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Endovenous radiofrequency ablation for the treatment of varicose veins

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Ahmed Kayssi at University of Toronto
Ahmed Kayssi
Marc Pope
Marc Pope
Marc Pope
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Ivica Vucemilo
Ivica Vucemilo
Ivica Vucemilo
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Christiane Werneck
Christiane Werneck
Christiane Werneck
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Abstract

Varicose veins are a common condition that can be treated surgically. Available operative modalities include saphenous venous ligation and stripping, phlebectomy, endovenous laser therapy and radiofrequency ablation. Radiofrequency ablation is the newest of these technologies, and to our knowledge our group was the first to use it in Canada. Our experience suggests that it is a safe and effective treatment for varicose veins, with high levels of patient satisfaction reported at short-term follow-up. More studies are needed to assess long-term effectiveness and compare the various available treatment options for varicose veins.
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COMMENTARY • COMMENTAIRE
©2015 8872147 Canada Inc. Can J Surg, Vol. 58, No. 2, April 2015 85
Endovenous radiofrequency ablation for the
treatment of varicose veins
V
aricose veins affect approximately 26% of the adult population and are
a frequent cause of discomfort, loss of productivity and deterioration
in health-related quality of life.
1
Numerous therapies have been
de veloped for the treatment of this condition. Conventional open surgical
interventions include ligation of the great saphenous vein at the saphenofem-
or al junction and stripping. Smaller veins have also been treated with phlebec-
tomies. More recently, less invasive modalities, such as foam sclerotherapy,
endovenous laser therapy (EVLT) and endovenous radiofrequency ablation
(RFA), have also been used. While endovenous approaches are associated with
fewer postoperative complications, such as hematoma, pain or saphenous
nerve injury, there is currently no strong evidence to suggest an overall advan-
tage for any particular treatment approach.
2
The RFA procedure involves using a catheter electrode to deliver a high-
frequency alternating radiofrequency current that leads to venous spasm, col-
lagen shrinkage and physical contraction.
3
The patient’s leg is prepped with
antiseptic solution and draped in a sterile fashion. With ultrasound guidance,
the vein is cannulated, and local tumescent anesthetic is then injected around
the target venous segment. The catheter is then introduced through a sheath.
The radiofrequency current is then delivered, resulting in circular homogen-
eous denaturation of the venous collagen matrix and endothelial destruction at
a temperature of 110–120° C. Venous segments 3–7cm in length are treated
in 20-second cycles. Patients are instructed to wear 20–30 mm Hg graduated
elastic compression stockings for at least 14 days.
Compared with conventional open surgery, RFA can be performed in the
outpatient setting without the requirement for hospital admission or general
anesthesia. However, the procedure is not feasible in tortuous or very small or
large veins, and it may be less cost-effective than open surgery because of the
cost of the catheters.
To our knowledge, our institution was the rst in Canada to offer RFA for
the management of varicose veins using the venet procedure with second-
generation ClosureFast catheters (Covidien). Between 2010 and 2013,
173pa tients underwent RFA performed by 3 vascular surgeons. The average
age of the patients was 52 ± 14 years, and 143 (83%) of the patients were
women. Our patients were referred to the clinic either by their family doctors
Ahmed Kayssi, MD, MSc, MPH
Marc Pope MD, MSc
Ivica Vucemilo, MD
Christiane Werneck, MD, MScCH
Accepted for publication
Oct. 15, 2014
Correspondence to:
C. Werneck
Division of Vascular Surgery
University of Toronto
89 Queensway West, Suite 500
Mississauga ON L5B 2V2
christiane.werneck@utoronto.ca
DOI: 10.1503/cjs.014914
Varicose veins are a common condition that can be treated surgically. Available
operative modalities include saphenous venous ligation and stripping, phlebec-
tomy, endovenous laser therapy and radiofrequency ablation. Radiofrequency
ablation is the newest of these technologies, and to our knowledge our group was
the rst to use it in Canada. Our experience suggests that it is a safe and effective
treatment for varicose veins, with high levels of patient satisfaction reported at
short-term follow-up. More studies are needed to assess long-term effectiveness
and compare the various available treatment options for varicose veins.
