is a novel minimally invasive treatment with advantages of safety, effectiveness, and simplicity, and it leaves no scars. Its indications can be expanded by combining EVLT with surgical strategies.

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J Cardiovasc Surg (Torino). 2005 Aug;46(4):395-405.
Endovenous laser ablation of varicose veins.
Min RJ, Khilnani NM.
Department of Radiology, Weill Medical College of Cornell University, New York, NY, USA.

Readily available non-invasive diagnostic tests now allow physicians to accurately map out abnormal venous pathways and identify all sources of reflux. Minimally invasive alternatives to surgical removal of incompetent truncal veins have been developed with impressive RESULTS: Endovenous laser treatment can be performed in the office under local anesthesia and is associated with virtually no recovery period. Better understanding of the primary mechanism of energy transfer by direct contact between the laser fiber tip and vein wall has underscored the importance of vein emptying. Improved utilization of tumescent anesthesia has helped facilitate circumferential laser fiber to vein wall contact and virtually eliminated the incidence of heat-related complications. Further refinements in the technique and optimization of laser energy parameters have improved success rates of vein closure from 90% to nearly 100%. Compared to surgery, endovenous laser has also demonstrated lower rates of recurrence largely due to the absence of neovascularity. This review of endovenous laser treatment should validate this exciting technique as a scientifically acceptable option for eliminating truncal vein reflux. If measured by patient acceptance and satisfaction, endovenous laser and other minimally invasive methods have already supplanted traditional surgery as the treatment of choice for superficial venous insufficiency.

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J Vasc Surg. 2005 Aug;42(2):296-303.
The efficacy of a new portable sequential compression device (SCD Express) in preventing venous stasis.
Kakkos SK, Griffin M, Geroulakos G, Nicolaides AN.
Department of Vascular Surgery, Faculty of Medicine, Imperial College, London, United Kingdom.

OBJECTIVE: It has been previously shown that the SCD Response Compression System, by sensing the postcompression refill time of the lower limbs, delivers more compression cycles over time, resulting in as much as a 76% increase in the total volume of blood expelled per hour. Extended indications for pneumatic compression have necessitated the introduction of portable devices. The aim of our study was to test the hemodynamic effectiveness of a new portable sequential compression system (the SCD Express), which has the ability to detect the individual refill time of the two lower limbs separately. METHODS: This was an open, controlled trial with 30 normal volunteers. The new SCD Express was compared with the SCD Response Compression System in the supine and semirecumbent positions. The refilling time sensed by the device was compared with that determined from velocity recordings of the superficial femoral vein using duplex ultrasonography. Baseline and augmented flow velocity and volume flow, including the total volume of blood expelled per hour during compression with the SCD Express, were compared with those produced by the SCD Response compression system in the same volunteers and positions. RESULTS: Both devices significantly increased venous flow velocity as much as 2.26 times baseline in supine position and 2.67 times baseline in semirecumbent position (all P < .001). There was a linear relationship between duplex ultrasonography-derived refill time and the SCD Express-derived refill time in both the supine (r = 0.39, P = .03) and semirecumbent (r = 0.71, P < .001) positions but not with the SCD Response. Refill time measured by the SCD Express device was significantly shorter and the cycle rate higher in comparison with the SCD Response in both positions. The single-cycle flow velocity and volume flow parameters generated by the two devices were similar in both positions. However, median (interquartile range) total volume of blood expelled per hour was slightly higher with the SCD Express device in the supine position (7206 mL/h [range, 5042-8437] vs 6712 mL/h [4941-10,676]; P = .85) and semirecumbent position (4588 mL/h [range, 3721-6252] vs 4262 mL/h [3520-5831]; P = .22). Peak volume of blood expelled per hour by the SCD Express device in the semirecumbent position was significantly increased by 10% in comparison with the SCD Response (P = .03). CONCLUSIONS: Flow velocity and volume flow enhancement by the SCD Response and SCD Express were essentially similar. The latter, a portable device with optional battery power that detects the individual refill time of the lower limbs separately, is anticipated to be associated with improved overall compliance and therefore optimized thromboprophylaxis. Studies testing its potential for improved efficacy in preventing deep vein thrombosis are justified.

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Eur J Vasc Endovasc Surg. 2005 Aug;30(2):198-208
Venous leg ulcer: a meta-analysis of adjunctive therapy with micronized purified flavonoid fraction.
Coleridge-Smith P, Lok C, Ramelet AA.
Department of Surgery, UCL Medical School, The Middlesex Hospital, London WIN 8AA, UK.

OBJECTIVE: To assess the effect of oral treatment with micronized purified flavonoid fraction (MPFF) on leg ulcer healing. DESIGN: Meta-analysis of randomised prospective studies using MPFF in addition to conventional treatment. MATERIALS AND METHODS: Five prospective, randomised, controlled studies in which 723 patients with venous ulcers were treated between 1996 and 2001 were identified. Conventional treatment (compression and local care) in addition to MPFF was compared to conventional treatment plus placebo in two studies (N = 309), or with conventional treatment alone in three studies (N = 414). The primary end point was complete ulcer healing at 6 months. RESULTS: At 6 months, the chance of healing ulcer was 32% better in patients treated with adjunctive MPFF than in those managed by conventional therapy alone (RRR: 32%; CI, 3-70%). This difference was present from month 2 (RRR: 44%; CI, 7-94%), and was associated with a shorter time to healing (16 versus 21 weeks; P = 0.0034). The main benefit of MPFF was present in the subgroup of ulcers between 5 and 10 cm2 in area (RRR: 40%; CI, 6-87%), and those present for 6-12 months duration (RRR: 44%; CI, 6-97%). CONCLUSION: These results confirm that venous ulcer healing is accelerated by MPFF treatment. MPFF might be a useful adjunct to conventional therapy in large and long standing ulcers.

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Dermatol Clin. 2005 Jul;23(3):443-55, vi.
Advances in the treatment of varicose veins: ambulatory phlebectomy, foam sclerotherapy, endovascular laser,
and radiofrequency closure.
Sadick NS.
Department of Dermatology, Weill Medical College of Cornell University, New York, NY 10021, USA. nssderm@sadickdermatology.com

Several recent advances in the treatment of varicose veins have improved the safety, efficacy, comfort, efficiency, and long-term success of therapy. The advances of ambulatory phlebectomy, foam sclerotherapy, endovascular laser, and radiofrequency ablation with closure have made a significant positive impact on patient satisfaction. Duration of treatment and recovery is shorter, discomfort is minimized, and results are generally excellent. Studies assessing long-term outcomes are ongoing, and treatment modalities are continuing to evolve.

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Med Sci Monit. 2005 Jul;11(7):CR337-43. Epub 2005 Jun 29.
Evaluation of two different intermittent pneumatic compression cycle settings in the healing of venous ulcers: a randomized trial.
Nikolovska S, Arsovski A, Damevska K, Gocev G, Pavlova L.
Clinic of Dermatovenerology, University Clinical Centre, Skopje, Macedonia. nikolsk@yahoo.com

BACKGROUND: Intermittent pneumatic compression (IPC) has been successfully used in the treatment of venous ulcers, although the optimal setting of pressure, inflation and deflation times has not yet been established. The aim of this study was to compare the effect of two different combinations of IPC pump settings (rapid vs slow) in the healing of venous ulcers. MATERIAL/METHODS: 104 patients with pure venous ulcers were randomized to receive either rapid IPC or slow IPC for one hour daily. The primary and secondary end points were the complete healing of the reference ulcer and the change in the area of the ulcer over the six months observational period, respectively. RESULTS: Complete healing of the reference ulcer occurred in 45 of the 52 patients treated with rapid IPC, and in 32 of the 52 patients treated with slow IPC. Life table analysis showed that the proportion of ulcers healed at six months was 86% in the group treated with the fast IPC regimen, compared with 61% in the group treated with slow IPC (p=0.003, log-rank test). The mean rate of healing per day in the rapid IPC group was found to be significantly faster compared to the slow IPC group (0.09 cm2 vs 0.04 cm2, p=0.0002). CONCLUSIONS: Treatment with rapid IPC healed venous ulcers more rapidly and in more patients than slow IPC. Both IPC treatments were well tolerated and accepted by the patients.These data suggest that the rapid IPC used in this study is more effective than slow IPC in venous ulcer healing.

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Dermatol Surg. 2005 Jun;31(6):631-5; discussion 635.
Double-blind prospective comparative trial between foamed and liquid polidocanol and sodium tetradecyl sulfate in the treatment of varicose and telangiectatic leg veins.
Rao J, Wildemore JK, Goldman MP.
Dermatology/Cosmetic Laser Associates of La Jolla, Inc., La Jolla, California 92037, USA.

BACKGROUND: Twenty subjects were treated with either polidocanol (POL) or sodium tetradecyl sulfate (STS) to compare the efficacy and adverse sequelae of each agent. OBJECTIVE: To determine the safety and efficacy of two widely used sclerosing agents. METHODS: After the exclusion of saphenofemoral junction incompetency, each subject's leg veins were categorized by size (< 1, 1-3, and 3-6 mm in diameter). Each leg was then randomized to be treated with 0.5%, 1%, or 1% foam of POL or 0.25%, 0.5%, or 0.5% foam of STS according to vein size. An independent panel of four physicians, blinded to treatment, performed randomized photographic evaluations obtained pretreatment and 12 weeks post-treatment. Subject satisfaction index and overall clinical improvement assessment were also obtained. RESULTS: An average 83% improvement was noted for all vein sizes in all subjects with both POL and STS after a single treatment. Subjects were satisfied with treatment, regardless of the sclerosing agent used or the vein size treated. There was no statistically significant difference in adverse effects between each group. CONCLUSION: Both POL and STS are safe and effective sclerosing agents in the treatment of varicose and telangiectatic leg veins. Both are very tolerable and demonstrate similar post-treatment sequelae.

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J Vasc Surg. 2005 Jun;41(6):1018-24; discussion 1025.
The immediate effects of endovenous diode 808-nm laser in the greater saphenous vein: morphologic study and clinical implications.
Corcos L, Dini S, De Anna D, Marangoni O, Ferlaino E, Procacci T, Spina T, Dini M.
Postgraduate School of Vascular Surgery, University of Udine, Italy. corcosleonardo.md@virgilio.it

BACKGROUND: We conducted this study to evaluate the immediate venous morphologic alterations produced in the great saphenous veins by the endovenous diode 808-nm laser used for the treatment of superficial venous insufficiency and varicose veins of the lower limbs and to clarify the clinical implications of the histologic findings. METHODS: Chosen for the study were 24 limbs of 16 patients with CEAP classification 3 to 6, ultrasound-documented greater saphenous insufficiency, and venous diameters between 3.9 mm and 17 mm (mean, 8.04 mm) without phlebitis, saphenous aneurysms, congenital malformations, or deep venous insufficiency. All limbs underwent surgical saphenofemoral disconnection, and the greater saphenous vein was treated with an endovenous diode 808-nm laser by continuous emission at 8 to 12 W and variable retraction speed (</>1 mm/s). Spinal or local, but not tumescent, anesthesia was used. Twenty-nine specimens (3 to 5 cm long) of 24 proximal greater saphenous and five anterior accessory saphenous veins were excised and studied by light microscopy for diameter and thickness of the venous wall, extent of injury into the intima, media, and adventitia, as well as penetration of thermal damage. RESULTS: The histologic evaluation showed thermal injury to the intima in all specimens and full-thickness intimal injury in 22 specimens (75%); the average penetration of thermal injury in 29 specimens was 194.40 microm (range, 10 to 900 microm; 14.61% of the mean wall thickness); complete intimal circumference injury occurred in 8 specimen veins <10 mm in diameter (27.5%), full thickness damage in 6 (20.7%), and perforation in 2 (6.9%). CONCLUSIONS: Saphenous ablation using 808-nm laser by variable retraction speed, combined with saphenofemoral interruption, leads to sufficient vein wall injury to assure venous occlusion. Full thickness thermal injury or perforation is infrequent. Optimal results can be obtained in veins <10 mm in diameter.

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Angiology. 2005 May-Jun;56(3):289-93.
Prevention of edema and flight microangiopathy with Venoruton (HR), (0-[beta-hydroxyethyl]-rutosides) in patients with varicose veins.
Cesarone MR, Belcaro G, Ricci A, Brandolini R, Pellegrini L, Dugall M, Di Renzo A, Vinciguerra G, Gizzi G, Cornelli U, Errichi BM, Corsi M, Ippolito E, Adovasio R, Cacchio M, Stuard S, Larnier C, Candiani C, Cerritelli F.
Vascular Laboratory and San Valentino Vascular Screening Project, Department of Biomedical Sciences, G D'Annunzio University, Chieti-Pescara and Faculty of Motor Sciences, Italy.

The aim of this open study was the evaluation of the effects of HR (Venoruton) at a dose of 1 g/day on the prevention and control of flight microangiopathy and edema in subjects with varicose veins and moderate chronic venous insufficiency flying for more than 11 hours. Patients with varicose veins, edema, but without initial skin alterations or complications, were included. Measurements of skin laser Doppler (LDF) resting flux (RF) venoarteriolar response (VAR), ankle swelling (RAS), and edema were made within 12 hours before and within 3 hours after the flights. The resulting edema after the flights was evaluated with a composite edema score (analogue scale line). A group of 20 subjects was treated with HR (1 g/day, starting 2 days before the flight and 1 g for every 12 hours on day of travel). Another group of 18 subjects formed the control group. The length of the flights was between 11 and 13 hours; all seats were in coach class. Fifty patients were enrolled and 38 patients were evaluable at the end of the trial. The 2 groups (treatment and control) were comparable for age and sex distribution. The decrease in RF was significant in both groups with a higher flux at the end of the flight in the HR group (p < 0.05). The venoarteriolar response was decreased at the end of the flights; the decrease was lower in the HR group (p < 0.05). The increase in RAS and the edema score were significantly lower in the HR group. In conclusion HR is useful for reducing the level of microangiopathy and the increased capillary filtration and in controlling edema in patients with venous disease in long flights. The higher level of flux and VAR and the reduction in edema indicate a positive effect of HR on the microcirculation. This study confirms that HR prophylaxis is effective to control flight microangiopathy associated with edema.

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Tidsskr Nor Laegeforen. 2005 Apr 7;125(7):891-4.
[Venous leg ulcers]
[Article in Norwegian]
Slagsvold CE, Stranden E.
Sirkulasjonsfysiologisk avdeling, Kirurgisk klinikk, Aker universitetssykehus, 0514 Oslo. carlerik.slagsvold@akersykehus.no

Patients with venous leg ulcers usually have extensive symptoms both related to their venous insufficiency and to the wound itself, often combined with a reduced quality of life. Prevalence of venous leg ulcers varies from 0.1 to 1.0%. Treatment costs are high and may amount to 1.5% of a nation's total spending on health care. Venous hypertension is the common denominator for all patients with venous leg ulcers. Isolated superficial as well as deep or combined venous insufficiency with or without insufficient perforators may cause ulceration. In the microcirculation, inflammation is involved, but the exact mechanisms behind the ulcer formation remain unresolved. During the examination, a presence of superficial venous insufficiency accessible for superficial resection must be established. In addition to a clinical examination, venous pressure measurements/plethysmography and colour duplex scanning is recommended in order to locate and evaluate the significance of the venous insufficiency. The key element in the treatment of venous ulcers is to reduce oedema and venous hypertension by adequate compression and elevation. If primary superficial venous insufficiency is established, venous resection is recommended. This may improve healing and reduce recurrences. In selected patients, deep venous reconstruction is an alternative approach.

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Int Angiol. 2005 Mar;24(1):75-9.
Transilluminated powered phlebectomy. Mid-term clinical experience.
Scavee V, Lemaire E, Haxhe JP.
Department of Thoracic and Vascular Surgery, Clinique Saint-Pierre, University Affiliated Hospital Universite Catholique de Louvain (UCL), Ottignies, Belgium.

AIM: Transilluminated powered phlebectomy (TIPP) was first described in 1996 by Sptiz et al. and was designed to allow minimally invasive surgical treatment of varicose veins (VV). We report our updated experience with TIPP technique. METHODS: Between January 2001 and February 2004, 84 patients underwent treatment by TIPP technique for primary symptomatic VV. Saphenofemoral junction with complete stripping of the great saphenous vein was performed in all patients. Incompetent perforating veins was ligated and prominent VV were ablated with TIPP technique. RESULTS: Mean age of patients was 50.6 years (range 29-79 years) and most of patients were women (73%). The major varicose vein risk factors were standing position and parity. Heaviness (62%), pain (57%) and unsightly veins (30%) were the most common indications for surgery. The mean number of surgical incisions was 6 (range 3-10), the average operative time was 59 min (range 30-100 min) and the mean cosmetic score (out of 10) at 6 weeks was 8 (range 2-10). The mean pain score (out of 10) was at 2 days, 7 days and 6 weeks was 5, 3 and 0, respectively. All the complications were documented. CONCLUSIONS: The TIPP technique is safe without any adverse events, presents advantages and inconvenient which are discussed in this paper.

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Khirurgiia (Mosk). 2005;(4):42-4.
[Surgical treatment of initial forms of varicose veins of the lower extremities]
[Article in Russian]
Gavrilenko AV, Vakhrat'ian PE.

