ArticleLiterature Review

Historical Overview of Varicose Vein Surgery

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Abstract

Varicose veins are as old as Hippocrates. Varicose vein treatments come and go. Surgery for varicose vein disease is one of the commonest elective general surgical procedures. The history of varicose vein surgery has been traced. We note the first descriptions of varicose veins, and we particularly focus on the ligation of the saphenofemoral junction, stripping of the great saphenous veins, phlebectomy, and perforant vein surgery. We end with the rapid rise of minimally invasive procedures, such as foam sclerotherapy, radiofrequency ablation, and endovenous lasertherapy. Within 10 years, the advantages of minimal invasiveness for these procedures, combined with claims of equivalent short-term outcomes and even better long-term results, have already influenced our everyday practice. At present, the gold standard treatment of varicose veins still is surgical ligation and stripping of the insufficient vein. Concomitantly or sequentially with the treatment of truncal insufficiency, residual varicosities can be treated by phlebectomy. New minimally invasive techniques, however, have changed the clinical landscape for varicose vein surgery tremendously. The dramatic changes of the last decade are probably the precursors of the next generation.

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... Prior to the late 1990s, the gold standard for the treatment of refluxing truncal veins was stripping and high ligation. 1 While the initial description of great saphenous vein (GSV) ligation dates back to the mid-1500s, this procedure was popularized in the late 1800s after Friedrich Trendelenburg authored a paper describing the technique. 1 Subsequently, American surgeons Mayo, Keller, and Van der Stricht described vein stripping procedures in the early 1900s, 1,2 and various modified and combined surgical techniques ensued. ...
... 1 While the initial description of great saphenous vein (GSV) ligation dates back to the mid-1500s, this procedure was popularized in the late 1800s after Friedrich Trendelenburg authored a paper describing the technique. 1 Subsequently, American surgeons Mayo, Keller, and Van der Stricht described vein stripping procedures in the early 1900s, 1,2 and various modified and combined surgical techniques ensued. In 1999, endovenous laser ablation for the treatment of superficial venous reflux was approved in the USA, and this has since become a mainstay of treatment for chronic venous insufficiency in the United States and abroad. ...
Article
Objective To provide an evidence-based overview of endovenous laser ablation and describe its role as an effective and durable technique for the management of superficial venous insufficiency. Methods The published literature on the treatment of varicose veins using endovenous laser ablation was reviewed. The literature search focused on the history of endovenous laser ablation, its safety and durability, known complications, and differences in outcomes based on the iterations of fiber type and laser wavelength. Results Treatment safety and efficacy of endovenous laser ablation appear to be based on the amount of energy administered over a defined distance, or the linear endovenous energy density. The ideal linear endovenous energy density varies with the laser wavelength and fiber-type. Post-operative pain and bruising may be reduced by the use of higher wavelength fibers or the use of radial or jacket-tip fibers as compared to bare-tip fibers. The incidence of endothermal heat-induced thrombosis remains low and has declined with increasing experience. Reports have demonstrated a greater than 90% technical success rate with saphenous endovenous laser ablation, long-term durability of ablation, and commensurate improvement in quality of life. Conclusions Endovenous laser ablation is a safe and durable treatment option for the management of incompetent superficial and perforator veins of the lower extremities. As an endothermal technology, it remains a key component of the standard of care for the treatment of chronic venous insufficiency.
... The surgical treatment of varicose veins has undergone many modifications from the open stripping technique to minimally invasive procedures. 1 One of the accepted modalities of therapy today is radio frequency ablation (RFA) with an endovenous technique. 1 The VNUS closure fast radiofrequency system (Coveidien, San Jose, CA, USA) comprising a generator and a bipolar catheter was developed as a minimally invasive technique using radiofrequency to generate heat which causes coagulation of the vessel wall and hence ablation. ...
... The surgical treatment of varicose veins has undergone many modifications from the open stripping technique to minimally invasive procedures. 1 One of the accepted modalities of therapy today is radio frequency ablation (RFA) with an endovenous technique. 1 The VNUS closure fast radiofrequency system (Coveidien, San Jose, CA, USA) comprising a generator and a bipolar catheter was developed as a minimally invasive technique using radiofrequency to generate heat which causes coagulation of the vessel wall and hence ablation. Despite widespread use of this device (the RFA technique was approved by the FDA in 1999 1 ) very little is published regarding the detailed histopathological effects of radiofrequency on the human vein. ...