Summary
COMMENTAIRE
86 J can chir, Vol. 58, N
o
2, avril 2015
or another vein clinic, and they underwent preoperative
Doppler ultrasonography to identify reux within the tar-
get vein. The decision to offer a patient RFA was based on
the target vein anatomy and diameter. The maximum vein
diameter considered for the procedure was 1.8cm, and the
minimum was 0.4 cm. Elderly patients also underwent
arterial duplex scans to rule out arterial insufciency.
Most (72%) patients underwent treatment of a single
limb, and 89% of patients underwent treatment of a single
vein. The great saphenous vein was most frequently
treated (81%), followed by the small saphenous (7%) and
the accessory great saphenous (1%).
Postoperatively, the median time that patients took off
work was 2 days. While 80 (69%) patients needed no post-
operative analgesia, 35 (30%) patients used over the coun-
ter oral analgesics, such as acetaminophen or ibuprofen.
Only 1 patient needed an opioid analgesic. Duplex ultra-
sonography performed 2–4 weeks after the procedure
demonstrated successful vein occlusion in 99% of patients.
Only 1 patient showed evidence of partial recanalization
on follow-up. Two (1%) patients reported persistent pain
at 30-day follow-up, and 6 (4%) patients demonstrated
skin discoloration. Eight (5%) patients with residual large
veins returned to our clinic after the follow-up period and
underwent phlebectomy procedures.
Telephone interviews were conducted several weeks after
the procedure to assess patient satisfaction. Of the 111 (65%)
patients contacted, 83% were extremely satised, 12% were
very satised, 3% were somewhat satised, and 2% were not
too satised with their RFA experiences. However, all of
those who responded indicated that they would have this
procedure again and would recommend it to a friend.
Our experience suggests that RFA is a safe and effective
treatment for the management of varicose veins that is
associated with a high success rate and patient satisfaction.
Only 1 patient in our series demonstrated target-vein
recanalization on follow-up. This was a cirrhotic patient
with a history of hepatic failure who was on chronic anti-
coagulation therapy for multiple medical comorbidities.
Her vein was also 1.5 cm in diameter, which was close to
the cutoff of 1.8 cm that we accept in our practice.
To our knowledge, our group is the rst to describe the
successful implementation of RFA in Canada, where public
health insurance guidelines have greatly restricted the criter ia
for reimbursing venous procedures and where many vein
surgeries are performed at private clinics. In the face of this
changing reimbursement landscape, we believe that RFA is a
viable alternative to more conventional open vein surgeries
and EVLT, which are more widely available in Canada.
Our work as well as studies by other groups will hope-
fully continue to enrich the debate on the most suitable
intervention for the management of venous disease. A
2011 review by Ontario’s Medical Advisory Secretariat
found that RFA was superior to open vein surgery when
comparing postoperative pain, duration of recovery, major
adverse effects and patient preference, while open surgery
was less costly than RFA.
4
However, the same review
found no evidence to suggest major differences in postop-
erative pain between RFA and EVLT when pain was
adjusted for analgesic use, and any differences did not per-
sist after 1-month follow-up. Furthermore, the 2 proced-
ures did not differ when comparing treatment effectiveness
or durability. This was mostly because of a lack of studies
that have assessed long-term recurrence after either treat-
ment. Prospective, long-term studies are thus clearly
needed to compare the clinical and cost-effectiveness of
both treatments and provide health care consumers with
the best standard of care.
Afliations: All authors are from the Division of Vascular Surgery,
Trillium Health Partners, University of Toronto, Mississauga, Ont.
Competing interests: None declared.
Contributors: All authors contributed substantially to writing and/or
revising and to the conception and design of the manuscript and
approved the nal version for publication.
References
1. Gloviczki P, Comerota AJ, Dalsing MC, et al. The care of patients
with varicose veins and associated chronic venous diseases: clinical
practice guidelines of the Society for Vascular Surgery and the Amer-
ican Venous Forum. J Vasc Surg 2011;53:2S-48S.
2. Nesbitt C, Eifell RK, Coyne P, et al. Endovenous ablation (radiofre-
quency and laser) and foam sclerotherapy versus conventional sur-
gery for great saphenous vein varices. Cochrane Database Syst Rev
2011;CD005624. Medline
3. Bergan JJ, Kumins NH, Owens EL, et al. Surgical and endovascular
treatment of lower extremity venous insufciency. J Vasc Interv Radiol
2002;13:563-8.