Experience in the treatment of 386 patients with stage 2-3 of varicose disease is analyzed. There are five main variants of surgical treatment in these patients: combined phlebectomy, sclero-obliteration of the trunk, short stripping with ligation of insufficient perforant veins, short stripping with excision or destruction of varicose branches, short stripping and sclero-obliteration of the trunk. It is demonstrated that minimally invasive surgical procedures decrease the number of postoperative subcutaneous haematomas, ensure good cosmetic effect, allow to avoid an injury of n.saphenus and lymphorrhea. It is concluded that minimally invasive surgical procedures may be used for treatment of initial forms of varicose disease.

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Khirurgiia (Mosk). 2005;(4):37-41.
[Surgical technologies in the treatment of varicose veins of the lower extremities complicated with trophic ulcer]
[Article in Russian]
Kuznetsov NA, Barinov VE, Teleshov BV, Trepilets VE, Zheltikov AN.

Results of an open randomized study of staged treatment of 94 patients suffering from varicose veins of the lower extremities with open infected trophic ulcers of the shank were analyzed. All the patients were divided into 3 groups depending on the treatment variant. Based on this study, clinical efficacy of early correction of upper vertical venous-venous reflux is substantiated. Efficacy of CO(2) laser application for sanation of trophic venous ulcers and practical importance of their auto-venous plastic reconstruction are demonstrated. Thus, up-to-date technologies provide differential treatment in patients with trophic venous ulcers.

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Eur J Vasc Endovasc Surg. 2005 Apr;29(4):433-9.
Treatment of Primary Varicose Veins by Endovenous Obliteration with the VNUS Closure System: Results of a Prospective
Multicentre Study.
Nicolini P.

Abstract Background Radio frequency obliteration of the saphenous veins has been introduced as a less invasive alternative to traditional surgery for varicose veins. Objective To report the efficacy of obliteration and clinical outcomes following endovenous obliteration of the saphenous vein with limited follow-up to 3 years Materials and methods Radiofrequency obliteration (Closure (R) system, VNUS Medical Technologies, San Jose, CA) was performed in 330 limbs of 294 patients in a prospective worldwide multicentre study with 31 participating sites. Follow-up duplex ultrasound and clinical examinations were performed at annual intervals. The main outcome measures were the completeness of occlusion of the treated vein segment, presence of reflux and presence of signs and symptoms of venous disease. Results Before treatment 3.9% of limbs were categorised as CEAP clinical class zero or one. This improved to 82.9% at 1 year, 83.1% at 2 years and 86.8% at 3 years following treatment. Varicose vein free rates were 1 year: 90.1%, 2 years: 87.2%, 3 years: 88.2%. Duplex ultrasound demonstrated a reflux-free rate of about 88% over 3 years. Total occlusion (TO) of veins was 1 year: 81%, 2 years: 80.4% and 3 years: 75%. Partial occlusion (PO, <5 cm open segment) was 1 year: 6.3%, 2 years: 7.4% and 3 years: 17.6%. Incomplete occlusion (IO, >5 cm open segment) was 1 year: 12.7%, 2 years: 12.2% and 3 years: 7.4%. Partial occlusion did not result in any differences in the symptom severity score, the number of symptom free limbs, or the varicose vein absence rates at any follow-up time point when compared to the total occlusion group. The varicose vein absence rates were significantly lower in the IO group comparing to the TO and PO groups. Conclusions Radiofrequency saphenous vein obliteration improves the symptoms of varicose veins. The reflux-free rates in the treated veins remain constant over a 3 year follow-up period. There is no difference in clinical outcomes between the TO and the PO limbs, suggesting clinical effectiveness of the PO category. Greater than a 5 cm open segment in treated veins poses a risk of recurrence.

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Semin Vasc Surg. 2005 Mar;18(1):49-56.
Severe chronic venous insufficiency: Primary treatment with sclerofoam.
Bergan JJ, Pascarella L.

Venous insufficiency, for practical purposes, can be divided into primary venous insufficiency and chronic venous insufficiency. The latter is characterized by advanced skin changes of hyperpigmentation, edema, ulceration, scarring from healed ulcers or open ulcerations. These are summarized in the CEAP classification as Classes 4, 5 and 6. Pretreatment evaluation is done with a standing ultrasound reflux examination. Thorough mapping of the extremity reflux is desirable. Physiologic tests of venous function, such as plethysmography, are unnecessary. Treatment is directed at closing refluxing axial veins as well as controlling those perforating veins with outward flow. Varicose veins contribute to axial reflux and must be obliterated. Arterial occlusive disease may complicate venous ulceration in as many as 15% of cases. Initial treatment of severe chronic venous insufficiency is usually carried out by controlling the edema with elastic bandaging or nonelastic support, such as the Unna boot or the CircAid dressing. Surgical intervention has been successful but the advent of foam sclerotherapy has proven to be an attractive alternative to surgery and has added a new tool for the treatment of severe chronic venous insufficiency. In this preliminary experience, the results are quite satisfactory and the technique has been shown to be effective, pain-free, inexpensive, with very little morbidity. Guidelines for obtaining sclerosants for use in foam sclerotherapy legally are provided.

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Semin Vasc Surg. 2005 Mar;18(1):41-8.
Superficial vein surgery and SEPS for chronic venous insufficiency.
Puggioni A, Kalra M, Gloviczki P.

Venous insufficiency in its severe forms leads to skin changes which, in turn may be treated by surgical therapy. Interventions are directed towards correction of the underlying abnormal venous physiology. This involves removal of varicose veins and ablation of incompetent axial veins and relevant perforating veins. In performing ablation of saphenous vein reflux, techniques include high ligation with stripping, radiofrequency ablation, endovenous laser therapy, and foam sclerotherapy. Incompetent perforator interruption can be accomplished surgically by subfascial endoscopic perforator surgery (SEPS) or controlled sclerotherapy using ultrasound. A variety of techniques have emerged to manage the varicose veins themselves. Surgical treatment of chronic venous insufficiency with high ligation in the groin and inversion stripping of the great saphenous vein to the knee combined with stab avulsion of varicose veins continues to be the standard in treatment of varicose veins. There are few comparisons of sclerotherapy of perforating veins with SEPS, but SEPS has become the most popular of surgical options.

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Semin Vasc Surg. 2005 Mar;18(1):19-24.
Saphenous ablation: Sclerosant or sclerofoam?
Smith PC.

During the last half of the 20 th century, sclerotherapy as a major treatment of varicose veins came and went. At first, it was widely heralded as a substitute for surgery but after a prospective randomized study by Hobbs, interest in sclerotherapy waned. Just before the turn of the 21 st century, Cabrera published his experience with foamed sclerosant in patients with great saphenous varices and arteriovenous malformations. Cabrera designed his treatment with the specific aim of obliterating the saphenous trunks. His technique consisted of filling the great saphenous vein in the thigh or the small saphenous vein in the calf with foamed sclerosant injected under ultrasound control. His initial report on long-term follow-up revealed that the results were at least comparable to surgery and perhaps somewhat better and his results have been confirmed by others. Investigations into treatment of small vein varices, including telangiectasias, has resulted in the finding that foam results in a 20% improved appearance compared to liquid sclerosant. The most popular sclerosants currently used as foams are polidocanol and sodium tetradecyl sulfate and of the many techniques used in making foams, the technique of Tessari has proven most popular. No randomized clinical trial comparing this technique to surgery has been published; however, the clinical series reports indicate that 80% to 90% of saphenous trunks remain occluded after 3 years when treated by foam sclerotherapy. Complications are seldom encountered but significant skin darkening and superficial thrombophlebitis are common. Temporary vision changes have occurred after foam and liquid sclerotherapy, with foam, these are always transient. Although the long-term efficacy of foamed sclerotherapy treatment is unlikely to be established for years, a number of phlebologists have taken up the practice because it has the advantage of not requiring general or regional anesthesia and takes much less time than equivalent surgical techniques.

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Rofo. 2005 Feb;177(2):179-87.
[Endovenous treatment of primary varicose veins: an effective and safe therapeutic alternative to stripping?]
[Article in German]
Kluner C, Fischer T, Filimonow S, Hamm B, Kroncke T.
Institut fur Radiologie, Charite Universitatsmedizin Berlin, Campus Mitte. claudia.kluner@charite.de

Endovenous laser therapy (EVLT) is a new, minimally invasive therapeutic option for treating primary varicose veins and provides an effective and safe alternative to conventional surgical management (stripping). Short-term and intermediate-term outcome is comparable to surgical stripping in terms of elimination of venous reflux (90 % - 98 %), resolution of visible varices (85 %), and improvement of subjective complaints such as sensations of heaviness and tension (96 %). Complications occur in 1 % - 3 % of cases, which is markedly below the rate of conventional surgical management (up to 30 %). The intermediate-term incidence of recurrent varicosis in a vein treated by EVLT depends on the laser fluence applied and is reported to range from 7 % - 9 % compared to 10 % - 20 % after surgical intervention. Based on a review of the current literature and our own experience, this survey article presents an overview of the indications and contraindications, the technique and pathophysiology of laser-induced venous occlusion, and the results and possible complications of EVLT.

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Curr Vasc Pharmacol. 2005 Jan;3(1):1-9.
Micronized purified flavonoid fraction (MPFF): a review of its pharmacological effects, therapeutic efficacy and benefits in the management of chronic venous insufficiency.
Katsenis K.
Vascular Surgery Dept. of 2nd Surgical Clinic of Athens University, Areteion Hospital, 76 Vas. Sofias Str., 11521 Athens, Greece. katsenis@aretaieion.uoa.gr

Initially, the progression of chronic venous insufficiency is related to venous hypertension. The earliest complaints or symptoms, as well as vessel wall deterioration, valve restructuring, and, eventually, varicose veins, result not only from elevation of pressure, but also from a cascade of biochemical events related to both the macro- and the microcirculation. Thickening and remodelling of the venous wall are influenced by two parameters: abnormal shear stress and hypoxia that activate the endothelium first at the level of valve cusps and then in large veins. Hypoxia leads to activation of the endothelium and leukocyte accumulation. By inhibiting endothelial activation, micronized purified flavonoid fraction (MPFF) (Daflon 500 mg), an edema-protective agent, can prevent the inflammatory cascade resulting from the leukocyte-endothelium interaction. This subsequently delays the appearance of reflux and inhibits the initiation of the vicious circle ending in enhanced venous pressure. This is how Daflon 500 mg relieves patients from symptoms and edema and possibly also prevents the appearance of varicose veins. Rheological disturbances also play a major role in the appearance of these disorders. Furthermore, venous hypertension provokes leakage from the vessels and capillaries exhibiting increased permeability, leading to increases in hydrostatic load, and overloading of the lymphatic network, which subsequently results fluid exudation causing edema. Microcirculatory dysfunction leads to capillary damage, skin changes and venous leg ulcers. The clinical efficacy of Daflon 500 mg in venous leg ulcers has been demonstrated by several randomised controlled studies, in which the rate of ulcer healing was significantly shortened. An explanation for the ability to speed ulcer healing comes from the protection Daflon 500 mg exerts on the microcirculation.

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Surg Today. 2005;35(1):47-51.
Clinical results of radiofrequency endovenous obliteration for varicose veins.
Ogawa T, Hoshino S, Midorikawa H, Sato K.
Cardiovascular Disease Center, Fukushima Daiichi Hospital, 16-2 Kitasawamata Nariide, Fukushima 960-8251, Japan.

PURPOSE: Radiofrequency (RF) endovenous obliteration is performed in the United States and several European countries for the minimally invasive treatment of saphenous-type varicose veins. We evaluated the clinical results of RF endovenous obliteration to treat varicose veins at Fukushima Daiichi Hospital. METHODS: We performed endovenous obliteration of 25 great saphenous varicose veins in 20 patients, under duplex ultrasound guidance. None of the varicose veins were tortuous in the thigh area. Venous occlusion was evaluated by duplex ultrasound under cuff compression with the patient standing, preoperatively, then 1 day and 1 month postoperatively. RESULTS: Saphenous obstruction was confirmed in all legs 1 day and 1 month postoperatively, as complete obstruction from the saphenofemoral junction in 1, as complete obstruction with only superficial epigastric venous flow in 23, and as near complete obstruction (patent length > 5 cm) in 1. The venous obstruction was caused by shrinkage of the vein (31.2% of the area at the saphenofemoral junction, 44% at the thigh, and 57.7% at the knee) and thrombus formation. The only complications of RF endovenous obliteration were clinical superficial thrombophlebitis (13%) and temporal sensory nerve injury (4%). CONCLUSION: Radiofrequency endovenous obliteration is as effective as, but less invasive than other treatments for saphenous varicose veins.

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Dermatol Surg. 2004 Nov;30(11):1386-90.
Microfoam ultrasound-guided sclerotherapy treatment for varicose veins in a subgroup with diameters at the junction of 10 mm or greater compared with a subgroup of less than 10 mm.
Barrett JM, Allen B, Ockelford A, Goldman MP.
Palm Clinic, Auckland, New Zealand. johnbarrett@palmclinic.co.nz

OBJECTIVE: The objective was to analyze the effectiveness of foam ultrasound-guided sclerotherapy treatment in saphenous veins and tributary veins with a diameter at the saphenofemoral or saphenopopliteal junction of > or =10 mm and compare these results with a subgroup of veins with diameters of < 10 mm. METHODS: A subgroup of 17 saphenous veins with a diameter at the saphenofemoral or saphenopopliteal junction of > or =10 mm were compared with a subgroup of 98 saphenous veins with a diameter of < 10 mm at the saphenofemoral or saphenopopliteal junction for clinical efficacy and patient satisfaction at a mean 2-year follow-up. RESULTS: A mean number of 2.15 treatments utilizing an average of 8.37 mL of foam sclerosing solution (3% sodium tetradecyl sulfate) were required to close all incompetent varicose veins in the < 10-mm group versus a mean of 2.8 treatments and 13.9 mL foam (3% sodium tetradecyl sulfate) for the > or =10-mm group. A total of 27.5% of saphenous veins of < 10 mm and 37.5% of saphenous veins > or = 10 mm required a second treatment at 3 months. One-hundred percent of patients believed that their legs were successfully treated at 2-year follow-up in both groups with 94% of the < 10-mm group noting improvements in quality of life and 100% in the > or =10-mm group. CONCLUSIONS: Ultrasound-guided foam sclerotherapy is effective in treating all sizes of varicose veins with high patient satisfaction and improvement in quality of life. Duplex ultrasound findings demonstrated a small increase in failure to close the saphenofemoral or saphenopopliteal junction with increasing size of junction diameter, but this does not significantly alter the results with respect to clearance of visible varicosities and patient satisfaction with results.

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Dermatol Surg. 2004 Nov;30(11):1380-5.
Intravascular 1320-nm laser closure of the great saphenous vein: a 6- to 12-month follow-up study.
Goldman MP, Mauricio M, Rao J.
Dermatology/Cosmetic Laser Associates of La Jolla, Inc., La Jolla, CA 92037, USA. MGoldman@SpaMD.com

OBJECTIVE: The objective was to determine the safety and efficacy of an intravascular laser with a novel wavelength to close the great saphenous vein. METHODS: Twenty-four cases of an incompetent great saphenous vein (0.5-1.2 cm in diameter) associated with distal varicose veins were treated with a 1320-nm intravascular laser at 5 W with an automatic pullback mechanism at 1 mm/s. Patients were evaluated with duplex ultrasound to determine efficacy of treatment at various time periods to at least 6 months after the procedure. RESULTS: All patients demonstrated complete closure of the incompetent great saphenous vein. In most cases, the treated great saphenous vein was not identifiable 6 months postoperatively. There was no recurrence of any varicose veins. All preoperative symptoms resolved after treatment, and no complications were noted. All patients were very pleased with the outcome of the procedure. CONCLUSIONS: At 6 months or greater follow-up, a 5-W, 1320-nm intravascular laser with 1 mm/s automatic pullback, delivered through a diffusion-tip fiber, is safe and effective in treating an incompetent great saphenous vein up to 1.2 cm in diameter.

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Cochrane Database Syst Rev. 2004 Oct 18;(4):CD004980.
Surgery versus sclerotherapy for the treatment of varicose veins.
Rigby K, Palfreyman S, Beverley C, Michaels J.
Sheffield Vascular Institute, Sheffield Teaching Hospitals NHS Trust, Vickers 16, Sheffield, UK.