... The word varicose vein was rst proposed by Hippocrates in 460 B.C. (1) and means "grape like". Varicose vein is a "subcutaneous dilated vein, 3 mm or larger in diameter, measured in upright position with demonstrable reux. ...
Article
Introduction And Aim: Varicose veins are dilated, tortuous and elongated veins & have been recognised as a chronic disorder since ancient times. It is a progressive disease, though not fatal but the morbidity is more. Present study aimed to evaluate the comparative efcacy of Trendelenburg Operation, Endovenous Laser Ablation, and Radiofrequency Ablation in Varicose Vein Management. Material And Method:This was a comparative study conducted in the Department of General Surgery, Rajindra Hospital, Patiala, including 60 patients presenting to the surgery OPD from January 2023 to May 2024. These patients were divided randomly into 3 groups: Trendelenburg Operation, Endovenous Laser Ablation, and Radiofrequency Ablation. A structured proforma was used to enter the detailed clinical history, mode of management received, and post-op follow up at short interval of 2 months, after obtaining consent at the time of admission. Observation: In this comparative study, mean age was 42.72 years, with 78.3% male preponderance. Majority of the patients belonged to C4 group with 31.7% out of the study group. Post-op pain was more for T.O group, as compared to the minimally invasive procedures. Estimated cost for the T.O, EVLA and RFA is 12,178, 53,500 and 38,815 respectively. The p-value was calculated to be 0.001 which is highly signicant. Conclusion: All the three modalities are effective for treating varicose veins. RFA and EVLA have fewer complication rates as compared to Trendelenburg operation, but recurrence rate is more for minimally invasive techniques.
... 6,7 Surgical procedures have a long history, running through a variety of methods and with a range of modifications over the years, of which saphenectomy with ligature at the saphenofemoral junction (SFJ) and saphenopopliteal junction (SPJ) have been the first choice for the great saphenous vein (GSV) and small saphenous vein (SSV), respectively, for a long time. 8 Use of lasers for endoluminal treatment emerged after a publication by Boné (apud Hamdan). 9 Since then, intravenous laser thermal ablation (also known as endovenous laser ablation, EVLA) began to be used for varicose veins and the classic surgical methods began to be questioned, not only because of their invasivity, but also because of the time taken for recovery, the need for hospital admission, the side effects, and the postoperative complications. ...
Article
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Background: Use of endolaser for chronic venous disease involves choosing the laser wavelength and optical fiber to use and the quantity of energy to be administered. Efficacy is assessed by the venous occlusion rate and safety is evaluated in terms of side effects. Objectives: To determine the incidence of total post-endolaser saphenous vein occlusion at 1-year follow-up. To describe side effects and their incidence and rates of reintervention or supplementary treatment during the postoperative period. Methods: A retrospective, observational cohort study with a quantitative approach, enrolling patients with saphenous vein incompetence treated with intravenous 1,470 nm laser ablation. Data were input to an MS Excel 2019 spreadsheet, calculating means and standard deviations with the software's Power Query supplement. Results: 38 patients and 104 venous segments were eligible for the study. 100% were occluded at 30 days and 99.04% were still occluded at 1 year after the procedure. Mean Linear Endovenous Energy Density administered to the internal saphenous vein was 2,040.52 W/cm/s with standard deviation of ± 1,510.06 W/cm/s and 1,168.4 W/cm/s with standard deviation of ± 665.011 W/cm/s was administered to the external saphenous vein. Pain along the saphenous path was the most common side effect, with eight cases (21.05%), followed by one case of paresthesia (2.63%). Conclusions: The total occlusion rate at 1-year follow-up suggests the technique is promising and is currently applicable in this sample. The incidence of pain and paresthesia may be caused by the high mean energy delivered in some cases. It is recommended that multicenter studies be conducted with larger and more uniform samples in terms of their Clinical-Etiological-Anatomical-Pathological classifications.
... A conduta pode ser feita, dependendo da recomendação, de forma conservadora ou de maneira cirúrgico-intervencionista, sendo, essa última, o padrãoouro para o tratamento das veias varicosas 6,7 . O histórico de procedimentos é de longa data, percorrendo diversos métodos e com amplas modificações, sendo a safenectomia com ligadura na junção safeno femoral (JSF) e safeno poplítea (JSP), respectivamente para as veias safenas magna (VSM) e parva (VSP), o método de escolha por longo período de tempo 8 . ...