4. Health Quality Ontario. Endovascular radiofrequency ablation for
varicose veins: an evidence-based analysis. Ont Health Technol Assess
Ser 2011;11:1-93.
... Most of the patients usually presents with swelling and leg pain, severe limitations in normal daily activities due to superficial venous insufficiency and a poor quality of life, because it can progress to cause complications of venous hypertension including skin ulceration. For proper diagnosis, classification of severity and management of varicose vein it is essential to do physical examination and venous study [3,4]. ...
... The patients are between the ages of 20 and 40. 35 years old on average Greater saphenous vein ligation and stripping has been a very common surgical procedure for more than a century, however more recent investigations have cast doubt on this procedure [3,4]. Treatment options for varicose veins include surgery, endovenous treatments using RFA or LA-SER, external laser therapy, injectable sclerotherapy, and conservative maintenance [2,3]. ...
A comparative study between Trendelenburg procedure vs radiofrequency ablation for varicose vein surgery in a tertiary care hospital Chennai- A cross-sectional study
Article
Full-text available
  • Aug 2022
Background, One of the most popular surgical procedures, varicose vein surgery serves as a crucial teaching technique for aspiring surgeons. The great saphenous and short saphenous systems in the lower limbs, which are tortuous and dilated, are the veins most commonly affected by varicose veins. A vessel wall disease or valvular pathology is the cause of a varicose vein. People who work all day standing up typically have long-term effects. The Trendelenburg procedure involves several phlebotomies for the dilated veins below the knee, along with the juxta femoral flush ligation of saphenous veins and vein stripping up to below the knee. The less invasive radiofrequency ablation therapy has replaced the Trendelenburg method and is growing in popularity since it has fewer drawbacks. Venous tissue is thermally damaged when a high-frequency alternating current is employed to transmit electrical energy into the tissue. More research is needed to compare the Trendelenburg and radiofrequency in the chosen group with regard to early ambulation, early return to work, the severity of postoperative pain, recovery time, and complications. Methods An analytical cross-sectional study including 100 people with varicose veins was undertaken from June 2017 to July 2019 and lasted one year and eleven months.
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... This catheter electrode will deliver a radiofrequency with high-frequency, which leads to venous spasm, collagen shrinkage, and physical contraction. 11 To determine the efficacy of RFA, there are three factors that can be assessed, venous occlusion, recanalization, and absence of recurrent reflux. RFA showed a good occlusion rate in less than three months, about 97%. ...
... However, most of the symptoms of this injury don't affect the patient's quality of life. 11,14 RFA also has a better cosmetic result because it only needs a small incision for insertion of the device. The patient who underwent the RFA method also has a higher early recovery rate and quickly returns to work. ...
Is Radiofrequency Ablation Better than Venous Stripping for Management of Chronic Venous Insufficiency?
Article
Full-text available
  • Nov 2021
Introduction Chronic venous insufficiency (CVI) is a disease of the vein due to valve dysfunc-tion, venous obstruction, or both. This results in increased vein pressure and related to disruption in the vein system. 1 The incidence is relatively high. Globally, the incidence of CVI is about 63.9% and more common in women compared to men. 2 The sign and symptoms may vary from heaviness sensation, leg pain, telangiectasia (spider veins), reticular veins, varicose veins, edema, lipodermatosclerosis, and venous ulcer. 3 For an extended period, CVI may decrease the quality of life of the patient because of immobility and symptoms that patients experience. 4 The treatment strategy for CVI has been established, and there are several strategies depends on the severity of the disease. Conservational methods, such as pharmacological therapy and compressive stocking therapy could be given. However , it's not the definitive treatment. Another therapy option is by surgical therapy such as vein stripping but it requires hospitalization. 