BACKGROUND: Varicose veins are a relatively common condition and account for around 54,000 in-patient hospital episodes per year. The two most common interventions for varicose veins are surgery and sclerotherapy. However, there is little comparative data regarding their effectiveness. OBJECTIVES: To identify whether the use of surgery or sclerotherapy should be recommended for the management of primary varicose veins. SEARCH STRATEGY: Thirteen electronic bibliographic databases were searched covering biomedical, science, social science, health economic and grey literature (including current research). In addition, the reference lists of relevant articles were checked and various health services research-related resources were consulted via the internet. These included health economics and HTA organisations, guideline producing agencies, generic research and trials registers, and specialist sites. SELECTION CRITERIA: All studies that were described as randomised controlled trials comparing surgery with sclerotherapy for the treatment of primary varicose veins were identified. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted and summarised data from the eligible studies using a data extraction sheet for consistency. All studies were cross-checked independently by the reviewers. MAIN RESULTS: A total of 2306 references were found from our searches, 61 of which were identified as potential trials comparing surgery and sclerotherapy. However, only nine randomised trials, described in a total of 14 separate papers, fulfilled the inclusion criteria. Fifty trials were excluded and one trial is ongoing and is due for completion in 2004. The trials used a variety of outcome measures and classification systems which made direct comparison between trials difficult. However, the trend was for sclerotherapy to be evaluated as significantly better than surgery at one year; after one year (sclerotherapy resulted in worse outcomes) the benefits with sclerotherapy were less, and by three to five years surgery had better outcomes. The data on cost-effectiveness was not adequately reported. REVIEWERS' CONCLUSIONS: There was insufficient evidence to preferentially recommend the use of sclerotherapy or surgery. There needs to be more research that specifically examines both costs and outcomes for surgery and sclerotherapy.

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Surg Clin North Am. 2004 Oct;84(5):1397-417, viii-ix.
New approaches for the treatment of varicose veins.
Teruya TH, Ballard JL.
Division of Vascular Surgery, Loma Linda University, 11175 Campus Street, Loma Linda, CA 92354, USA.

New, minimally invasive techniques for the treatment of varicose veins including radiofrequency ablation (RFA), endovenous laser therapy (EVLT), and transilluminated power phlebectomy (TIPP) represent effective and possibly superior alternatives to traditional saphenous vein stripping and stab avulsion of varicose veins.Further experience with these procedures will help to determine which ones will become the method of choice for treating this complex disease process. Some of these new techniques may not prove to be effective in the hands of all treating specialists. However,it is very likely that some of these techniques, such as foam sclerotherapy and RFA, will replace the procedures that we currently use today.

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J Vasc Surg. 2004 Oct;40(4):634-9.
Causes of varicose vein recurrence: late results of a randomized controlled trial of stripping the long saphenous vein.
Winterborn RJ, Foy C, Earnshaw JJ.
Department of Vascular Surgery, Gloucestershire Royal Hospital, United Kingdom.

BACKGROUND: The purpose of this study was to investigate the long-term outcomes following stripping of the long saphenous vein during primary varicose vein surgery and to identify factors which may predict recurrence and the need for reoperation. METHODS: The original study was designed as a randomized trial of 100 patients (133 legs) who underwent saphenofemoral ligation with or without long saphenous vein stripping. After invitation 11 years later, 51 patients (74 legs) underwent clinical review and duplex imaging and completed an Aberdeen Varicose Vein Symptom Severity Score (AVVSSS). The hospital notes of the original cohort of patients were used to compile cumulative data and assess predictive factors. RESULTS: A cumulative total of 83 legs had developed clinically recurrent varicose veins by 11 years (62%). There was no statistically significant difference between the ligation-only and the stripping groups. Reoperation was required for 20 of 69 legs that underwent ligation alone compared with 7 of 64 legs that had additional long saphenous vein stripping (relative risk [RR], 2.65; 95% confidence interval, 1.20 to 5.84; P = .012). By life table analysis, freedom from reoperation at 11 years was 70% after ligation, compared with 86% after stripping ( P = .01). The presence of neovascularization (RR, 2.88; P = .15) , an incompetent superficial vessel in the thigh (RR, 3.24; P = .03) or an incompetent saphenofemoral junction on duplex imaging at 2 years postoperatively (RR, 4.89; P = .0001) increased the risk of a patient's developing clinically recurrent veins. Patients with visible recurrent varicose veins had a significantly worse AVVSSS ( P = .001). CONCLUSION: Stripping the long saphenous vein is recommended as part of routine varicose vein surgery as it reduced the risk of reoperation by 60% after 11 years, although it did not reduce the rate of visible recurrent veins.

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Eur J Vasc Endovasc Surg. 2004 Sep;28(3):246-52.
Reduction of neoreflux after correctly performed ligation of the saphenofemoral junction. A randomized trial.
Frings N, Nelle A, Tran P, Fischer R, Krug W.
Mosel-Eifel-Klinik, Varicose Veins Clinic, Bad Bertrich, Germany.

BACKGROUND: Neoreflux at the sapheno-femoral junction (SFJ) is an important cause of recurrent great saphenous varicose veins. This study compares four surgical methods of ligating the SFJ with the aim to reduce the rate of neoreflux. METHOD: In a prospective study, 379 patients (500 SFJ ligations) were randomised to one of four surgical procedures at the SFJ (125 groins each). In group A (control group) the SFJ was ligated in standard fashion with Vicryl (absorbable ligature); in group B, after Vicryl ligation continuous Prolene (non-absorbable) was sutured over the stump endothelium to prevent any contact with surrounding tissue; in group C. SFJ ligation was done with Ethibond (non-absorbable); in group D Ethibond ligation was followed by Prolene oversewing. The final study group included 114 patients (152 groins) who were all known to be free from recurrent groin reflux 3 months postoperatively and had colour duplex venous imaging 2 years after operation. RESULTS: Duplex imaging identified neoreflux at the SFJ in 10 out of 114 groins after 2 years (7%). There were differences in the rates between the four groups: Group A 3/31 (10%), Group B 0/32, Group C 5/44 (11%) and Group D 2/45 (4%). Neoreflux was significantly reduced in the two groups with endothelial closure (B and D): 2/70 (3%) versus 8/75 (11%, p<0.025). CONCLUSION: Recurrent reflux in the groin was reduced by over sewing the ligated SFJ in patients having varicose vein surgery. This adds weight to the theory of neovascularisation as a cause of recurrent veins and offers a means to reduce clinical recurrence rates.

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Yonsei Med J. 2004 Aug 30;45(4):577-83.
Venous hemodynamic changes in the surgical treatment of primary varicose vein of the lower limbs.
Kim IH, Joh JH, Kim DI.
Division of Vascular Surgery, Samsung Medical Center, 50 Irwondong, Kangnamku, Seoul 135-710, Korea. dikim@smc.samsung.co.kr

Venous hemodynamic changes after the surgery of primary varicose veins were evaluated. (Materials and methods) We retrospectively analyzed 1,211 patients (1,407 limbs) who underwent surgery for primary varicose veins from 1994 to 2002. The venous hemodynamics were evaluated using air- plethysmography (APG) preoperatively and one month postoperatively in the viewpoints of ambulatory venous pressure (AVP), venous volume (VV), venous filling index (VFI), and ejection fraction (EF). (Results) The surgical modalities included 958 cases of greater saphenous vein high ligation (GSV HL) and stripping with varicosectomy (VS), 222 cases of short saphenous vein (SSV) HL and VS, 143 cases of external banding valvuloplasty of GSV and VS, and 44 cases using VNUS and VS. The reduction rate of VV was 20.9 +/- 14.1% in the GSV stripping group, 12.0 +/- 14.7% in the GSV valvuloplasty group, 18.3 +/- 16.1% in the VNUS group, and 20.6 +/- 15.9% in the SSV group. The reduction rate of VFI was 63.6 +/- 20.7% in the GSV stripping group, 38.8 +/- 40.9% in the GSV valvuloplasty group, 60.1 +/- 23.9% in the VNUS group, and 37.6 +/- 30.2% in the SSV group. The increasing rate of EF was 25.0 +/- 28.2% in the GSV stripping group, 21.0 +/- 30.0% in the GSV valvuloplasty group, 29.4 +/- 31.9% in the VNUS group, and 30.0 +/- 36.5% in the SSV group. The reduction rate of AVP was 25.4 +/- 32.2% in the GSV stripping group, -6.1 +/- 58.1% in the GSV valvuloplasty group, 28.4 +/- 38.5% in the VNUS group, and 14.1 +/- 49.0% in the SSV group. All of the patients showed improvements in venous hemodynamics by showing a decrease in VV, VFI, AVP, and an increase in EF. However, there was no difference in the change of venous hemodynamics according to the type of surgery.

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Am J Surg. 2004 Jul;188(1A Suppl):26-30.
Minimally invasive vein surgery: its role in the treatment of venous stasis ulceration.
Elias SM, Frasier KL.
Center for Vein Disease, Englewood Hospital and Medical Center, 180 North Dean Street, Englewood, New Jersey 07631, USA. veininnovations@aol.com

Although traditional modalities used to treat venous disease and subsequent stasis ulceration have proved to be effective, they can have associated morbidities, such as postoperative pain, limited mobility, wound infection and dehiscence, as well as missed varicosities and/or incompetent perforator veins resulting in additional procedures. Recent advances have been made in minimally invasive vein surgery (MIVS) techniques that can decrease operative morbidity, number and size of incisions, recovery time, as well as operative time. These techniques are as durable as open procedures. The following procedures will be discussed: transilluminated powered phlebectomy, radiofrequency ablation of the greater saphenous vein closure, subfascial endoscopic perforator surgery, and percutaneous vein valve bioprosthesis. The advent of MIVS techniques allows the surgeon to manage venous pathophysiology associated with all 3 venous systems. MIVS is proving to be an important complement in the overall care of venous stasis ulceration.

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Hautarzt. 2004 Jun;55(6):533-42.
[Emergencies in phlebology]
[Article in German]
Pannier F, Rabe E.
Klinik und Poliklinik fur Dermatologie der Rheinischen Friedrich-Wilhelms-Universitat, Bonn. felizitas.pannier-fischer@ubk.uni-bonn.de

Venous diseases which require emergency care include deep venous thrombosis, superficial thrombophlebitis and variceal bleeding. The clinical diagnosis of deep venous thrombosis is often inaccurate, but can be confirmed in most cases with noninvasive tools such as sonography and d-dimer testing. Standard therapy includes compression of the leg and low molecular weight heparin in a therapeutic dosage. Superficial thrombophlebitis includes a variety of disease processes involving superficial veins, some thrombotic and others inflammatory. The most important is varicophlebitis or varicothrombosis, which involves the deep venous system in up to 20% of cases. Along with immediate surgical procedures when the thrombus reaches the deep venous system in the groin, short term therapy with low molecular weight heparin can be used. Variceal bleeding is a typical complication of severe varicose veins. It can be treated by elevating the leg and compression therapy. In addition sclerotherapy or ligation of the bleeding vein can be performed.

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Angiology. 2004 May-Jun;55 Suppl 1:S1-5.
Microcirculatory efficacy of topical treatment with aescin + essential phospholipids gel in venous insufficiency and hypertension: new clinical observations.
Belcaro G, Cesarone MR, Dugall M.
Irvine2 Vascular Laboratory, Department of Biomedical Sciences, G. D'Annunzio University, Italy. cardres@pe.abol.it

Aescin + essential phospholipids (AEPL) topical gels are used for local treatment of venous and microcirculatory alterations (varicose veins, chronic venous insufficiency). Bruises, swelling, thrombophlebitis, and contusions are effectively treated with AEPL. Active ingredients are escinate and essential phospholipids (EPL). The aim of this new study was the evaluation of the efficacy of the effects of AEPL gel on the microcirculation in subjects with chronic venous insufficiency, venous hypertension (CVH), and venous microangiopathy. Patients were assessed measuring skin flux with laser-Doppler flowmetry (LDF). After 2 weeks of local treatment, all individual values (100%) were significantly decreased (p < 0.05), indicating an improvement in the microcirculation. In all treated patients, flux decreased at least 30% (indicating a decrease in the level of venous microangiopathy) (p < 0.05). Considering these observations, topical treatment with AEPL in areas of venous microangiopathy is beneficial, can prevent ulceration, and improves the skin healing processes.

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Ann Chir. 2004 May;129(4):248-57.
[Endovenous therapy for varicose veins of the lower extremities]
[Article in French]
Perrin M.

Endovenous treatment for varicose veins of the lower extremities is an old technique. New technologies such as radiofrequency and laser have revived its indications. Thermal energy which is delivered to the vein wall results in a fibrous retraction and eventually complete obstruction of the vessel.

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Dermatol Surg. 2004 May;30(5):723-8.
Efficacy of sclerotherapy in varicose veins-a prospective, blinded, placebo-controlled study.
Kahle B, Leng K.
Department of Dermatology, University of Heidelberg, Heidelberg, Germany.

Objective. The objective of this study was to investigate the efficacy of sclerotherapy for varicose veins in a randomized blinded study. Methods. Twenty-five patients with varicose veins (C(2-4), E(P), A(SP), P(R)) were included. Fourteen subjects received polidocanol (Aethoxysklerol) and 11 patients received normal saline injections. Compression was applied for 1 week. One, 4, and 12 weeks later controls were performed using duplex ultrasonography. The quotient of venous by arterial volume flow was used as quantitative hemodynamic pattern. Patients and the examiner were unaware of which liquid had been injected. Results. In comparison to group 2, 76.8% of the veins treated with polidocanol were completely occluded (p<0.0001). In group 1 the venoarterial flow index decreased from 1.45+/-0.66 to 1.06+/-0.2 (p=0.05). In 11 occluded veins of 14 (group 1), the venoarterial flow index decreased from 1.5+/-0.07 to 0.98+/-0.12 (p<0.05), which is a level found in competent veins. In group 2, the venoarterial flow index remained stable increased. Conclusions. Injection sclerotherapy using polidocanol (Aethoxysklerol) is efficient to obliterate varicose veins and to improve venous hemodynamics. RESEARCH WAS SUPPORTED BY A FINANCIAL GRANT FROM FABRIK KREUSSLER GMBH & CO, WEISBADEN, GERMANY.

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Dermatol Surg. 2004 May;30(5):718-22.
Comparative study of duplex-guided foam sclerotherapy and duplex-guided liquid sclerotherapy for the treatment of superficial venous insufficiency.
Yamaki T, Nozaki M, Iwasaka S.
Department of Plastic and Reconstructive Surgery, Tokyo Women's Medical University, Tokyo, Japan.

Purpose. To compare the preliminary results of hemodynamic changes between duplex-guided foam sclerotherapy and duplex-guided liquid sclerotherapy. Methods. Seventy Seven limbs in 77 patients with isolated greater saphenous vein incompetence were treated with duplex-guided sclerotherapy. Thirty Seven limbs were treated with duplex-guided foam sclerotherapy and the remaining 40 limbs were treated with duplex-guided liquid sclerotherapy. Pretreatment exam was performed using a color duplex scanner and air plethysmography. The sclerosing foam was produced by Tessari's method using 1% and 3% polidocanol. The varicose vein was injected with 2 mL of 1% polidocanol or 1% polidocanol foam, and then 1 mL of 3% polidocanol or 3% polidocanol foam was injected into the greater saphenous vein under duplex guidance. Venous obstruction and recanalization were screened by serial posttreatment duplex examination, and posttreatment air plethysmography analysis was performed 3, 6, 9, and 12 months after the sclerotherapy. Results. Duplex scanning demonstrated complete occlusion in the greater saphenous vein for duplex-guided foam sclerotherapy in 25 limbs (67.6%), which was a significantly higher proportion than for the duplex-guided liquid sclerotherapy (7 limbs, 17.5%, p<0.0001). Recurrent varicose veins were found in 3 patient (8.1%) in the duplex-guided foam sclerotherapy group and 10 (25%) in the duplex-guided liquid sclerotherapy group at 1-year (p=0.048). In duplex-guided foam sclerotherapy, venous filling index values remained normal during the subsequent follow-up examinations, whereas in duplex-guided liquid sclerotherapy, venous filling index began to increase, and there was a significant difference at 6 months between duplex-guided foam sclerotherapy and the duplex-guided liquid sclerotherapy (p<0.0005). At 9 months, there was a significant difference in the residual venous fraction between the two groups, and the residual venous fraction value continued to improve in duplex-guided foam sclerotherapy (p=0.033). Conclusions. Duplex-guided foam sclerotherapy could have greater promise compared to duplex-guided liquid sclerotherapy in the treatment of superficial venous insufficiency.

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J Endovasc Ther. 2004 Apr;11(2):132-8.
Endovenous laser ablation of the saphenous vein for treatment of venous insufficiency and varicose veins: early results from a large single-center experience.
Perkowski P, Ravi R, Gowda RC, Olsen D, Ramaiah V, Rodriguez-Lopez JA, Diethrich EB.
Department of Cardiovascular and Endovascular Surgery, Arizona Heart Institute and Hospital, 1632 North 20th Street, Phoenix, AZ 85006, USA.

PURPOSE: To report early results of a single-center experience with endovenous laser ablation of the saphenous vein (ELAS). METHODS: From February 2002 to January 2003, 165 eligible patients (116 women; mean age 59.1 years, range 27-90) were treated with ELAS for venous insufficiency in 203 lower limbs. All patients were symptomatic, and the majority (62%) had class 4 or higher clinical disease (CEAP classification). Eighteen (8.9%) patients had ulcers. A 940-nm diode laser was used in an office setting under local tumescent anesthesia to deliver 100 to 140 laser applications along the course of the vein. Two weeks of compression bandages and a 1-week course of ibuprofen were prescribed postoperatively. All patients underwent a duplex scan of the target vein at 2 weeks. RESULTS: The great (154, 76%), short 37 (18%), and accessory 12 (6%) saphenous veins were ablated, achieving a 97% clinical success rate. Postoperative complications were few (mild induration and ecchymosis) and well tolerated (no DVT or nerve injury). Of the 6 (3.0%) recanalized target veins, 4 were only partially open and successfully treated with sclerosis. Of the 18 patients with active ulceration, 15 (83%) demonstrated healing after ELAS. In a satisfaction survey of patients more than 1 year after ELAS treatment, 84% of the 31 responders claimed their symptoms had diminished to none or minimal; 97% were mostly or very satisfied with their treatment results. CONCLUSIONS: ELAS for symptomatic saphenous vein incompetence and varicose veins has excellent short-term subjective and objective outcomes. This technique appears to be very successful in reducing symptoms, resolving varicose veins, and healing ulcers.