Article
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Resumo Contexto O uso do endolaser para doença venosa crônica envolve a escolha do comprimento de onda, fibra óptica e energia dispensada. Sua eficácia é avaliada pela taxa de oclusão venosa e, a segurança, pelos efeitos colaterais. Objetivos Demonstrar a incidência de oclusões venosas totais de veias safenas pós-endolaser no seguimento de 1 ano. Descrever a incidência e os efeitos colaterais e a necessidade de reintervenção ou complemento da terapêutica no pós-operatório. Métodos Estudo observacional retrospectivo de uma coorte com abordagem quantitativa de pacientes com insuficiência das veias safenas tratados com laser ablação endovenosa de 1.470 nm. Dados cadastrados em planilha MS Excel 2019, com cálculos de médias e desvios padrão pelo suplemento Power Query do Software. Resultados Foram elegíveis para o estudo 38 pacientes e 104 segmentos venosos, dos quais 100% estavam ocluídos em 30 dias e 99,04% em 1 ano pós-procedimento. O Linear Endovenous Energy Density médio para safena interna foi de 2.040,52 W/cm/s com desvio padrão ± 1.510,06 W/cm/s e 1.168,4 W/cm/s com desvio padrão de ± 665,011 W/cm/s para safena externa. Dor no trajeto da safena foi o principal efeito colateral, com oito casos (21,05%), seguido de parestesia, com um caso (2,63%). Conclusões Taxa de oclusão total no seguimento de 1 ano sugerindo técnica promissora e com atual aplicabilidade na amostra. A incidência da dor e parestesia podem ser justificadas pela alta média de energia utilizada em alguns casos. Recomenda-se a realização de estudos multicêntricos, com amostras maiores e mais homogêneas em relação à classificação Clínica-Etiológica-Anatômica-Patológica.
... CVI is a common condition and VV treatment is one of the most-commonly performed surgical procedures world-wide (8,9). The incompetence can be in the superficial, deep or both venous systems of the lower limb. ...
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Chronic venous incompetence (CVI) is a common condition, and varicose vein treatment is one of the most-common surgical procedures performed worldwide. Common symptoms of CVI are pain, cramps, itching, feeling of leg heaviness and venous claudication. Advanced CVI can lead to skin changes, eczema and venous ulcers. While the cause of the disease is un-known, it often starts with venous enlargement and valve dysfunction. The overall aims of this thesis are: 1) to develop quantitative diagnostic measurements using strain-gauge plethysmography (SGP) with standardised superficial venous occlusion and duplex ultrasound (DUS); 2) to evaluate the effects of radiofrequency ablation (RFA) and high ligation/stripping (HL/S) for patients with great saphenous vein (GSV) incompetence; and 3) to evaluate the cost-effectiveness of GSV treatment. The first of the four studies involved patients with GSV incompetence. For these patients, SGP with superficial venous occlusion was performed before and after GSV treatment. SGP was able to predict the haemodynamic outcome of the treatment in the majority of the limbs examined. The conclusion is that SGP with standardised superficial venous occlusion may be used for predicting the outcome of GSV treatment. The second study evaluated the short-term outcomes of GSV treatment using RFA and HL/S regarding haemodynamics and quality of life (QoL). Both treatments lead to significant improvements in QoL, with no signifcant differences between the treatments. Despite successful treatment, the majority of the limbs in both treatment groups had significant residual reflux located mainly in the calf (i.e., below the treated area). The residual reflux may be a risk factor for future symptom relapses and need to be examined in more-long-term studies. The third study examined quantitative DUS and SGP parameters in relation to clinical severity and QoL. DUS-derived volume flow and SGP re-flux time showed weak but significant correlations with clinical severity (C in CEAP). The conclusion is that the current gold standard using the qualitative DUS-derived reflux time for CVI diagnostics should be revised and replaced with a more-relevant quantitative parameter. The fourth study evaluated the cost-effectiveness of GSV treatment with 1 year of follow-up. Both RFA and HL/S provided significant improvements in QoL. RFA is very cost-effective and is associated with fewer days missed from work compared to HL/S. Cost-wise, both methods are well be-low the national threshold for cost-effective treatment. Due to its higher cost, HL/S should be reserved for cases that require this method.
... The the gold standard for varicose vein surgery is combination of high ligation, stripping and division with multiple stab avulsions is described as [28][29][30] according to the guidelines in India 31 . This was done in 5.9% cases in the present study and in 42.8%-75% in other studies 28,32 . ...