5 Development of CVI therapy has resulted in more advanced endovenous therapy with good efficacy and reduced complication. Ra-diofrequency ablation (RFA) is a promising minimal invasive therapy for CVI patients. 6 Radiofrequency Ablation And Venous Stripping The treatment for CVI is based on the severity of the disease, assessed by the CVI staging. The well-known classification for CVI is the Clinical-Etiological-Anatomical -Pathophysiological (CEAP) classification. For decades, treatment using surgical ligation and stripping of the great saphenous vein had been the gold standard for CVI. 7 However, this technique caused several complications ranging from neovascularization (exceeds 30%) and injury of the saphenous nerve. 8,9 To optimize the outcome and prevent serious complications, newer technique J Indon Med Assoc, Volum: 71, Nomor: 5, Oktober-November 2021 Is Radiofrequency Ablation Better than Venous Stripping for Management of CVI 207 J Indon Med Assoc, Volum: 71, Nomor: 5, Oktober-November 2021 has been developed. Radiofrequency abla-tion (RFA) is a minimal-invasive endove-nous heat-based procedure in treating CVI that shows promising result. The endovenous method has some benefits, such as fewer complications post procedure compared to venous stripping. 10 The procedure of RFA is done by using a catheter electrode guided by ultra-sound. This catheter electrode will deliver a radiofrequency with high-frequency, which leads to venous spasm, collagen shrinkage, and physical contraction. 11 To determine the efficacy of RFA, there are three factors that can be assessed, venous occlusion, recanali-zation, and absence of recurrent reflux. RFA showed a good occlusion rate in less than three months, about 97%. A study by Proebstle et al. showed a 100% occlusion rate after the initial procedure and a 95% occlusion rate after five years of follow up. 12,13 There was also a shorter hospitalization, reduced postoperative pain, and improvement in the quality of life after the patient underwent RFA procedure. 14 Compared to the gold standard, RFA is auspicious. The success rate from venous stripping-ligation and RFA are slightly different. 13-16 However, in a randomized clinical trial study by Mendes et al. there is a 20% difference in the primary success rate of the venous stripping-ligation method (100% primary success rate) and RFA method. (80% success rate). 10 The complication in the vein stripping-ligation is more apparent than in RFA. Neovascularization and nerve injury are the most common complications that can be found after vein surgery (up to 30% in vein stripping-ligation), and saphenous nerve injury is less found in RFA. However, most of the symptoms of this injury don't affect the patient's quality of life. 11,14 RFA also has a better cosmetic result because it only needs a small incision for insertion of the device. The patient who underwent the RFA method also has a higher early recovery rate and quickly returns to work. There was also a shorter hospitalization and reduced postoperative pain. A study in Canada showed that the patient could work as early as two days after the RFA procedure. It was also noted that 69% of the patients did not need any analgesia agents. 11 Subramonia et al. evaluated the pain that the patients experienced during the first week after the procedure. Patients who underwent RFA procedure had less pain in the first week compared to the vein-stripping method (1.7 vs 4). Although RFA has several benefits, it has a higher cost when compared to vein stripping-ligation. The cost of RFA could range 4-5 times more than the cost for stripping-ligation. 17
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... The use of RF energy to produce tissue retraction has recently found a wide range of medical applications (17)(18)(19)24,25). In an animal model of wide-neck the leak to be targeted with RF, TEE and ICE provide real-time visualization of the tip of the ablation catheter ( Figure 1C) and of its depth within the leak. ...
... Among patients with patent foramen ovale, 90% did not show any residual interatrial communication after RF energy delivery along the upper septum primum(19). Similarly, RF energy was successfully tested for endovenous treatment of varicose veins(17,25), to promote wound healing(26), to treat sleep apnea via stiffening and reduction of the soft palate(27), and many more. The proposed mechanism for the described tissue effects of RF energy is based on the promotion of fibroblast proliferation and collagen synthesis, which may lead to tissue shrinkage and physical contraction. ...