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Ann Vasc Surg. 2004 Jan 20 [Epub ahead of print]
Early Experience with Radiofrequency Ablation of the Greater Saphenous Vein.
Wagner MD WH, Levin MD PM, Cossman MD DV, Lauterbach MD SR, Louis Cohen MD J, Farber MD A.
Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, CA.

Radiofrequency ablation of the greater saphenous vein (GSV) has been proposed as an alternative to conventional ligation and stripping in the treatment of varicose veins. We have reviewed our initial experience with this new technology in 28 procedures on 24 patients. Preoperative duplex scans confirmed venous valvular incompetence of the GSV in all patients. Intraoperative ultrasound was used to measure the depth of the GSV, to precisely place the radiofrequency catheter adjacent to the saphenofemoral junction, and to confirm the results of the ablative procedure. Occlusion of the GSV was seen on 96% of completion scans and in all patients within 1 week of the procedure. Duplex scans were available for 21 limbs at 3 months and for 3 at 1 year. Persistent occlusion was documented in all cases. No patient had paresthesias or thermal skin injury. Two patients had transient superficial thrombophlebitis around the knee in a treated segment of the GSV. One patient was found to have extension of an asymptomatic, nonocclusive thrombus into the common femoral vein on a routine scan 3 days after surgery. Postoperative patient questionnaires showed that 96% of respondents were very satisfied with the procedure. Radiofrequency ablation of the GSV appears to be a safe alternative to conventional stripping and ligation. Subjective assessment by the surgeons suggests an earlier return to work and active lifestyle compared to traditional extirpative techniques. Longer follow-up is required to establish the durability of the procedure.

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J Vasc Surg. 2004 Jan;39(1):189-95.
Duplex ultrasound scan findings two years after great saphenous vein radiofrequency
endovenous obliteration.
Pichot O, Kabnick LS, Creton D, Merchant RF, Schuller-Petroviae S, Chandler JG.
Division of Vascular Medicine, Grenoble University Hospital, 38043 Grenoble Cedex 9, France. opichot@wanadoo.fr

OBJECTIVE: To assess the clinical and duplex ultrasound scan findings in the groin and thigh 2 years after great saphenous vein (GSV) radiofrequency endovenous obliteration (RFO). METHODS: Sixty-three limbs in 56 patients with symptomatic varicose veins and GSV incompetence were treated with RFO, usually with adjunctive stab-avulsion phlebectomies, and examined at a median follow-up of 25 months, by using a color-coded, duplex sonography protocol that mandated views in at least two planes of the saphenofemoral junction (SFJ) and its tributaries and at three GSV levels in the thigh. RESULTS: The commonest duplex finding in the groin was an open, competent, SFJ with a < or =5-cm patent terminal GSV segment conducting prograde tributary flow through the SFJ (82%). Despite the presence of a total of 104 patent junctional tributaries, SFJ reflux was uncommon, affecting only five limbs. GSV truncal occlusion was observed in 90% of treated GSVs. Limited segmental treatment was successful in three limbs with a midthigh reflux source well below competent terminal and subterminal valves. Six GSV trunks had partial or no occlusion, but only one refluxed. These were anatomical RFO failures (9.5%) but were clinically improved, including the refluxing limb. Neovascularity was not identified in any groin. Thigh varicosities were observed in 12 limbs, including telangiectasias and isolated small tributary branches. New varicosities, linked to refluxing thigh perforators (two), or patent SFJ tributaries (three), were present in five limbs. CONCLUSION: RFO is the ideological opposite of high ligation without GSV stripping. It leaves physiologic tributary flow relatively undisturbed, does not incite groin neovascularity, eliminates the GSV as a refluxing conduit in >90% of limbs and has a 2-year, postadjunctive phlebectomy varicosity prevalence of 7.9%, with symptom score improvement in 95% of limbs with an initial score higher than zero.

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Ann Vasc Surg. 2004 Jan 20 [Epub ahead of print]
Early Experience with Radiofrequency Ablation of the Greater Saphenous Vein.
Wagner MD WH, Levin MD PM, Cossman MD DV, Lauterbach MD SR, Louis Cohen MD J, Farber MD A.
Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, CA.

Radiofrequency ablation of the greater saphenous vein (GSV) has been proposed as an alternative to conventional ligation and stripping in the treatment of varicose veins. We have reviewed our initial experience with this new technology in 28 procedures on 24 patients. Preoperative duplex scans confirmed venous valvular incompetence of the GSV in all patients. Intraoperative ultrasound was used to measure the depth of the GSV, to precisely place the radiofrequency catheter adjacent to the saphenofemoral junction, and to confirm the results of the ablative procedure. Occlusion of the GSV was seen on 96% of completion scans and in all patients within 1 week of the procedure. Duplex scans were available for 21 limbs at 3 months and for 3 at 1 year. Persistent occlusion was documented in all cases. No patient had paresthesias or thermal skin injury. Two patients had transient superficial thrombophlebitis around the knee in a treated segment of the GSV. One patient was found to have extension of an asymptomatic, nonocclusive thrombus into the common femoral vein on a routine scan 3 days after surgery. Postoperative patient questionnaires showed that 96% of respondents were very satisfied with the procedure. Radiofrequency ablation of the GSV appears to be a safe alternative to conventional stripping and ligation. Subjective assessment by the surgeons suggests an earlier return to work and active lifestyle compared to traditional extirpative techniques. Longer follow-up is required to establish the durability of the procedure.

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J Vasc Surg. 2004 Jan; 39(1): 189-95.
Duplex ultrasound scan findings two years after great saphenous vein radiofrequency
endovenous obliteration.
Pichot O, Kabnick LS, Creton D, Merchant RF, Schuller-Petroviae S, Chandler JG.
Division of Vascular Medicine, Grenoble University Hospital, 38043 Grenoble Cedex 9, France. opichot@wanadoo.fr

OBJECTIVE: To assess the clinical and duplex ultrasound scan findings in the groin and thigh 2 years after great saphenous vein (GSV) radiofrequency endovenous obliteration (RFO). METHODS: Sixty-three limbs in 56 patients with symptomatic varicose veins and GSV incompetence were treated with RFO, usually with adjunctive stab-avulsion phlebectomies, and examined at a median follow-up of 25 months, by using a color-coded, duplex sonography protocol that mandated views in at least two planes of the saphenofemoral junction (SFJ) and its tributaries and at three GSV levels in the thigh. RESULTS: The commonest duplex finding in the groin was an open, competent, SFJ with a < or =5-cm patent terminal GSV segment conducting prograde tributary flow through the SFJ (82%). Despite the presence of a total of 104 patent junctional tributaries, SFJ reflux was uncommon, affecting only five limbs. GSV truncal occlusion was observed in 90% of treated GSVs. Limited segmental treatment was successful in three limbs with a midthigh reflux source well below competent terminal and subterminal valves. Six GSV trunks had partial or no occlusion, but only one refluxed. These were anatomical RFO failures (9.5%) but were clinically improved, including the refluxing limb. Neovascularity was not identified in any groin. Thigh varicosities were observed in 12 limbs, including telangiectasias and isolated small tributary branches. New varicosities, linked to refluxing thigh perforators (two), or patent SFJ tributaries (three), were present in five limbs. CONCLUSION: RFO is the ideological opposite of high ligation without GSV stripping. It leaves physiologic tributary flow relatively undisturbed, does not incite groin neovascularity, eliminates the GSV as a refluxing conduit in >90% of limbs and has a 2-year, postadjunctive phlebectomy varicosity prevalence of 7.9%, with symptom score improvement in 95% of limbs with an initial score higher than zero.

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J Vasc Surg. 2004 Jan; 39(1): 88-94.
Prospective randomized controlled trial: conventional versus powered phlebectomy.
Aremu MA, Mahendran B, Butcher W, Khan Z, Colgan MP, Moore DJ, Madhavan P, Shanik DG.
St James's Vascular Institute, St James's Hospital, Dublin 8, Ireland.

OBJECTIVES: Transilluminated powered phlebectomy (TriVex) is a new surgical technique that uses tumescent dissection, transillumination, and powered phlebectomy. The purpose of this study was to compare TriVex with conventional varicose vein surgery in terms of pain, cosmesis, recurrence, complications, and operating time. METHODS: One hundred eighty-eight limbs in 141 patients (33 men, 108 women; mean age, 42.5 years) with varicose veins were randomised to conventional (n = 100) or TriVex (n = 88). Exclusion criteria were venous ulceration or deep venous disease. Varicosities were graded with CEAP and clinical assessment (grades 1-3), and were similar in both groups. Randomization was single blinded. Long or short saphenous vein ligation or stripping was performed as indicated with duplex scanning. Operative time was from skin incision to leg bandaging. Phlebectomy was performed with conventional stab avulsions or TriVex. Patients completed assessment forms preoperatively and postoperatively (2, 6, 26, 52 weeks), and this was supplemented with physician clinical evaluation. Pain was assessed with visual analog score. RESULTS: There was a significant difference in the number of incisions for phlebectomy in the two groups (conventional, n = 29; TriVex, n = 5; P <.0001). TriVex was faster in the grade 3 (extensive) group, but this did not reach statistical significance. There was no difference in mean postoperative pain score over 8 days in the two groups (P =.4624). At 2 weeks there was no significant difference between the groups with regard to bruising (P =.77), cellulitis (P =.33), and numbness (P =.33). At 6 weeks there was no significant difference between the groups with regard to nerve injury (P =.97), residual veins (P =.79), cosmetic score (P =.837), and overall satisfaction (P =.878). At 6 and 12 months, there was no significant difference in cosmesis (P =.955, P =.088, respectively) or recurrence (P =.27, P =.11, respectively). CONCLUSIONS: TriVex is a safe and effective method for excision of varicosities and compares well, after a learning curve, with conventional surgery in regard to complications and recurrence. It has the advantage of a trend toward reduced operating time in extensive varicosities, and significantly fewer incisions, although there was no perceived difference in cosmesis during follow-up.

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Dermatol Surg. 2004 Jan; 30(1): 6-12.
Microfoam ultrasound-guided sclerotherapy of varicose veins in 100 legs.
Barrett JM, Allen B, Ockelford A, Goldman MP.
Palm Clinic, Auckland, New Zealand Dermatology/Cosmetic Laser Associates of La Jolla, Inc., La Jolla, California.

OBJECTIVE. : To demonstrate the efficacy of duplex-guided foam sclerotherapy measured against patient symptom relief and quality of life. METHODS. : An analysis was performed of 100 randomly chosen legs with varicose veins treated with ultrasound-guided foam sclerotherapy with a mean follow-up of 22.5 months. RESULTS. : An average number of 2.1 treatments using an average of 8.7 mL of foam sclerosing solution were required to close incompetent varicose veins. Thirty-one percent of leg varicose veins required a second treatment at 3 months; 100% of patients felt that their legs were successfully treated with resolution of all symptoms in 85% and resolution in all varicose veins in 92%. CONCLUSION. : Ultrasound-guided foam sclerotherapy is effective in treating varicose veins with high patient satisfaction with results and improvement in quality of life.

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Dermatol Surg. 2003 Dec; 29(12): 1170-5; discussion 1175.
Evaluation of the efficacy of polidocanol in the form of foam compared with liquid form in sclerotherapy of the greater saphenous vein: initial results.
Hamel-Desnos C, Desnos P, Wollmann JC, Ouvry P, Mako S, Allaert FA.
Center Hospitalier Prive Saint Martin, 18 Rue des Rocquemonts, 14050 Caen-Cedex, France. claudine.hamel-desnos@wanadoo.fr

BACKGROUND: Foamed sclerosing agents have been used with enthusiasm by phlebologists for more than 5 decades. Any type of varicose veins can and has been treated with this technique. Numerous publications have stressed the advantages of foamed sclerosing agents on the basis of empiric and experimental criteria and have described various individual techniques to prepare foams. Until now, however, no comparative study for the treatment of large varicose veins with foam or liquid exists. OBJECTIVE: The purpose of this first randomized, prospective, multicenter trial was to study the elimination of reflux, the rate of recanalization, and possible side effects of foam sclerotherapy (FS) compared with conventional liquid sclerotherapy for the greater saphenous vein (GSV). METHODS: Eighty-eight patients were randomized into two groups: One group was treated with sclerosing foam (45 patients) and the other with sclerosing liquid (43 cases). Sclerotherapy was performed with direct puncture of the vessel under duplex guidance. The reference sclerosing agent was polidocanol in a 3% solution. The foam was prepared using the Double Syringe System (DSS) method. Only one injection of 2.0 or 2.5 mL liquid or foam was allowed, depending on the diameter of the GSV. Results were assessed according to the protocol. RESULTS: Follow-up after 3 weeks showed 84% elimination of reflux in the GSV with DSS foam versus 40% with liquid sclerosant (P < 0.01). At 6 months, six recanalizations were found in the liquid group versus two in the foam group. After 1 year, no additional recanalization was observed with either foam or liquid. Longer term studies are underway. Side effects did not differ between both groups. CONCLUSION: The efficacy of sclerosing foam (DSS) compared with sclerosing liquid in therapy of the GSV is superior, a finding that had already gained empirical recognition but for which there has not been any clinical evidence to date.

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J Vasc Surg. 2003 Nov; 38(5): 935-43.
Recurrence after varicose vein surgery: a prospective long-term clinical study with duplex ultrasound scanning and air plethysmography.
van Rij AM, Jiang P, Solomon C, Christie RA, Hill GB.
Department of Surgery, Dunedin School of Medicine, University of Otago, New Zealand. andre.vanrij@stonebow.otago.ac.nz

OBJECTIVE: We observed long-term venous ultrasound and plethysmographic changes after varicose vein surgery, to determine factors that influence recurrence. METHODS AND MATERIALS: This observational sequential prospective study was carried out in an institutional referral center with day surgery. Subjects were 92 consecutive patients, ages 20 to 75 years, with symptomatic varicose veins in 127 limbs, who were able to complete regular assessment. Superficial varicose vein surgery included significant perforator vessels only, defined at preoperative duplex ultrasound scanning and air plethysmography. Similar follow-up assessments were performed at 3 weeks, 3 months, and 1, 3, and 5 years. RESULTS: At 3 weeks venous reflux but not muscle pump function was consistently improved in all limbs. However, inadequate surgery at the major junctions was clearly identified as contributing to recurrence of disease in 7.2% of limbs. Recurrence of varicose veins occurred in 1 of 100 limbs (1%) at the saphenofemoral junction and in 8 of 33 (25%) limbs at the saphenopopliteal junction. However, after 3 years disease recurrence at these sites had increased to 23% and 52%, respectively. Incompetent perforator vessels increased progressively in number. Clinical recurrence was 47.1%, and consistent with this was gradual deterioration in air plethysmographic measures of reflux, with physiologic recurrence (venous filling index, >2 mL/s) in 66% at 5 years. Late recurrence was predicted in limbs with multiple sites of reflux preoperatively, venous filling index greater than 2 mL/s, and some other persistent abnormality at duplex scanning at 3 weeks. There was no recurrence in 40 limbs in which these factors were normal at at 3 weeks. However, 29 of 53 limbs with normal venous filling index after operative intervention had deteriorated at 3 years. CONCLUSION: Incomplete superficial surgery, in particular at the saphenofemoral and saphenopopliteal junctions, is a less frequent cause of recurrent disease, and neovascular reconnection and persistent abnormal venous function are the major contributors to disease recurrence.

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J Vasc Surg. 2003 Nov; 38(5): 896-903.
Microthrombectomy reduces postsclerotherapy pigmentation: multicenter randomized trial.
Scultetus AH, Villavicencio JL, Kao TC, Gillespie DL, Ketron GD, Iafrati MD, Pikoulis E, Eifert S.
Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.