Radiofrequency Energy Applications Targeting Significant Residual Leaks After Watchman Implantation A Prospective, Multicenter Experience
Article
  • Jul 2021
Objectives The aim of this study was to evaluate the efficacy of radiofrequency (RF) energy applications targeting the atrial side of a significant residual leak in patients with acute and chronic evidence of incomplete percutaneous left atrial appendage (LAA) occlusion. Background RF applications have been proved to prevent recanalization of intracranial aneurysms after coil embolization, thereby favoring complete sealing. From a mechanistic standpoint, in vitro and in vivo experiments have demonstrated that RF promotes collagen deposition and tissue retraction. Methods Forty-three patients (mean age 75 ± 7 years mean CHA2DS2-VASc score 4.6 ± 1.4, mean HAS-BLED score 4.0 ± 1.1) with residual leaks ≥4 mm after Watchman implantation were enrolled. Procedural success was defined as complete LAA occlusion or presence of a mild or minimal (1- to 2-mm) peridevice leak on follow-up transesophageal echocardiography (TEE), which was performed approximately 45 days after the procedure. Results RF-based leak closure was performed acutely after Watchman implantation in 19 patients (44.2%) or scheduled after evidence of significant leaks on follow-up TEE in 24 others (55.8%). The median leak size was 5 mm (range: 4-7 mm). On average, 18 ± 7 RF applications per patient (mean maximum contact force 16 ± 3 g, mean power 44 ± 2 W, mean RF time 5.1 ± 2.5 minutes) were performed targeting the atrial edge of the leak. Post-RF median leak size was 0 mm (range: 0-1 mm). A very low rate (2.3% [n = 1]) of major periprocedural complications was observed. Follow-up TEE revealed complete LAA sealing in 23 patients (53.5%) and negligible residual leaks in 15 (34.9%). Conclusions RF applications targeting the atrial edge of a significant peri-Watchman leak may promote LAA sealing via tissue remodeling, without increasing complications. (RF Applications for Residual LAA Leaks [REACT]; NCT04726943)
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... Historically, it was described in ancient texts in China and Egypt. Pathology may be encountered among all age groups in the community worldwide, with a prevalence estimated between 30-40% in the general population (1)(2)(3) . The data regarding the incidence of varicose veins are indefinite; however, approximately 50% of people over 40 years are estimated to have varicose veins or telangiectasias in America and Europe (4) . ...
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... reported an occlusion rate of 99% during the follow-up period. [18] In our study, the GSV occlusion rate was 100% at 6 months, which is consistent with results in published reports. ...
Clinical characterization of consecutive patients treated with endovenous radiofrequency ablation of the great saphenous vein in Northwest China
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INTRODUCTION The goal of this study was to characterize consecutive patients in Northwest China treated with endovenous radiofrequency ablation (RFA) and foam sclerotherapy over a 10-month period in 2020. METHODS A total of 55 (31 men) patients were analyzed. An ultrasound examination was performed preprocedure and at set intervals up to 6 months postprocedure. The clinical-etiological-anatomical-pathophysiological classification, Venous Clinical Severity Score (VCSS), and heaviness, achiness, swelling, throbbing, and itching (HASTI) score were used. RESULTS Ultrasound confirmed 23 (41.8%) patients had unilateral disease and 32 (58.2%) had bilateral disease. Of the total 87 limbs, C2 predominated (42;48.3%). At 6 months postprocedure, VCSS improved in the C2, C4, C5, and C6 classes ( P < 0.001); HASTI improved in the C2, C3, C4, and C5 classes ( P < 0.001). CONCLUSION This is one of the few clinical characterizations of patients who had RFA and foam sclerotherapy in Northwest China. Overall, both the VCSS and the HASTI score demonstrated improvement postintervention.
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... It has a life-long prevalency approximately 30% in general population. 10 It leads to discomfort in the lower extremities, cramps, pain and in advanced cases, edema, pigmentation and ulcer formation all of which signifi cantly affect the quality of life of the patients. 11 The sapheno-femoral junction insuffi ciency and/or refl ux disease of the VSM are blamed for superfi cial venous refl ux phenomenon in most instances. ...
Increased CRP/albumin ratio is associated with superficial venous reflux disease and varicose vein formation
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Full-text available
  • Aug 2021
Background: It has been recently postulated that infl ammation may have an effect on varicose vein development and prognosis, besides increased venous pressure. CRP/albumin (CAR) is a novel infl ammatory marker associated with poor prognosis in a various group of patients. Our aim in this study was to investigate the relation between varicose greater saphenous vein (VSM) diameter and CAR. Methods: A total of 150 patients with patients VSM insuffi ciency (Group 1, n: 114) and normal VSM (n: 36) were included in the study. The diameter of the VSM was measured with B-mode ultrasound, and refl ux was quantifi ed based on valve closure time using Doppler spectral tracings. Blood samples were taken during recruitment. The CAR value is determined by dividing the serum CRP level to the albumin level. Results: There were 21 (18.4%) males and 93 (81.5%) females in Group 1 and 7 males and 29 females in Group 2. Mean age of the patients were similar in both groups (48.02-12.20 years in Group 1 vs. 44.9-8.92 years in Group 2, p = 0.44). Mean BMI of the patients did not differ signifi cantly (Group 1: 26.4-3.7 kg/m2 correvs. Group 2: 25.7-4.2 kg/m2, p = 0.13). The mean diameter of VSM was measured 5.70-0.29 mm in Group 1 whereas 3.21-0.34 mm in Group 2 (p = 0.0023). Mean CRP and albumin values in Group 1 were 6.18-4.99 mg/L and 4.45-0.27 g/dL whereas 4.25-2.46 mg/L and 6.18-1.14 g/dL in Group 2, respectively (p value for CRP = 0.049, p value for albumin = 0.074). CRP/albumin was 1.28-1.34 in Group 1 and 1.11-1.21 in Group 2, which was not statistically signifi cant (p = 0.58). There was a positive moderately strong correlation between VSM diameter and CRP/albumin ratio as well as superfi cial venous refl ux disease (r: 0.48). Conclusion: CRP/albumin ratio is associated with increased incidence of varicose veins and increased diameter of greater saphenous vein; hence, superfi cial venous refl ux disease. The fi ndings support the hypothesis that systemic infl ammation may play a role in varicose vein disease.