OBJECTIVE: Postsclerotherapy pigmentation occurs in nearly 30% of patients. Hemosiderin, from degradation of the venous thrombus, is the possible cause. The hypothesis that early removal of the thrombus may eliminate or decrease the incidence of pigmentation has not been proved or documented. The objective of this study was to investigate the effects of early microthrombectomy on incidence of postsclerotherapy pigmentation. MATERIAL AND METHODS: This multicenter, randomized, controlled study involved 101 patients with varicose veins (100 women, 1 man; mean age, 46 years [range, 25-68 years]). Patients were divided into two groups, with veins 1 mm or less in diameter (group 1, n = 50) or veins 3 mm or less in diameter (group 2, n = 51). Group 1 was treated with Sotradecol (STD) 0.25%, and group 2 with STD 0.50%. In each patient, an area of varicosities was selected and divided into halves. One half was randomized to microthrombectomy and the other half served as control. Microthrombectomy was performed 1 to 3 weeks after treatment in the randomized half. Standard photographs were obtained before and 16 weeks after treatment, and were evaluated by three independent reviewers who were blinded to treatment assignments. Each reviewer received an identical set of pretreatment and posttreatment 10 x 15-cm color photographs of the study area, and completed a scoring sheet. Average of the scores was used to evaluate primary (pigmentation) and secondary (overall clinical improvement) end points. The paired t test and chi-square test were used for statistical analysis. RESULTS: In group 1, microthrombectomized areas had statistically significant less pigmentation (P =.0047) and better overall clinical improvement scores (P =.0002) compared with the control side. In group 2 there was no significant difference between the two areas, but patients reported significant relief of pain and inflammation associated with postsclerotherapy thrombophlebitis. CONCLUSION: In veins 1 mm or smaller, microthrombectomy reduced pigmentation and improved overall clinical results. In veins 3 mm or smaller, statistical significance was not achieved, but thrombectomy resulted in faster resolution of the postsclerotherapy pain and inflammation. On the basis of these results, microthrombectomy after sclerotherapy is recommended.

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Cardiovasc Surg. 2003 Oct; 11(5): 341-5.
Stripping operation with preservation of the calf saphenous veins for primary varicose veins: hemodynamic evaluation.
Nishibe T, Nishibe M, Kudo F, Flores J, Miyazaki K, Yasuda K.
Department of Cardiovascular Surgery, Hokkaido University School of Medicine, Sapporo, Japan. tnishibe@fujita-hu.ac.jp

PURPOSE: To study early changes in venous hemodynamics in stripping operation with preservation of the calf saphenous veins. PATIENTS AND METHODS: From October 1999 to December 2000, 110 extremities of 73 patients were treated for primary varicose veins. Based on preoperative ascending venography, 40 extremities underwent the groin-to-knee stripping of the GSV, 20 underwent the proximal division of the LSV, and 50 received combinations of both surgeries. To evaluate venous hemodynamic changes, air plethysmography was performed before operation and 7-14 days after operation. RESULTS: The venous volume, venous filling index and residual volume fraction were improved after surgery, but the ejection fraction did not change. The overall incidence of nerve injury was 4.5% (five limbs). CONCLUSIONS: In stripping operations, the preservation of the calf saphenous veins, which is shown to be advantageous in reducing saphenous or sural nerve injuries, does not adversely affect early venous hemodynamic improvement.

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Forsch Komplementarmed Klass Naturheilkd. 2003 Oct; 10(5): 242-7.
[Efficacy of Arnica in varicose vein surgery: results of a randomized, double-blind, placebo-controlled pilot study]
[Article in German]
Wolf M, Tamaschke C, Mayer W, Heger M.
Praxis fur Homoopathie, Berlin-Karow, Deutschland. manfred.wolf@berlin.de

INTRODUCTION: In homeopathy ARNICA is widely used as a woundhealing medication and for the treatment of hematomas. OBJECTIVE: In this pilot study the efficacy and safety of ARNICA D12 in patients following varicose vein surgery were investigated. DESIGN: Prospective, randomized, double-blind, placebo-controlled pilot trial according to ICH GCP guidelines. SETTING: The study was conducted by a surgeon at the Angiosurgical Clinic, Berlin- Buch. INTERVENTION: After randomized allocation, 60 patients received either ARNICA D12 or placebo. Start of medication occurred the evening before operation with 5 globules. On the operation day one preoperative and hourly postoperative dosages after awakening were given. On days 2-14 of the study 5 globules 3 times a day were given. OUTCOME CRITERIA: Surface (in cm(2) and using a three-point verbal rating scale) and intensity of hematomas induced by operation, complications of wound healing, and intensity of pain (five-point verbal rating scale) as well as efficacy and safety of the study medication were assessed. RESULTS: Hematoma surface was reduced (from day 7 to day 14) under ARNICA by 75.5% and under placebo by 71.5% (p = 0.4726). The comparison of hematoma surface (small, medium, large) using the verbal rating scale yielded a value of p = 0.1260. Pain score decreased by 1.0 +/- 2.2 points under ARNICA and 0.3 +/- 0.8 points under placebo (p = 0.1977). Remission or improvement of pain was observed in 43.3% of patients in the ARNICA group and in 27.6% of patients in the placebo group. Tolerability was rated as very good in all cases. CONCLUSION: The results of this pilot study showed a trend towards a beneficial effect of ARNICA D12 with regard to reduction of hematoma and pain during the postoperative course. For a statistically significant proof of efficacy of ARNICA D12 in patients following varicose vein surgery a larger sample size is necessary. Copyright 2003 S. Karger GmbH, Freiburg

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Tech Vasc Interv Radiol. 2003 Sep; 6(3): 116-20.
Sclerotherapy treatment of telangiectasias and varicose veins.
Zimmet SE.
Zimmet Vein and Dermatology Clinic, Austin, TX 78701, USA.

Telangiectasias and/or varicose veins are present in about 33% of adult women and 15% of adult men. Although they may be only of cosmetic concern, superficial varices often cause significant symptoms such as pain, aching, heaviness, and pruritus. Venous ulceration is commonly caused solely by superficial venous insufficiency. Superficial thin-walled veins may rupture and hemorrhage. Sclerotherapy is a nonsurgical procedure that can be used to treat both small and large varices of the superficial venous system and perforators. This involves injecting a sclerosant intraluminally to cause fibrosis and eventual obliteration of a vein. The most common sclerosants used in the U.S. include sodium tetradecyl sulfate, polidocanol, 23.4% saline, and a combination of 25% dextrose with 10% saline. Treatment generally proceeds from proximal to distal and largest to smallest vein, based on a reflux map developed from physical examination, Doppler, and duplex ultrasound. Sclerotherapy results can be optimized and the risk of complications minimized by choosing the proper sclerosant, sclerosant concentration, sclerosant volume, and injection sites for the vein(s) being treated. Post-treatment instructions, particularly compression and ambulation, are designed to improve the results and safety of sclerotherapy. Adequate understanding of an appropriate history and physical, ultrasound evaluation, anatomy, pathophysiology, knowledge of sclerosing solutions, patient selection, and post-treatment care, as well as the ability to prevent, recognize, and treat complications are required before embarking on treatment. Copyright 2003 Elsevier Inc. All rights reserved.

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Tech Vasc Interv Radiol. 2003 Sep; 6(3): 121-4.
Minimally invasive vein surgery: ambulatory phlebectomy.
Olivencia JA.
Iowa Vein Center, West Des Moines, IA 50266, USA.

Ambulatory phlebectomy has proven to be an effective treatment for varicose veins. Alone or complementing the treatment of incompetent long or short saphenous vein by high ligation, saphenectomy, or transcatheter occlusion, ambulatory phlebectomy not only adequately and satisfactorily removes the diseased veins but also results in a series of extremely small micro-incisions, which are cosmetically pleasing to the patient and the surgeon. Furthermore, the entire procedure can be performed under local anesthesia on an ambulatory basis. Copyright 2003 Elsevier Inc. All rights reserved.

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J Vasc Interv Radiol. 2003 Aug; 14(8): 991-6.
Endovenous laser treatment of saphenous vein reflux: long-term results.
Min RJ, Khilnani N, Zimmet SE.
Cornell Vascular, Weill Medical College of Cornell University, 416 East 55th Street, New York, New York 10022, USA. rjm2002@med.cornell.edu

PURPOSE: To report long-term follow-up results of endovenous laser treatment for great saphenous vein (GSV) reflux caused by saphenofemoral junction (SFJ) incompetence. MATERIALS AND METHODS: Four hundred ninety-nine GSVs in 423 subjects with varicose veins were treated over a 3-year period with 810-nm diode laser energy delivered percutaneously into the GSV via a 600- micro m fiber. Tumescent anesthesia (100-200 mL of 0.2% lidocaine) was delivered perivenously under ultrasound (US) guidance. Patients were evaluated clinically and with duplex US at 1 week, 1 month, 3 months, 6 months, 1 year, and yearly thereafter to assess treatment efficacy and adverse reactions. Compression sclerotherapy was performed in nearly all patients at follow-up for treatment of associated tributary varicose veins and secondary telangiectasia. RESULTS: Successful occlusion of the GSV, defined as absence of flow on color Doppler imaging, was noted in 490 of 499 GSVs (98.2%) after initial treatment. One hundred thirteen of 121 limbs (93.4%) followed for 2 years have remained closed, with the treated portions of the GSVs not visible on duplex imaging. Of note, all recurrences have occurred before 9 months, with the majority noted before 3 months. Bruising was noted in 24% of patients and tightness along the course of the treated vein was present in 90% of limbs. There have been no skin burns, paresthesias, or cases of deep vein thrombosis. CONCLUSIONS: Long-term results available in 499 limbs treated with endovenous laser demonstrate a recurrence rate of less than 7% at 2-year follow-up. These results are comparable or superior to those reported for the other options available for treatment of GSV reflux, including surgery, US-guided sclerotherapy, and radiofrequency ablation. Endovenous laser appears to offer these benefits with lower rates of complication and avoidance of general anesthesia.

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J Vasc Surg. 2003 Aug; 38(2): 207-14.
Prospective randomized study of endovenous radiofrequency obliteration (closure procedure) versus ligation and stripping in a selected patient population (EVOLVeS Study).
Lurie F, Creton D, Eklof B, Kabnick LS, Kistner RL, Pichot O, Schuller-Petrovic S, Sessa C.
Straub Foundation, Straub Clinic and Hospital, 1100 Ward Avenue, Suite 1045, Honolulu, HI 96814, USA. tedlurie@yahoo.com

PURPOSE: This study was designed as a prospective multicenter randomized comparison of procedure-related complications, patient recuperation, and quality-of-life outcomes between patients undergoing vein stripping with high ligation and patients undergoing great saphenous vein (GSV) obliteration with temperature-controlled radiofrequency ablation without adjunctive high ligation (Closure procedure). METHODS: Eighty-five patients (86 limbs) from five sites (France, 2; Austria, 1; United States, 2) were randomly allocated to undergo radiofrequency obliteration (RFO) or stripping and high ligation (S&L). Final analysis included data for 44 limbs in the RFO group and 36 limbs in the S&L group. Follow-up examinations were performed at 72 hours, 1 week, 3 weeks, and 4 months. All patients completed the CIVIQ2 quality-of-life (QOL) questionnaire and underwent clinical and ultrasound examinations at each follow-up visit. RESULTS: Immediate success on the day of treatment was reported for 95% (42 of 44) of limbs in the RFO group and 100% (36 of 36) of limbs in the S&L group. In seven RFO limbs (16.3%) a scan obtained 72 hours after the procedure showed flow in the proximal GSV. Five of these segments had reflux in the open segment. At 1 week two of these closed, and an additional segment closed at 3 weeks. In no cases did flow reappear after complete occlusion of the GSV. Time to return to normal activities was significantly less in the RFO group (mean, 1.15 days; 95% confidence interval [CI], 0.05-2.34) compared with the S&L group (mean, 3.89 days; CI, 2.67-5.12; P =.02). In the RFO group, 80.5% of patients returned to routine activities of daily living within 1 day, compared with 46.9% of patients in the S&L group (P <.01). Patients in the RFO group were able to return to work in 4.7 days (CI, 1.16-8.17), compared with 12.4 days (CI, 8.66-16.23) for the S&L group (P <.05). Analysis of the QOL surveys showed statistically significant differences in favor of the RFO group for global score and pain score during follow-up. The magnitude of the difference, however, progressively decreased between 1 week and 4 months. CONCLUSIONS: In the absence of significant complications, such as deep vein thrombosis and pulmonary embolism, severe neuritic sequelae, and skin burns, there are significant early advantages to endovascular obliteration of the GSV compared with conventional vein stripping.

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Chir Ital. 2003 Jul-Aug; 55(4): 555-60.
[Day care varicose vein surgery in elderly patients. 10 years of experience]
[Article in Italian]
Canonico S, Campitiello F, Santoriello A, Apperti M, De Bellis W, Califano U.
Sezione di Chirurgia, Dipartimento di Geriatria, Gerontologia e Malattie del Metabolismo, Facolta di Medicina e Chirurgia, Seconda Universita degli Studi di Napoli.

At present the surgical treatment of lower limb varicose veins is performed mainly as day case surgery. Since 30% of elderly people suffer from this disease, the feasibility of phlebological operations in elderly patients in a day care setting is an emerging problem. All patients (2032 patients) who underwent varicose vein surgery in our Geriatric Surgery Department over a 10-year period from January 1993 to December 2002 were evaluated retrospectively; 312 patients (15.35%) were aged above sixty-five years. In this group of elderly patients, 214 (68.6%) were operated on as inpatients and 98 (31.4%) as day care cases; in the younger group, 60.23% were treated in a day care regimen. All patients were examined and selected depending on general conditions, local conditions and logistics. Among the general conditions the exclusion criteria for elderly patients were concomitant diseases (43.9%) and anxiety (17.8%); as a consequence of local conditions, 31 patients (14.5%) with extensive bilateral varices and 27 patients (12.6%) with complicated recurrent disease were excluded from day care surgery; 24 patients (11.2%) were excluded because of logistics. Almost half (44.9%) of the elderly patients required multiple admissions for diagnostic investigations. The elderly patients underwent fewer saphenous strippings (7.1% vs 15.9%) and below-knee strippings (48.0% vs 56.9%); on the other hand, there were more operations on perforating veins (7.1% vs 1.4%), more varicectomies 10.2% vs 1.7%) and more skin grafts for ulcers (8.2% vs 2.2%). No problems occurred during the interventions and none of the patients had to be re-admitted to hospital for complications. This study provides evidence that varicose veins can be safely managed in a day care unit even in elderly patients, though careful preoperative selection is necessary.

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Ugeskr Laeger. 2003 Jul 28; 165(31): 3013-5.
[Treatment of recurrent varices in the region of the long saphenous vein. A follow-up study]
[Article in Danish]
Klitfod L, Baekgaard N.
Karkirurgisk Afdeling B, Amtssygehuset i Gentofte, DK-2900 Hellerup.

INTRODUCTION: The recurrence rate for varicosities is up to 40%, which leads to reoperation for many patients. The purpose of this study was to evaluate the results after stripping the long saphenous vein in addition to the reoperation in the groin. The study was designed as a retrospective follow-up study and was set at the department of vascular surgery, Amtssygehuset i Gentofte. MATERIAL AND METHODS: The operations were performed from January 1st to the end of December 2000 and consisted of reoperation in the groin and stripping of the long saphenous vein from groin to knee in 39 patients with 44 legs which had been operated. No patients had had their saphenous vein stripped earlier. The follow-up consisted of duplex scanning and the mean follow-up time was 18 months. RESULTS: Thirty legs (68%) were cured, twelve (27%) had reflux in the thigh--eight from a Hunterperforant and four in a long saphenous vein duplication. Two (5%) had remaining reflux in the groin. DISCUSSION: The recurrence rate in the groin (5%) is acceptable. Stripping of the long saphenous vein in addition to reoperation in the groin reduces the recurrence rate. The recurrence rate at the thigh is not acceptable and a possible explanation for this is the potential role of some kind of long saphenous vein duplications. Half of the patients with recurrence are offered a new operation. We believe that the operating surgeon should focus more on duplication of the vein at the pre-operative duplex scanning in order to reduce the recurrence rate further. New varicosities can arise from an insufficient Hunterperforant even when the whole superficial system is stripped.

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Ugeskr Laeger. 2003 Jul 28; 165(31): 3009-13.
[Recurrence after surgery of varices in the region of the long saphenous vein]
[Article in Danish]
Kjeld T, Baekgaard N.
Amtssygehuset i Gentofte, Karkirurgisk Afdeling B. thomaskjeld@hotmail.com

The article documents that among patients with saphenofemoral reflux inadequate surgery on the saphenofemoral junction was the cause of recurrence in 40% and 43% respectively of patients treated at hospitals and in out-clinics, but in only 14% when operation was performed by a specialized vascular surgeon. The causes of recurrence are described in the literature as follows: inadequate ligation, recanalisation, neovascularisation, non-saphenofemoral reflux, long saphenous vein duplication, incompetent perforator veins and inadequate stripping of the long saphenous vein. Our examination of the past ten years of literature in this area leads to the conclusion that patients with varicose veins caused by saphenofemoral reflux should be examined clinically as well as with colour-Doppler-ultrasonography. The main cause of recurrence is insufficient surgery. The surgeon may reduce recurrence rates by combining stripping of the long saphenous vein to the knee including duplications with thorough ligation of the saphenofemoral junction and ligation of adjacent side-branches. Stab avulsions are obligatory.

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Dermatol Surg. 2003 Jun; 29(6): 616-9.
Transilluminated powered phlebectomy: advantages and disadvantages of a new technique.
Shamiyeh A, Schrenk P, Huber E, Danis J, Wayand WU.
Ludwig Boltzmann Institute for Operative Laparoscopy at the Second Surgical Department, Academic Teaching Hospital, Linz, Austria. andreas.shamiyeh@aon.at

BACKGROUND: Transilluminated powered phlebectomy is a new procedure for minimal invasive varicose vein surgery. OBJECTIVE: To evaluate this technique for its benefit and the technique-related risks and complications. METHODS: Thirty patients were prospectively operated with this new technique by the same surgeon (11 of them bilaterally [41 legs in all]). According to the sonography, sapheno-femoral-junction ligation and stripping of the long saphenous vein were done if necessary. The phlebectomy of the side branches was done with the new system (Trivex System/Smith and Nephew). The postoperative follow-up was at 10 days and 6 weeks. RESULTS: There was no intraoperative complication. The mean operation time per leg was 40 minutes. Twenty-five patients had an uneventful postoperative course. Twenty two have been very satisfied with the cosmetically result. Two patients required reoperation because of postoperative hematoma. One patient developed a seroma, which could be managed via puncture. One patient developed persistent brown scar. The overall morbidity was 12.2%. CONCLUSION: Using transilluminated powered phlebectomy, multiple and large incisions could be reduced. A perfect cosmetic outcome might be reached if the surgeon is aware of technique-related complications. To evaluate the real value of this technique, further randomized trials are necessary.

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Angiology. 2003 May-Jun; 54(3): 307-15.
Foam-sclerotherapy, surgery, sclerotherapy, and combined treatment for varicose veins: a 10-year, prospective, randomized, controlled, trial (VEDICO trial).
Belcaro G, Cesarone MR, Di Renzo A, Brandolini R, Coen L, Acerbi G, Marelli C, Errichi BM, Malouf M, Myers K, Christopoulos D, Nicolaides A, Geroulakos G, Vasdekis S, Simeone E, Ricci A, Ruffini I, Stuard S, Ippolito E, Bavera P, Georgiev M, Corsi M, Scoccianti M, Cornelli U, Caizzi N, Dugall M, Christopoulos D, Veller M, Venniker R, Cazaubon M, Griffin M.
Irvine 2 Vascular Laboratory, Department Biomedical Sciences, and San Valentino Vascular Screening Project, Chieti University, Pescara, Italy. cardres@pe.abol.it

The study compared, by a prospective, randomized method, 6 treatment options: A: Sclerotherapy; B: High-dose sclerotherapy; C: Multiple ligations; D: Stab avulsion; E: Foam-sclerotherapy; F: Surgery (ligation) followed by sclerotherapy. Results were analyzed 10 years after inclusion and initial treatment. Endpoints of the study were variations in ambulatory venous pressure (AVP), refilling time (RT), presence of duplex-reflux, and number of recurrent or new incompetent venous sites. The number of patients, limbs, and treated venous segments were comparable in the 6 treatment groups, also comparable for age and sex distribution. The occurrence of new varicose veins at 5 years varied from 34% for group F (surgery + sclero) and ligation (C) to 44% for the foam + sclero group (E) and 48% for group A (dose 1 sclero). At 10 years the occurrence of new veins varied from 37% in F to 56% in A. At inclusion AVP was comparable in the different groups. At 10 years the decrease in AVP and the increase in RT (indicating decrease in reflux), was generally comparable in the different groups. Also at 10 years the number of new points of major incompetence was comparable in all treatment groups. These results indicate that, when correctly performed, all treatments may be similarly effective. "Standard," low-dose sclerotherapy appears to be less effective than high-dose sclero and foam-sclerotherapy which may obtain, in selected subjects, results comparable to surgery.

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ANZ J Surg. 2003 May; 73(5): 267-74.
Intermediate to long-term results of repairing incompetent multiple deep venous valves using external valvular stenting.
Lane RJ, Cuzzilla ML, McMahon CG.
The Mater Hospital, Peninsular Private Hospital and Dalcross Private Hospital, Sydney, Australia. pulse@onclick.net

INTRODUCTION: Chronic venous insufficiency is a major cause of morbidity in the community. The purpose of the present study was to assess the efficacy and safety of repairing multiple deep venous valves with an External Valvular Stent. METHODS: Forty-two limbs with chronic venous disease were operated on between 1987 and 1991. The patients included in the present series have now had more than 5 years of follow up (mean: 7.9 years; range: 5.4-11.9 years). Most patients had primary deep venous incompetence. There were 125 valve repairs out of 146 venographically suitable valves primarily in the superficial femoral and popliteal veins (2.98 per limb). Follow up was incomplete because of the duration of the trial. RESULTS: Following surgery ulcer areas decreased from a mean preoperative value of 12.9 cm2 to 1.2 cm2 at 86 months with almost 80% of the ulcers healed. All symptoms, pain, swelling, cramps and pigmentation were improved at a statistically significant level. The 90% infrared photoplethysmography recovery time almost doubled from 6.7 s preoperatively to 12.4 s at 36 months and were unchanged in the long term. Venous pressures were only significant at 12 months post implantation. Using multivariant analysis, the number of stents implanted was statistically associated with an increased number of ulcers healing. The site of venous valve repairs seems to be irrelevant to all of the variables. CONCLUSION: Multiple deep venous valve repairs are appropriate and the best form of treatment for specifically selected individuals with primary deep venous incompetence.

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World J Surg. 2003 May; 27(5): 551-3. Epub 2003 Apr 28.
Stripping operation with sclerotherapy for primary varicose veins due to greater saphenous vein reflux: three-year results.
Miyazaki K, Nishibe T, Sata F, Imai T, Kudo FA, Flores J, Miyazaki YJ, Yasuda K.
Department of Cardiovascular Surgery, Hokkaido University School of Medicine, Kita-14, Nishi-5, Kita-Ku, Sapporo 060-8648, Japan. jungeka@med.hokudai.ac.jp

The purpose of this study was to compare the recurrence-free rates of stripping with varicectomy and stripping with sclerotherapy for the treatment of primary varicose veins due to greater saphenous vein insufficiency. This is a multicenter retrospective analysis of 186 patients and 220 limbs treated for primary varicose veins due to greater saphenous vein reflux from January 1996 to December 1997. The difference between the two groups was evaluated by the Chi(2) test or t-test. The recurrence-free rates were estimated by the Kaplan-Meier life-table method. The mean follow-up period was 3.2 +/- 1.1 years. The clinical backgrounds of patients with varicectomy stripping and sclerotherapy stripping were not significantly different between the two groups. The overall recurrence-free rates at 1 and 3 years were 97.0% and 91.4%, respectively. The recurrence-free rates at 3 years were 93.5% for stripping with varicectomy and 88.6% for stripping with sclerotherapy. No statistical difference was found between the two groups. The recurrence rate after stripping with sclerotherapy was equivalent to that after stripping with varicectomy. Thus concurrent varicectomy can be replaced with sclerotherapy.

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Eur J Vasc Endovasc Surg. 2003 May; 25(5): 473-5.
Hook phlebectomy versus transilluminated powered phlebectomy for varicose vein surgery: early results.
Scavee V, Lesceu O, Theys S, Jamart J, Louagie Y, Schoevaerdts JC.
Department of Thoracic and Cardiovascular Surgery, University Clinics of Mont-Godinne, Universite Catholique de Louvain, 1 Avenue G. Therasse, B-5530 Yvoir, Belgium.

OBJECTIVES: to compare Transilluminated Powered Phlebectomy (TIPP) (TriVex System) with Muller's hook phlebectomy. MATERIALS AND METHODS: between January and April 2001, 40 patients (group 1) undergoing TIPP were non-randomly compared to 40 patients undergoing Muller's hook phlebectomy (group 2) in the course of conventional vein stripping and perforator ligation. All patients had at least C2 CEAP disease. RESULTS: hospital stay averaged 2 days (range 1-3 days; median 2 days) and was similar for the two groups. TIPP took significantly longer (56+/-12 vs 45+/-10 min, p<0.001) but was associated with significantly fewer incisions (6 [2-8] vs 8 [4-21], p<0.001). The mean pain score (out of 10) at 2 and 7 days and 6 weeks was 5, 2 and zero after TIPP and 4, 2 and zero after hook phlebectomy. The incidence of postoperative haematoma formation was significantly higher after TIPP (45 vs 25%, p=0.06), especially in the calf region (25 vs 2.5%,p =0.003). CONCLUSION: TIPP was slower (although speed increased with practice) associated with more haematoma (although this reduced with practice) and fewer incisions. In other respects (pain, cosmetic satisfaction, other complications, residual varices) it was not significantly different from hook phlebectomy. Greater clinical experience with the technique and randomized studies are required to determine whether TIPP is a valuable addition to our armamentarium.

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Ann Vasc Surg. 2003 May; 17(3): 290-5. Epub 2003 Apr 22.
Treatment of varicose veins: an assessment of intraoperative and postoperative compression sclerotherapy.
Iwamoto S, Ikeda M, Kawasaki T, Monden M.
Department of Surgery and Clinical Oncology, Graduate School of Medicine, Osaka University, Osaka, Japan.

Since thrombotic complications, such as superficial thrombophlebitis and subsequent skin pigmentation, are common after sclerotherapy, we conducted a study to evaluate whether combining sclerotherapy with ligation of varicose veins minimizes complications and what timing for sclerotherapy would be most beneficial-accompanying surgery or several weeks postsurgery. Surgical intervention and compression sclerotherapy were performed consecutively on 111 limbs (group A), and sclerotherapy was performed 28 days after surgical intervention on 87 limbs (group B). The volume of sclerosant used and the frequency of complications (thrombus formation and pigmentation) were analyzed. Plasma levels of thrombin-antithrombin III complex (TAT) and D-dimer (DD), as markers for activation of coagulation, were compared. In group A, the total volume of sclerosant used in patients with complications was significantly higher than that in patients without complications. The frequency of thrombus formation and of pigmentation was significantly lower (p <0.01) in group B (10% and 18%, respectively) than in group A (21% and 37%, respectively). The plasma levels of TAT 7 days after treatment were significantly lower in group B (3.4 +/- 1.2 mg/L) than in group A (4.9 +/- 1.1 mg/L). Performing compression sclerotherapy 28 days after surgical intervention is effective for reducing complications and a good alternative for patients with an underlying hypercoagulable state.

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Ann Vasc Surg 2003 Apr 22; [epub ahead of print]
Treatment of Varicose Veins: An Assessment of Intraoperative and Postoperative
Compression Sclerotherapy.
Iwamoto SI, Ikeda M, Kawasaki T, Monden M.
Department of Surgery and Clinical Oncology, Graduate School of Medicine, Osaka University, Osaka, Japan.

Since thrombotic complications, such as superficial thrombophlebitis and subsequent skin pigmentation, are common after sclerotherapy, we conducted a study to evaluate whether combining sclerotherapy with ligation of varicose veins minimizes complications and what timing for sclerotherapy would be most beneficial-accompanying surgery or several weeks postsurgery. Surgical intervention and compression sclerotherapy were performed consecutively on 111 limbs (group A), and sclerotherapy was performed 28 days after surgical intervention on 87 limbs (group B). The volume of sclerosant used and the frequency of complications (thrombus formation and pigmentation) were analyzed. Plasma levels of thrombin-antithrombin III complex (TAT) and D-dimer (DD), as markers for activation of coagulation, were compared. In group A, the total volume of sclerosant used in patients with complications was significantly higher than that in patients without complications. The frequency of thrombus formation and of pigmentation was significantly lower (p <0.01) in group B (10% and 18%, respectively) than in group A (21% and 37%, respectively). The plasma levels of TAT 7 days after treatment were significantly lower in group B (3.4 +/- 1.2 mg/L) than in group A (4.9 +/- 1.1 mg/L). Performing compression sclerotherapy 28 days after surgical intervention is effective for reducing complications and a good alternative for patients with an underlying hypercoagulable state.

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Eur J Vasc Endovasc Surg 2003 Apr;25(4):313-8
Minimally invasive surgical management of primary venous ulcers vs. compression treatment: a randomized clinical trial.
Zamboni P, Cisno C, Marchetti F, Mazza P, Fogato L, Carandina S, De Palma M, Liboni A.
Department of Surgical, Anaesthesiological, and Radiological Sciences, Day-Surgery Unit, University of Ferrara, Italy.

OBJECTIVES: to compare minimally invasive surgical haemodynamic correction of reflux (CHIVA) with compression in the treatment of venous ulceration.DESIGN: prospective randomised study. MATERIALS AND METHODS: from a cohort of 80 patients with 87 venous leg ulcers, 47 were randomised to either surgery or compression. RESULTS: at a mean follow-up of 3 years, healing was 100% (31 days) in the surgical and 96% (63 days), in the compression group (p<0.02). The recurrence rate was 9% in the surgical and 38% in the compression group (p<0.05). In the surgical group, all plethysmographic parameters except ejection fraction, had improved significantly at 6 months in the surgical group, and at 3 years residual volume fraction remained in the normal range. Finally, quality of life significantly improved in the operated group. CONCLUSIONS: this study supports the effectiveness of surgical therapy for leg ulceration secondary to superficial venous reflux.

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Dermatol Surg 2003 Mar;29(3):221-6
Ambulatory phlebectomy versus compression sclerotherapy: results of a randomized controlled trial.
de Roos KP, Nieman FH, Neumann HA.
Department of Dermatology, Bernhoven Hospital, Veghel, The Netherlands. kpdr@wish.net

BACKGROUND: Although no randomized controlled trial has assessed the effects of either compression sclerotherapy or ambulatory phlebectomy, both techniques are used to treat varicose veins worldwide. We performed a randomized controlled trial to compare recurrence rates of varicose veins and complications after compression sclerotherapy and ambulatory phlebectomy. METHODS: From September 1996 to October 1998, we randomly allocated 49 legs to compression sclerotherapy and 49 legs to ambulatory phlebectomy. Our primary outcome parameters were as follows: recurrence rates at 1 and 2 years and complications related to therapy. Eighty-two patients were included, of whom 16 were included with both of their legs. The number of treated legs was therefore 98, but two patients were lost to follow-up. RESULTS: One year recurrence amounted to 1 out of 48 for phlebectomy and 12 out of 48 for compression sclerotherapy (P<0.001); at 2 years, six additional recurrences were found, but then solely for compression sclerotherapy (P<0.001). Significant differences in complications occurring more in phlebectomy than in compression sclerotherapy therapy were blisters, teleangiectatic matting, scar formation, and bruising from bandaging. CONCLUSION: Our results show that ambulatory phlebectomy is an effective therapy for varicose veins of the leg. Recurrence rates are significantly lower than for compression sclerotherapy therapy. If varicose veins persist 4 weeks after compression sclerotherapy, it can be argued that to reduce the risk of future recurrence ambulatory phlebectomy should be considered as the better treatment option.

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Ned Tijdschr Geneeskd 2003 Jan 18;147(3):117-20
[Favorable results with duplex-guided compression sclerotherapy for varices of the small saphenous vein; a retrospective study]
[Article in Dutch]
Bullens-Goessens YI, Heij JF, Veraart JC.
Academisch Ziekenhuis, afd. Dermatologie, Postbus 5800, 6202 AZ Maastricht.

OBJECTIVE: Assessment of the efficacy of duplex-guided compression sclerotherapy in patients with varices of the small saphenous vein (SSV). DESIGN: Retrospective. METHOD: Data were collected from 109 patients (14% male and 86% female; average age 51.4 years (SD: 10.6)) with 121 SSV varices which were sclerosed under duplex guidance with polidocanol 3% during the period 1 December 1998-31 May 2001 in the Dermatology department at Maastricht University Hospital, the Netherlands. After-care consisted of a compression bandage for 1 week and a therapeutic elastic stocking for 6 weeks. Check-ups took place after 3-6 months and after 12 months. Sclerosis was repeated if the procedure had failed. Success was defined as occlusion or by the absence of reflux and a reduction in the complaints. RESULTS: After 3-6 months the treatment was successful in 88/113 varices (78%) for which data were available, and after 12 months treatment was successful in 46/57 (81%). CONCLUSION: Sclerosis of the SSV under duplex guidance, with repeat treatment if required, gave favourable results.

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Rozhl Chir 2003 Jan;82(1):49-53
[Surgery of the saphenous-popliteal junction: a delicate procedures with potential risks]
[Article in Czech]
Kaspar S, Danek T, Maixner R, Stiegler P.
Flebocentrum Hradec Kralove.

The authors evaluate the results achieved in two groups of patients operated on for varicose veins in small saphenous vein (SSV) territory in 3 year interval. In the first group gathered from January to December 1998 (114 patients--36 men and 78 women, 123 procedures--118 primary and 5 re-do) the operative indication was based on the clinical examination and continual doppler evaluation. These patients were operated on in general, spinal or local and flash general anaesthesia. In the second group gathered in the same period of the year 2001 (72 patients--21 men and 51 women) 75 procedures were performed (3 patients with bilateral operation). In this group, 49 patients with 50 procedures were selected. The diagnosis was based not only on clinical and continuous doppler examination, but mainly on colour flow duplex mapping. The operation was performed on strictly ambulatory basis using pure local anaesthesia completed with small dose of sedation. Any patient needed complementary sclerotherapy one month after procedure. In mid-term follow-up complementary conservative treatment was necessary in 51 p.c. of the whole series. CONCLUSION: Use of colour coded duplex ultrasound in preoperative evaluation of varicose veins patients enabled us to precise preoperative diagnosis, to diminish the number of aggressive surgical procedures in favour of less traumatic operations and to perform this surgery on ambulatory basis. Nevertheless, small sahenous vein surgery still remains delicate and sometimes also hazardous.