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Can internal cooling radiofrequency catheters with local hypothermia eliminate the need for tumescent anesthesia? A single-center, retrospective, observational study
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  • Sep 2024
Background: Tumescent anesthesia not only prolongs the operation time but also induces postoperative pain, bruising, and swelling. This study investigated the effectiveness and safety of tumescentless RFA using an internal cooling system with a VENISTAR catheter and local hypothermia. Methods: We retrospectively analyzed patients who had undergone RFA for above-knee (AK) great saphenous vein (GSV) between March 2023 and November 2023. We compared the efficacy and safety of tumescentless RFA between group T (conventional tumescent group, n = 50) and group N (non-tumescent group, n = 59). Results: The operative time was shorter in group N than in group T (group N: 31.37 min, group T: 42.31 min, p < .01), with no severe adverse events occurred in either group, such as endovenous heat-induced thrombosis or deep vein thrombosis. Postoperative pain (Group N, 0.53% vs Group T, 0.52%; p = .86), postoperative complications such as bruising (Group N, 6.78% vs Group T, 4%; N= .34) and paresthesia (Group N, 1.7% vs Group T, 6%; p = .27) showed no significant difference between the two groups on postoperative day 10. Conclusion: Tumescentless RFA with internal cooling and local hypothermia shows promising results with minimal complications. This novel approach represents a recent advancement in endovenous RFA that omits additional tumescent anesthesia.
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The Efficacy of Radiofrequency Ablation for the Treatment of Symptomatic Varicose Veins of Lower Limbs
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Background Radiofrequency ablation (RFA) is a minimally invasive treatment for lower limb varicose veins. Studies indicate that RFA results in immediate occlusion of 90%–100% of treated long saphenous veins. Evidence suggests that post-operative scans rarely alter patient management or outcomes. Objective The aim of this study was to assess the potential necessity of routine postoperative scanning in the treatment of varicose veins. Method Retrospective data were collected for the patients who had RFA under a single consultant from November 2015 to June 2018. Descriptive statistics were calculated to summarize patient demographics, procedural details, and outcome measures. Results A total of 124 patients underwent radiofrequency ablation (RFA). Most of the patients (n = 114, 92%) demonstrated complete ablation, indicating a high success rate for the procedure. Conclusion This study suggested that routine postoperative scanning should be discontinued as this did not alter patient management in over 99% of cases. The resources currently used for postoperative scans could be redirected towards other critical areas.
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Objectives This was an open-label randomized comparative two arms study to assess the efficacy and clinical outcome of endovenous thermal ablation on reticular veins and telangiectasias in patients with lower limbs varicose veins with incompetent Sapheno-femoral Junction. Patients and methods A total of 40 patients [15 (37.5%) males and 25 (62.5%) females] with reflux of the long saphenous vein were subjected to radiofrequency ablation (RFA). 20 patients had RFA alone while the other 20 patients underwent RFA and injection sclerotherapy. Then patients were followed up on 1 week after the procedure, 3 months, 6 months, and 1 year by duplex and clinically using venous clinical severity score. Results There were 37.5% males and 62.5% females. There was a statistically significant difference in both groups regarding patients’ symptoms (pain, heaviness, and swelling) before and after serial times of follow-up, which was assessed by the VCSS, denoting marked improvement of patients’ symptoms. Also, there was a statistically significant difference ( P <0.001) concerning duplex results regards the reflux before and following RFA. Reticular veins follow-up, we found that in group A they were present among 35% of patients on 1-week follow-up. This increased to reach 70% after 1 year of follow-up, however, in group B they were absent among all patients on 1 week follow-up. They were present among 15% of patients after 1 year of follow-up. Conclusion RFA with concomitant sclerotherapy for the associated minor veins have proved to be safe, cost-effective and more patient satisfaction than RFA without concomitant sclerotherapy.