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Int Angiol 2002 Jun;21(2 Suppl 1):46-51
Phlebectomy. Technique, indications and complications.
Ramelet AA.
Place Benjamin-Constant 2, Lausanne, CH-1003 Switzerland.

Phlebectomy, first described by Aulus Cornelius Celsus (25 BC - 45 AD), was re-invented 40 years ago by Dr. Robert Muller, in Neuchatel, Switzerland. This safe, esthetic, effective and economical operative technique has now been fully developed and adopted all over the world. Phlebectomy hooks enable venous extraction through minimal skin incisions (1-3 mm) or even needle punctures, assuring complete and definite eradication of the veins. The small size of the skin incisions usually results in little or no scarring, contrary to that found in classical venous surgery, and avoids the possible complications of sclerotherapy, such as skin necrosis or residual hyperpigmentation. Sites particularly appropriate for ambulatory phlebectomy include incompetent saphenous veins (except the sapheno-femoral and in most cases the sapheno-popliteal junctions), their major tributaries, perforating, groin pudendal veins, reticular veins (popliteal fold, lateral thigh and leg) and veins of the ankles and the dorsal venous network of the foot. Curettage of telangiectasias is a less well known indication, but it is also quite effective in removing networks of thick blue spider veins. Ambulatory phlebectomy of body areas, other than the legs, include dilated periorbital, temporal or frontal venous networks and venous dilatation of the abdomen, arms or dorsum of the hands. Long term results, if the indications and technique were correct, are excellent. Complications, in skillful hands, seldom occur. They may be classified as cutaneous, vascular, neurological or general and are usually benign.

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Int Angiol 2002 Jun;21(2 Suppl 1):40-5
Sclerotherapy of varicose leg veins. Technique, indications and complications.
Kern P.
Specialist in FMH Angiology, Internal Medicine, Vevey, Switzerland. phkern@bluewin.ch

The aim of treatment by sclerotherapy is the fibrous occlusion of varicose veins and the absence of recanalization of an intravascular thrombus. Modern sclerotherapy started at the beginning of the 20(th) century in Europe. Tournay in France, Sigg in Switzerland and Fegan in Ireland developed different schools of practice. Recently ultrasound-guided sclerotherapy has appeared, mainly for the treatment of saphenous trunks and incompetent perforating veins. The precise diagnosis of varicose vein disease and the recognition of the most proximal point of reflux dictates the choice of optimal treatment and reduces the risk of recurrence and complications such as pigmentation or matting. The risk of complications depends on the agent used, its concentration and the quantity injected. Sclerotherapy is the treatment of choice for spider veins and is indicated in the treatment of reticular and short saphenous varicose veins. There is currently no consensus on the place of sclerotherapy in the treatment of the long saphenous vein and incompetent perforating veins. Neither is there a consensus on the type and duration of the compression to be applied after sclerotherapy. Sclerotherapy is safe and in the hands of experts the risk and secondary side effects of the treatment are minimal.

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Vasc Endovascular Surg 2002 Jan-Feb;36(1):41-50
Subfascial endoscopic perforator vein surgery in patients with post-thrombotic
venous insufficiency—is it justified?
Kalra M, Gloviczki P, Noel AA, Rooke TW, Lewis BD, Jenkins GD, Canton LG, Panneton JM.
Division of Vascular Surgery, Mayo Clinic, Rochester, MN 55905, USA.

Previous results following subfascial endoscopic perforator vein surgery were reported to be worse in post-thrombotic syndrome than in limbs with primary valvular incompetence. This report comprises a larger patient cohort with longer follow-up. The goal of this study was to determine if subfascial endoscopic perforator vein surgery is justified in patients with post-thrombotic venous insufficiency. The clinical data of 91 consecutive patients who underwent subfascial endoscopic perforator vein surgery with or without superficial reflux ablation over a 7-year period from May 1993 to June 2000 were retrospectively analyzed. Fifty-four females and 37 males (median age, 53 years; range, 20-77) underwent 103 subfascial endoscopic perforator vein surgery procedures. Forty-two limbs were classified as C6 (active ulcer), 34 as C5 (healed ulcer), and 24 as C4 (lipodermatosclerosis). Thirty procedures were performed in post-thrombotic limbs. Concomitant superficial reflux ablation was performed in 74 limbs (72%); saphenous vein stripping had been previously performed in 29 (28%). Deep venous incompetence was present in 89% of limbs; 13% had venous outflow obstruction on plethysmography. Cumulative ulcer healing in post-thrombotic limbs was not significantly different from limbs with primary valvular incompetence; 30-, 60-, and 90-day healing rates were 44%, 72%, and 72% vs 39%, 70%, and 87%, respectively (p =
associated with delayed ulcer healing (p = 0.02). Cumulative ulcer recurrence in all limbs was 4%, 20%, and 27% at 1, 3, and 5 years, respectively. Ulcer recurrence in post-thrombotic limbs was higher than in limbs with primary valvular incompetence at 1, 3, and 5 years; 16%, 47%, and 56% vs 0%, 8%, and 15%, respectively (p = 0.001). Recurrent ulcers were small, superficial, and easier to heal. Clinical improvement was significant even in post-thrombotic limbs; median clinical score decreased from 9.5 to 3 (p = 0.001), and median outcome score was +2 (mean 1.9; range, -1 to 3). Median clinical score in patients with primary valvular incompetence improved from 6 to 1.5 (p = 0.0001). Subfascial endoscopic perforator vein surgery with superficial reflux ablation promoted ulcer healing, improved clinical outcome, and resulted in a low long-term ulcer recurrence rate in limbs with primary valvular incompetence. Despite good clinical outcome in post-thrombotic limbs, ulcer recurrence was high. These results imply that the role of subfascial endoscopic perforator vein surgery with superficial reflux ablation in patients with post-thrombotic limbs continues to be controversial.

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Br J Community Nurs 2003 Mar;:17-22
Cohesive short stretch bandages in the treatment of venous leg ulceration.
Charles H, Moore C, Varrow S.
St Charles Hospital, North Kensington, London, UK. legs@mailbox.co.uk

These two case studies report how a cohesive short-stretch bandage was employed to promote venous leg ulcer healing. The two patients were obese and in addition had champagne bottle shaped legs. The cohesive short-stretch bandage was applied following the shape of the leg. By using a cohesive short-stretch bandage this provided bandage stability. This sustained compression resulted in oedema and pain reduction and promoted wound healing.

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AORN J 2002 Dec;76(6):981-90; quiz 991-4
Treating varicose veins with transilluminated powered phlebectomy.
Zotto LM.
Department of Smith and Nephew, Inc, Endoscopy Division, Andover, Mass., USA.

In the past, patients endured hours of surgery, many incisions, and multiple scars to manually remove painful, unsightly, swollen varicose veins. Patients now have a new treatment option. Endoscopic resection and ablation of superficial varicosities is possible using a powered vein resector, irrigated illuminator, and tumescent anesthesia. This article describes this new technique, called transilluminated powered phlebectomy, and explains how the procedure reduces the number of incisions and provides direct visualization of the veins as they are resected.

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Vestn Khir Im I I Grek 2002;161(5):33-5
[Minimally invasive surgery of varicose disease]
[Article in Russian]
Lesko VA, Ianushko VA, Malashchitskii EA, Zasimovich VN, Nazaruk AM, Moguchii VV, Efimovich LL.

The authors present a comparative analysis of operative treatment of 301 patients with the varicose disease operated on by traditional methods, and 206 patients subjected to minimally invasive operations. In the first group 8.3% of the patients had wound complications, 1.3% had ligature fistulas, 56% had neuropathies of ankles and feet. A comparison with the patients operated on by the minimally invasive method has shown that the operations were of shorter duration, with less blood loss, the postoperative period was 2.4 times shorter with inconsiderable pains not requiring narcotic anesthesia. Wound complications were noted in three times fewer cases, the number of neuropathies was as little as 3.9%, the period of temporary disablement was 1.4 times shorter.

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Bratisl Lek Listy 2002;103(11):434-6
Limited versus total stripping of vena saphena magna.
Herman J, Lovecek M, Svach I, Duda M.
2nd Department of Surgery, Teaching Hospital of Palackiensis University, Olomouc, Czech Republic. hermanj@post.cz

BACKGROUND: There are two different ways to operate on patients with varicose veins. OBJECTIVES: Prospective evaluation of two groups of patients operated on in two different ways to find out more convenient procedure for varicose veins surgery. METHODS: The results of 577 patients operated on for lower limbs varicose veins were evaluated. The patients were divided into two groups. The first group comprised of 125 patients in whom limited stripping of vena saphena magna was performed. The second group comprised of 397 patients in whom total stripping of vena saphena magna was applied. In the remaining 55 patients an operation other than VSM was performed in the venous system of lower limbs. During the follow-up three months after the operation the main attention was paid to a possible neurological disturbance. RESULTS: Much better results were observed in the group of patients treated with the method of limited stripping. Neurological disturbances occurred in two patients only (i.e. 1.6%). Within the other group disturbances were encountered in 28 patients (i.e. 7%). CONCLUSIONS: Limited stripping of vena saphena magna results in lower number of neurological disturbances. (Tab. 1, Ref. 10.).

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Cochrane Database Syst Rev 2002;(4):CD001486
Surgery for varicose veins: use of tourniquet.
Rigby KA, Palfreyman SJ, Beverley C, Michaels JA.
Sheffield Vascular Institute, Sheffield Teaching Hospitals NHS Trust, Vickers 16, Sheffield, UK.

BACKGROUND: Varicose vein surgery is a common surgical procedure but there is no consensus regarding the best surgical technique. The use of tourniquets during varicose vein surgery has been advocated as a means of reducing the potential for blood loss during the operation. OBJECTIVES: To identify whether the use of a tourniquet should be recommended when undertaking surgery for the management of primary varicose veins. SEARCH STRATEGY: The reviewers searched the Cochrane Peripheral Vascular Diseases Group trials register (last searched November 2001), thirteen electronic bibliographic databases, including the Cochrane Controlled Trials Register (CCTR) (last searched Issue 3, 2001), covering biomedical science, social science, health economic and grey literature (including current research). In addition, the reference lists of relevant articles were checked and various health services research related resources were consulted via the Internet. These included health economics and HTA organisations, guideline producing agencies, generic research and trials registers, and specialist sites. SELECTION CRITERIA: All studies described as randomised controlled trials that examined the use of tourniquets during surgery for patients with primary varicose veins were included. DATA COLLECTION AND ANALYSIS: Data from eligible studies were extracted and summarised independently by two reviewers. All studies were cross-checked independently by the reviewers. MAIN RESULTS: A total of twenty published papers and nineteen studies were identified. Only three of these were randomised controlled trials and were included in the review. Sixteen studies were excluded as they were non-randomised and one was a duplicate study. All three trials had a small sample size and reported the trial design, outcome measures and analysis poorly. There were also variations in the outcome measures used between the trials. In addition, there was no consistency on the reporting of mean and medians for blood loss during the operation. It was therefore not possible to pool the data to perform meta-analysis. However, the reported blood loss when using a tourniquet was between 0 and 16mls compared to between 107 to 133mls when not using a tourniquet (p<0.01). REVIEWER'S CONCLUSIONS: Although there were significant quality issues with the available evidence, the use of a tourniquet would appear to reduce blood loss during surgery. There were no reported differences between the use or non-use of a tourniquet in terms of complications and morbidity. However, the available trials were not of sufficient size to detect rarer complications such as nerve damage.

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Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2002 Nov;16(6):374-5
[Subfascial endoscopic perforator vein surgery in treatment of varicose of lower limb]
[Article in Chinese]
Li XX, Wu ZM, Wang SM.
Department of Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou Guangdong, P. R. China 510080.

OBJECTIVE: To investigate the therapeutic effect of subfascial endoscopic perforator vein surgery (SEPS) in treatment of varicose of the lower limb. METHODS: From 1999. 11 to 2000. 12, 108 patients with varicose of the lower limb underwent venous surgery and 34 of them were treated by SEPS. There were 16 males and 18 females aged 20-79(averaged 51.4 years). Thirty limbs (26 cases) had open ulcers and the diameter of ulcer was 1.5-12.0 cm. Eleven limbs (8 cases) had severe pigmentation and the skin changes had been presented for 1 month to 15 years. According to the severity of illness, flush saphenofemoral ligation, great saphenous vein stripping, percutaneous continuous venous circum suture, external femoral vein valve repair and SEPS were performed separately or simultaneously. RESULTS: Active ulcers healed in 19 limbs after 1 month, in 7 limbs after 3 months, and in the other 4 ulcers after skin transplantation. There was no ulcer recurrence during follow-up (ranged 9-22 months). CONCLUSION: SEPS can accelerate the healing of venous ulcers, and it is one of important methods in the treatment of chronic venous insufficiency.

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Eur J Vasc Endovasc Surg 2002 Nov;24(5):445-9
Can interposition of a silicone implant after sapheno-femoral ligation prevent recurrent varicose veins?
De Maeseneer MG, Giuliani DR, Van Schil PE, De Hert SG.
Department of Vascular Surgery, University Hospital Antwerp, Belgium.

OBJECTIVES: To investigate whether a silicone implant at the sapheno-femoral ligation site could prevent recurrent varicosities.MATERIALS AND METHODS: Two non-randomised groups of patients were studied prospectively. In group A 173 patients and 212 limbs had sapheno-femoral ligation, while 172 patients and 210 limbs additionally had a piece (2x3cm) of silicone sheet sutured to the saphenous stump to cover the anterior half of the common femoral vein. The implant was fixed in apposition to the deep vein by carefully closing the cribriform fascia. Colour duplex scanning was performed after 2 and 12 months. RESULTS: In the no implant group neovascularisation was observed in 35 (17%) after 12 months, but only in 13 (6%) limbs treated with a silicone implant (p<0.05). CONCLUSIONS: Interposition of a partition of silicone implant seems to lower the incidence of neovascularisation one year after saphenofemoral ligation. This technique may constitute an efficient method to prevent recurrence at the correctly ligated saphenous stump.

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MMW Fortschr Med 2002 Sep 5;144(35-36):22-7
[Kneipp hydrotherapy, sclerotherapy, crossectomy. What really helps in varicose veins and
spider veins?]
[Article in German]
Diehm C, Diehm N.
Innere Abt., Klinikum Karlsbad-Langensteinbach gGmbH, Akademisches Lehrkrankenhaus, Universitat Heidelberg. Curt.Diehm@kkl.srh.de

Varicose veins are irreversibly dilated epifascial and perforating veins resulting from degenerative vascular wall changes. Depending on etiology, they are classified into primary and secondary forms. The majority of the primary varicosities (75%) are hereditary. A clinical differentiation is made between varicosities of major vessels, side branch varicosities, varicosis of the perforating veins, reticular, and cutaneous vessel varicosities, with mixed forms also being known. Inspection and palpation are of predominant importance for the diagnosis, while Doppler and duplex ultrasonography serve mainly to document valvular incompetence. Treatment is determined by the findings, symptoms and the individual situation, and comprises, in addition to such general measures as activity, hot/cold foot baths, obliteration and surgery. A conservative alternative is rigorously applied compression treatment, which is also the most important concomitant measure to sclerotherapy and surgical operation.

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Lasers Surg Med 2002;31(4):257-62
Endovenous laser photocoagulation (EVLP) for varicose veins.
Chang CJ, Chua JJ.
Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan. chengjen@adm.cgmh.org.tw

BACKGROUND AND OBJECTIVES: Untreated varicose veins have significant morbidity and potential mortality. Treatment aims to relieve symptoms, improve appearance, and to prevent deterioration. Current therapeutic options include graduated compression stockings, sclerotherapy, ambulatory phlebectomy, surgical ligation, and stripping. Results of laser photocoagulation of vascular anomalies have been encouraging. Applying these concepts of laser-tissue interactions, we developed a new method of treatment for varicose veins of the lower extremities. STUDY DESIGN/MATERIALS AND METHODS: One hundred and forty-nine patients with 252 varicose greater saphenous veins underwent endovenous laser photocoagulation (EVLP) from January 1996 to January 2000. Subject's age ranged between 23 years 9 months and 80 years 7 months with a mean age of 50 years 8 months. There were 122 females and 27 males. Only patients with primary varicose veins and saphenofemoral reflux documented by Duplex ultrasound were treated. All patients received surgical ligation of the saphenofemoral junction (SFJ). EVLP was performed using the neodymium:yttrium-aluminium-garnet (Nd:YAG) (1,064 nm) laser, delivered with a 600 microm optical fiber. Laser power was set at 10 or 15 W, delivered with a pulse duration of 10 seconds. The outcome was compared before and after EVLP, based on the score of severity of the varicose veins by Hach's classification. RESULTS: The range of total delivered energy is from 9,200 to 20,100 J. The entire procedure was completed in 95-175 minutes (mean 122.33 minutes) for bilateral procedures, and 65-100 minutes (mean 81.07 minutes) for unilateral procedures. The follow-up period ranged from 12 to 28 months with a mean of 19 months. One hundred and forty-one patients with 244 legs involved (96.8%) demonstrated remarkable improvement (P < 0.05). Common early complications of EVLP are: local paraesthesia of the treated area in 92 legs (36.5%), ecchymosis and dyschromia in 58 legs (23.0%), superficial burn injury in 12 legs (4.8%), superficial phlebitis in four legs (1.6%), and localized hematoma in two legs (0.8%) at 3 weeks post-operatively. The final outcome showed no significant morbidity or mortality. All patients recovered completely. CONCLUSIONS: EVLP is a simple effective treatment modality for varicose veins. This less invasive method can minimize the complications of conventional surgery. Copyright 2002 Wiley-Liss, Inc.

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World J Surg 2002 Dec;26(12):1507-11
Long-term results of vein sparing varicose vein surgery.
Raivio P, Perhoniemi V, Lehtola A.
Department of Vascular Surgery, Helsinki University Central Hospital, Haartmaninkatu 4, Haartmaninkatu, FIN-00029 Helsinki, Finland. peter.ravio@hus.fi

The aim of this study was to assess the long-term functional outcome of vein sparing varicose vein surgery using handheld Doppler ultrasound (HHD). The series consisted of 171 consecutive day-case surgery patients operated on for uncomplicated lower limb varicose veins. Venous segments considered competent were spared based on clinical examination and HHD, which was performed preoperatively only when deemed necessary by the surgeon. After a mean follow-up of 8 years all patients were examined, a systematic HHD evaluation was performed, and the findings were classified according to the CEAP (Clinical, Etiological, Anatomical, Pathophysiological) classification, and disability scoring was performed. During the follow-up period 17% of the legs were reoperated or scheduled for reoperation. At follow-up 79% of all patients were asymptomatic without reoperation. In 24%, recurrent varicosities were present and venous reflux was demonstrated by HHD. Recurrence was two times more common when the saphenofemoral junction had originally been left intact. Of all recurrent cases, reflux was demonstrated in the long saphenous vein (LSV) above the knee in 62%, in the LSV below the knee in 7%, in the short saphenous vein (SSV) in 16%, in the posterior arch vein in 38%, and in a thigh perforator in 8%. Of the legs reoperated during the follow-up period 41% presented with venous reflux at the follow-up visit. We conclude that HHD efficiently reveals sites of reflux that have been missed during previous surgery and that a thorough preoperative HHD examination and marking of reflux routes is required.

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Vestn Khir Im I I Grek 2002;161(2):53-6
[Technology for sclerosurgical treatment of upper veno-venous reflux of the
large subcutaneous vein in varicose vein patients]
[Article in Russian]
Sukovatykh BS, Nazarenko PM, Belikov LN, Rodionov OA, Shcherbakov AN, Sukovatykh MB.

Under analysis were results of a complex ultrasound examination and the following treatment of 101 patients with varicose disease which had developed due to a high veno-venous ejection. The decision on the method of treatment depended on the variant of reflux spread and the degree of dilatation of the large subcutaneous vein. Four variants of spreading the reflux were established: in the inguinal area only (3.8%), along the femur to the level of the knee articulation (13.6%), femur and the upper third of the shin (66.8%), from the groin to the malleolus (15.8%). Selective interventions consisting in scleroobliteration or removal of the large subcutaneous vein within the limits of the femur or upper third of the shin were fulfilled in 84.2% of the patients. Sclerotherapy was used in veins having the diameter from 5 to 7 mm, sclerosurgery--with the diameter from 8 to 10 mm, surgical treatment in veins with the diameter more than 10 mm. The effectiveness of liquidation of the reflux was 95.2%.

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Ann Vasc Surg 2002 Jul;16(4):488-94
Powered phlebectomy (TriVex) in treatment of varicose veins.
Cheshire N, Elias SM, Keagy B, Kolvenbach R, Leahy AL, Marston W, Pannier-Fischer F, Rabe E, Spitz GA.
Department of Surgery, St. Mary's Hospital, London, UK.

This study assesses the operation of transilluminated powered phlebectomy for removal of varicose veins. It was a prospective, noncomparative, multicenter, pilot study designed to evaluate the safety and efficacy of the powered varicose vein extractor for ablation of primary varicose veins. A total of 114 patients (117 limbs) were recruited from four centers in Europe and four centers in the United States. Safety of the varicose vein extractor was evaluated by recording nature and severity of all adverse events and complications. Efficacy was assessed by the patient, an independent study nurse, and the surgeon. Operations were performed under general, spinal, or epidural anesthesia and tumescent anesthesia was added with infusions of dilute lidocaine with epinephrine. Transillumination was achieved with a specially designed cannula, and the vein extraction was done using a vein resector with a rotating tubular inner cannula encased in a stationary outer sheath dissector. Demographic information regarding the 28 men and 89 women included in the study are detailed. Eighty-four percent of the limbs were CEAP class 2 with only 16% being in classes 3 and 4. Accompanying greater saphenous vein stripping was done in 67% of the limbs in the United States and 88% in those in Europe. Proximal ligation only was used in one limb in the United States and eight in Europe. The study showed that transilluminated powered phlebectomy used in varicose vein removal is swift and efficacious with a conservation of operating time and the results being satisfactory to the patient and clinician alike.

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Vasc Endovascular Surg 2002 May-Jun;36(3):179-92
The treatment of varicose veins with external stenting to the saphenofemoral junction.
Lane RJ, Cuzzilla ML, Coroneos JC.
Dalcross Private Hospital, Sydney, Australia.

Presented are the experiences with 1,516 external valvular stents (Venocufft and Venocuff II) implanted at the saphenofemoral junction (SFJ) between 1985 and 2000. To assess the applicability of the procedure it was found that the appropriate implantation was performed in 34% of 310 consecutive venous procedures. To assess patient preference between external valvular stenting and simultaneous contralateral stripping, 56 consecutive patients were followed up at 3 months postoperatively. Four percent preferred stripping, 4% had no preference, and 92% preferred Venocuff IItrade mark implantation. Competence at the SFJ with specific duplex ultrasound indicators was 94% at 3 months (n = 100) and 90% at 4.8 years (n = 107). Minimal residual reflux (less than 50 mL/minute with maximum Valsalva) was present in the remainder but did not produce symptoms and very rarely progressed over the mean time of 5 years. The internal diameter (ID) of the long saphenous vein (LSV), 3 cm distal to the SFJ, changed from 7.6 +/- 2.3 mm to 4.9 +/- 1.1 mm (p < 0.001) and at the knee from 6.9 +/- 1.9 mm to 3.7 +/- 1.0 mm (p < 0.001). Patients presenting with underlying deep venous disease began with significantly higher ID, ie, 9.0 +/- 2.1 mm at the upper end of the LSV and 7.1 +/- 2.0 mm at the knee, but postoperatively the IDs reverted to those of postoperative patients with a normal deep venous system. To assess patients with recurrences, 366 limbs had simultaneous stripping and contralateral SFJ repair with the Venocuff II. Of these 33 (9%) had recurrences at 4.9 years, 82% of them on the stripping side, and on the repair side half of the recurrences had a competent SFJ (9%). Limbs with an incompetent lateral or anterior accessory system, with an incompetent SFJ (168), were compared with 11 matched randomized controls where stripping was performed. The recurrence rate was 1.2% versus 36% on the strip side. The follow-up for these cases was 6.4 years. Pregnancy (n = 14) produces a high recurrence rate, but stripping and valve repairs were not significantly different, ie, despite small numbers, there was a very strong tendency toward higher recurrence rates on the stripped side. The complication rate was small and the cost of the device is low. The method allows a repairable nonablative approach that can be offered in patients where no other surgical treatment can or should be offered. External stenting to the SFJ is the preferred option for early to moderate varicose veins involving the LSV where the clinical and ultrasonic indicators have been fulfilled.

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Magy Seb 2002 Apr;55(2):68-71
[Cryosurgery and endoscopy in the treatment of varicose veins]
[Article in Hungarian]
Vizsy L, Beznicza H, Batorfi J.
Nagykanizsa MJV, Korhaza, nos Sebeszeti Osztaly, 8800 Nagykanizsa.

Multiplex wide incisions and often deforming scars following varicose surgery are out of date. Nowadays cryoprobes are used to remove epifascial varicose veins, while endoscopy is used to treat transfascial (perforating) venous insufficiency. We analyse the results of 1000 cryovaricectomies performed in the last 8 years. Complications developed in 5.8%, mostly were self-limiting. It is a fast operation, offering good aesthetic result, and hospital stay is short. Subfascial endoscopic perforating veins surgery (SEPS) have been carried out in 2 years in 28 patients, 8 had active ulcers, combined operation have been performed in 20 patients. There were 3 wound complications, which was a very good result compared with high complication rate of earlier used open divisions. The biggest advantage of the procedure is, that it can be performed even if the ulcer is active, since the operation is performed on intact area. Both methods meet the requirements of minimal invasive surgery, with excellent cosmetic and functional results.

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J Vasc Surg 2002 May;35(5):958-65
Endovenous obliteration versus conventional stripping operation in the treatment of primary varicose veins: a randomized controlled trial with comparison of the costs.
Rautio T, Ohinmaa A, Perala J, Ohtonen P, Heikkinen T, Wiik H, Karjalainen P, Haukipuro K, Juvonen T.
Department of Surgery, Oulu University Hospital, Kajaanintie 50, SF-90230 Oulu, Finland. tero.rautio@oulu.fi

OBJECTIVE: The aim of this randomized study was to compare a new method of endovenous saphenous vein obliteration (Closure System, VNUS Medical Technologies, Inc, Sunnyvale, Calif) with the conventional stripping operation in terms of short-term recovery and costs. METHODS: Twenty-eight selected patients for operative treatment of primary greater saphenous vein tributary varicose veins were randomly assigned to endovenous obliteration (n = 15) or stripping operation (n = 13). Postoperative pain was daily assessed during the 1st week and on the 14th postoperative day. The length of sick leave was determined. The RAND-36 health survey was used to assess the patient health-related quality of life. The patient conditions were controlled 7 to 8 weeks after surgery, and patients underwent examination with duplex ultrasonography. The comparison of costs included both direct medical costs and costs resulting from lost of productivity of the patients. Costs that were similar in the study groups were not considered in the analysis. RESULTS: All operations were successful, and the complication rates were similar in the two groups. Postoperative average pain was significantly less severe in the endovenous obliteration group as compared with the stripping group (at rest: 0.7, standard deviation [SD] 0.5, versus 1.7, SD 1.3, P =.017; on standing: 1.3, SD 0.7, versus 2.6, SD 1.9, P =.026; on walking: 1.8, SD 0.8, versus 3.0, SD 1.8, P =.036; with t test). The sick leaves were significantly shorter in the endovenous obliteration group (6.5 days, SD 3.3 days, versus 15.6 days, SD 6.0 days; 95% CI, 5.4 to 12.9; P <.001, with t test). Physical function was also restored faster in the endovenous obliteration group. The estimated annual investment costs of the closure operation were US $3360. The other direct medical costs of the Closure operation were about $850, and those of the conventional treatment were $360. With inclusion of the value of the lost working days, the Closure treatment was cost-saving for society, and when 40% of the patients are retired (or 60% of the productivity loss was included), the Closure procedure became cost-saving at a level of 43 operations per year. CONCLUSION: Endovenous obliteration may offer advantages over the conventional stripping operation in terms of reduced postoperative pain, shorter sick leaves, and faster return to normal activities, and it appears to be cost-saving for society, especially among employed patients. Because the procedure is also associated with shorter convalescence, this new method may potentially replace conventional varicose vein surgery.

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Dermatol Surg 2002 Jan;28(1):52-5
Treatment of varicose and telangiectatic leg veins: double-blind prospective comparative trial between aethoxyskerol and sotradecol.
Goldman MP.
Department of Dermatology/Medicine, University of California, San Diego, USA. MGDERM@aol.com

BACKGROUND: One hundred twenty-nine patients were treated with either polidocanol (POL) or sodium tetradecyl sulfate (STS) to compare the efficacy and adverse sequelae of each agent. OBJECTIVE: To determine the safety and efficacy of two sclerosing solutions. METHODS: Each patient's leg veins that did not have incompetence from the saphenofemoral junction (SFJ) were divided into three categories by size (<1 mm, 1-3 mm, 3-6 mm). Each leg was randomly treated with either 0.25%, 0.5%, or 1.5% of STS or 0.5%, 1.0%, or 3% of POL respective of size. An independent, three-panel, blindly randomized photographic examination was obtained pretreatment and at 4 and 16 weeks. Patient satisfaction index and overall clinical improvement assessment were also obtained. RESULTS: All patients had an average of 70% improvement and were 70-72% satisfied in all vein categories treated with either solution. There was no significant difference in adverse effects between each group except for a decrease in ulcerations and swelling in the POL group. CONCLUSION: Both STS and POL are safe and effective sclerosing solutions for varicose and telangiectatic leg veins.

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Dermatol Surg 2002 Jan;28(1):11-5
Sclerosing foam in the treatment of varicose veins and telangiectases: history and analysis of
safety and complications.
Frullini A, Cavezzi A.
Studio Flebologico, Incisa Valdarno, Florence, Italy. alef@dada.it

OBJECTIVE: To review the use of sclerosing foam in the treatment of varicose veins, to describe the different techniques of foam preparation, and to report the complications of our 3-year experience with this treatment. METHOD: From November 1997 to the end of October 2000, 453 patients were treated with a sclerosing foam for large, medium, and minor varicosities with sodium tetradecylsulfate (STS) or polidocanol (POL). A first group of 257 patients (90 for minor varicosities and 167 for medium to large veins) received a sclerosing foam according to the Monfreux technique. From December 1999 to October 2000, 196 patients were treated with a sclerosing foam prepared according to Tessari's method (36 for minor size veins or teleangectasias and 170 for medium-large veins). Every patient was studied with (color-flow) duplex scanning before and after the treatment and large vein injections were administered under duplex guide. RESULTS: The immediate success rate was 88.1% in the first group for the medium-large veins. In the same districts we registered an early success rate in 93.3% for the patients treated with the Tessari's method. The complication rate (mostly minor complications) was 8.5% in the first group and 7.1% in the second group. CONCLUSION: The use of sclerosing foam may become an established therapy in the treatment of varicose veins with a high success rate, low cost, and low major complication rate. According to our actual experience and knowledge, the safe amount of foam should not exceed the 3-ml limit, but further advancements could come from standardization of the foam preparation technique.

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Cochrane Database Syst Rev 2002;(1):CD001732
Injection sclerotherapy for varicose veins.
Tisi PV, Beverley CA.
Department of Vascular Surgery, Bedford Hospital, Kempston Road, Bedford, Bedfordshire, UK, MK42 9DJ. pvtisi@rcsed.ac.uk

BACKGROUND: Injection sclerotherapy for varicose veins has been used widely since 1963, following popularisation of the technique by Fegan. The treatment aims to obliterate the lumen of varicose veins or thread veins, however, there is limited evidence regarding its efficacy. OBJECTIVES: To determine whether sclerotherapy is effective in terms of symptomatic improvement and cosmetic appearance; has an acceptable complication rate; and to define rates of symptomatic or cosmetic varicose vein recurrence following sclerotherapy. SEARCH STRATEGY: Publications describing randomised controlled trials (RCTs) of injection sclerotherapy for varicose veins (excluding comparisons with surgery) were sought through EMBASE and MEDLINE (from inception to March 2001) and hand-searching relevant journals, using the search strategy described by the Cochrane Peripheral Vascular Diseases Review Group. Bibliographies of papers identified were examined for further RCTs. Manufacturers of sclerosants were contacted for further trial information. SELECTION CRITERIA: RCTs of injection sclerotherapy versus graduated compression stockings or 'observation', or comparing different sclerosants, doses and post-compression bandaging techniques on patients with symptomatic and/or cosmetic varicose veins or thread veins were considered for inclusion in the review. DATA COLLECTION AND ANALYSIS: Ten studies were included in the analysis. These compared: sodium tetradecyl sulphate (STD) versus an alternative sclerosant; sclerosant with or without local anaesthetic; application of Molefoam versus Sorbo pads to injection sites; elastic compression bandaging versus conventional bandaging; and short-term bandaging versus standard bandaging. Data were abstracted by both authors. MAIN RESULTS: No RCTs compared sclerotherapy to graduated compression stockings or other non-surgical treatments. Two studies compared STD to alternative sclerosants and found no significant differences in outcome or complication rates. Adding local anaesthetic to sclerosant reduced the pain from injection (one study) but had no other effects. Comparison of Molefoam and Sorbo pad pressure dressings found no difference in outcome for erythema (redness) or successful sclerosis. The degree and duration of elastic compression had no significant effect on varicose vein recurrence rates, cosmetic appearance or symptomatic improvement. Increased compression prevented slipping of dressings but caused increased discomfort, as did increasing duration of compression. REVIEWER'S CONCLUSIONS: Evidence from RCTs suggests that type of sclerosant, local pressure dressing, degree and length of compression have no significant effect on the efficacy of sclerotherapy for varicose veins. This supports the current place of sclerotherapy in modern clinical practice, which is usually limited to treatment of recurrent varicose veins following surgery, and thread veins. A comparison of surgery versus sclerotherapy would be valuable.

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