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Skin is exposed to a variety of potential stressors and stimulators that may impact homeostasis, healing, tumor development, inflammation, and irritation. As such it is important to understand the impact that these stimuli have on skin health and function, and to develop therapeutic interventions. Animal experiments have been the gold standard for testing the safety and efficacy of therapeutics and observing disease pathology for centuries. However, complex ethics, costs, time consumption, and interspecies variation limit the transferability of results to humans and reduce their repeatability and reliability. Furthermore, traditional 2D cell studies are not representative of human tissue. Skin tissue is a dynamic environment, and when cells are isolated in unphysiologically stiff, static petri dishes their behavior, and phenotypic expression is altered. Increasingly complex in vitro models of human skin, including organoids, 3D bio-printing, and skin-on-a-chip platforms, present the opportunity to gain insight into how stressors affect tissue at a cellular level in a controlled and repeat-able environment. This insight can be leveraged to further understand pathological skin conditions and better formulate and validate drugs and therapeu-tics. Here, we will discuss the application of in vitro skin modeling to investigating the effects of mechanical, electromagnetic, and chemical stressors on skin. K E Y W O R D S 3D bioprinting, drug development, in vitro, organoid, skin model, skin-on-chip This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.
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Endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus conventional surgery for varicose veins
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Full-text available
  • Oct 2011
Minimally invasive techniques to treat great saphenous varicose veins include ultrasound-guided foam sclerotherapy (USGFS), radiofrequency ablation (RFA) and endovenous laser therapy (EVLT). Compared with conventional surgery (high ligation and stripping (HL/S)), proposed benefits include fewer complications, quicker return to work, improved quality of life (QoL) scores, reduced need for general anaesthesia and equivalent recurrence rates. To review available randomised controlled clinical trials (RCT) data comparing USGFS, RFA, EVLT to HL/S for the treatment of great saphenous varicose veins. The Cochrane Peripheral Vascular Diseases (PVD) Group searched their Specialised Register (July 2010) and CENTRAL (The Cochrane Library 2010, Issue 3). In addition the authors performed a search of EMBASE (July 2010). Manufacturers of EVLT, RFA and sclerosant equipment were contacted for trial data. All RCTs of EVLT, RFA, USGFS and HL/S were considered for inclusion. Primary outcomes were recurrent varicosities, recanalisation, neovascularisation, technical procedure failure or need for re-intervention, patient quality of life (QoL) scores and associated complications. Secondary outcomes were type of anaesthetic, procedure duration, hospital stay and cost. CN, RE, VB, PC, HB and GS independently reviewed, assessed and selected trials which met the inclusion criteria. CN and RE extracted data. The Cochrane Collaboration's tool for assessing risk of bias was used. CN contacted trial authors to clarify details. Thirteen reports from five studies with a combined total of 450 patients were included. Rates of recanalisation were higher following EVLT compared with HL/S, both early (within four months) (5/149 versus 0/100; odds ratio (OR) 3.83, 95% confidence interval (CI) 0.45 to 32.64) and late recanalisation (after four months) (9/118 versus 1/80; OR 2.97 95% CI 0.52 to 16.98), although these results were not statistically significant. Technical failure rates favoured EVLT over HL/S (1/149 versus 6/100; OR 0.12, 95% CI 0.02 to 0.75). Recurrence following RFA showed no difference when compared with surgery. Recanalisation within four months was observed more frequently following RFA compared with HL/S although not statistically significant (4/105 versus 0/88; OR 7.86, 95% CI 0.41 to 151.28); after four months no difference was observed. Neovascularisation was observed more frequently following HL/S compared with RFA, but again this was not statistically significant (3/42 versus 8/51; OR 0.39, 95% CI 0.09 to 1.63). Technical failure was observed less frequently following RFA compared with HL/S although this was not statistically significant (2/106 versus 7/96; OR 0.48, 95% CI 0.01 to 34.25). No randomised clinical trials comparing HL/S versus USGFS met our study inclusion criteria. QoL scores and operative complications were not amenable to meta-analysis. Currently available clinical trial evidence suggests RFA and EVLT are at least as effective as surgery in the treatment of great saphenous varicose veins. There are insufficient data to comment on USGFS. Further randomised trials are needed. We should aim to report and analyse results in a congruent manner to facilitate future meta-analysis.
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The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum
Article
  • May 2011
The Society for Vascular Surgery (SVS) and the American Venous Forum (AVF) have developed clinical practice guidelines for the care of patients with varicose veins of the lower limbs and pelvis. The document also includes recommendations on the management of superficial and perforating vein incompetence in patients with associated, more advanced chronic venous diseases (CVDs), including edema, skin changes, or venous ulcers. Recommendations of the Venous Guideline Committee are based on the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system as strong (GRADE 1) if the benefits clearly outweigh the risks, burden, and costs. The suggestions are weak (GRADE 2) if the benefits are closely balanced with risks and burden. The level of available evidence to support the evaluation or treatment can be of high (A), medium (B), or low or very low (C) quality. The key recommendations of these guidelines are: We recommend that in patients with varicose veins or more severe CVD, a complete history and detailed physical examination are complemented by duplex ultrasound scanning of the deep and superficial veins (GRADE 1A). We recommend that the CEAP classification is used for patients with CVD (GRADE 1A) and that the revised Venous Clinical Severity Score is used to assess treatment outcome (GRADE 1B). We suggest compression therapy for patients with symptomatic varicose veins (GRADE 2C) but recommend against compression therapy as the primary treatment if the patient is a candidate for saphenous vein ablation (GRADE 1B). We recommend compression therapy as the primary treatment to aid healing of venous ulceration (GRADE 1B). To decrease the recurrence of venous ulcers, we recommend ablation of the incompetent superficial veins in addition to compression therapy (GRADE 1A). For treatment of the incompetent great saphenous vein (GSV), we recommend endovenous thermal ablation (radiofrequency or laser) rather than high ligation and inversion stripping of the saphenous vein to the level of the knee (GRADE 1B). We recommend phlebectomy or sclerotherapy to treat varicose tributaries (GRADE 1B) and suggest foam sclerotherapy as an option for the treatment of the incompetent saphenous vein (GRADE 2C). We recommend against selective treatment of perforating vein incompetence in patients with simple varicose veins (CEAP class C(2); GRADE 1B), but we suggest treatment of pathologic perforating veins (outward flow duration ≥500 ms, vein diameter ≥3.5 mm) located underneath healed or active ulcers (CEAP class C(5)-C(6); GRADE 2B). We suggest treatment of pelvic congestion syndrome and pelvic varices with coil embolization, plugs, or transcatheter sclerotherapy, used alone or together (GRADE 2B).
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Surgical and Endovascular Treatment of Lower Extremity Venous Insufficiency
Article
  • Jul 2002
  • J VASC INTERV RADIOL
Lower extremity venous insufficiency is a highly prevalent condition. Now it is understood that telangiectasias, reticular varicosities, and true varicose veins are physiologically similar and etiologically identical. The four main influences causing these abnormalities are heredity, female sex, gravitational hydrostatic forces, and hemodynamic muscular compartment pressure. There are clear indications and goals for intervention. A cornerstone in the treatment of venous insufficiency is elimination of sources of venous hypertension. One of these is the refluxing greater saphenous vein. Minimally invasive saphenous ablation can be achieved by radiofrequency energy and laser light energy. These new techniques eliminate the psychologic barrier to treatment caused by the term "stripping" and allow the objectives of surgery to be achieved with minimal invasion and quick recovery. Endovenous techniques show great promise. They provide minimal invasion, often under local anesthesia and intravenous sedation, thereby eliminating the need for general anesthesia. Objectives of venous insufficiency have been established and the endoluminal minimally invasive techniques developed in recent years appear to accomplish their goals.
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Endovascular radiofrequency ablation for varicose veins: an evidence-based analysis
  • Jan 2011
  • 1-93
  • Health Quality Ontario
Health Quality Ontario. Endovascular radiofrequency ablation for varicose veins: an evidence-based analysis. Ont Health Technol Assess Ser 2011;11:1-93.