Article
Introduction: Incompetent valves of deep, superficial or perforating veins lead to varicose veins. Dilated, elongated or tortuous subcutaneous veins of lower legs are a manifestation of increase in venous pressure. This increase in venous pressure results from the reflux of blood due to incompetence. The diseased Great Saphenous Vein (GSV) is removed by High Saphenous Ligation and Stripping (HLS) surgery. Aims and Objectives: To study the clinical and socio-demographic profile, precipitating factors/ risk factors, complications and clinical outcomes of management of varicose veins. Material and Methods: Data collected from 150 patients with varicose veins by appropriate history taking and clinical examination, relevant radiological and laboratory investigations and follow-up of cases to study the clinical outcome. Results: Study was conducted with 150 patients. Most common age group affected with primary varicose veins was between 41-60 yrs of age with male predominance (64.7%). Most of the cases in present study were engaged in work involving long standing hours i.e. farming (34%) and housewives (28%). Most common presenting complaints were oedema (88%), dilated veins (74%) and pain (71.3%). Conservative management was tried in all cases while Trendelenburg operation and SPJ ligation was done in 26.7% and 9.3% cases. Stripping and PERF ligation was done in 28.7% and 25.3% cases respectively. A total of 24.7% were lost to follow up. By the end of 6 month, quality of life improved in 70% cases. By the end of 6 month, symptoms improved in 72.5% cases while it disappeared in 26.5% cases. Conclusion: Males have been found to have larger incidence than females. They are mostly affected in their fourth and fifth decade of life. Ulceration and pain are the frequent findings in this condition. Compression stocking has beneficial effects if prolonged standing cannot be avoided during work hours. Trendelenburg operation with flush ligation with subfascial or extra fascial stripping is the definitive management and shows significant clinical improvement.
... Early diagnosis and treatment of the disease prevents further complications and improve quality of life. 1,3 The disease can have various presentations with different uncomplicated reflux patterns, involving superficial, deep, and perforating veins, alone or in combinations. It can present late with complications like severe skin changes, healed or unhealed ulcer and thrombosis, or sometimes can be late asymptomatic presentation also. ...
Article
Full-text available
Introduction: The trend of varicose vein disease seems to be rising globally and its treatment options and outcome vary from the institution by institution. Management of the disease has also changed from high ligation, stripping, avulsion, and sclerotherapy to minimally invasive endovenous thermal ablation. Methods: A retrospective observational study was carried out to find out the treatment methods and outcome of lower limb varicose vein disease at the cardiothoracic vascular surgery unit of the surgery department of B.P. Koirala Institute of Health Science from February 2019 to February 2020. The medical record of the patients was studied, relevant data entered and analyzed in statistical package for social sciences statistical software. Results: Total registered patient during the study period were 46; which included 29(63%) male and 17(37%) female with mean age 38.41±10.12. Saphenous femoral junction reflux was seen in 38(82.60%) cases, saphenous popliteal junction reflux was seen in nine (19.60%) cases while perforator reflux was seen in 37(80.40%) cases. Saphenous femoral junction ligation, saphenous popliteal junction ligation was performed in 36(78.30%) and 7(15.20%) cases respectively. Stripping of the greater saphenous vein was done in 35(76.10%) cases, and 9(19.60%) cases were managed conservatively. Only 5(10.90%) cases developed infection, and none of the cases were found with recurrence or nerve injury. All the cases remained satisfied during the management course. Conclusions: Saphenous femoral junction reflux was seen common and saphenous femoral junction ligation was performed on majority of the cases. Only 10% cases developed infection and all patients were satisfied during management course. Early surgical management of the disease overcomes complications and improves in the quality of life of the patients.
... Хірургічне лікування варикозного розширених вен є чи не найпоширенішим видом планових загальних оперативних утручань. у своїй історії хірургія варикозно-розши-рених вен удосконалювалась від простого перев'язування сафено-феморального з'єднання чи видалення великих підшкірних вен до малоінвазивних процедур, таких як пінна склеротерапія, радіочастотна абляція та внутрішньовенна лазерна терапія [10]. новітні малоінвазивні методи кардинально змінили клінічний ландшафт хірургії варикозного розширення вен, скоротили час відновлення після операції. ...
Article
Актуальність. Новітні малоінвазивні методи кардинально змінили клінічний ландшафт хірургії варикозного розширення вен, скоротили час відновлення після операції. Всі ці зміни стали можливими завдяки невпинному поглибленню знань про топографо- анатомічні особливості великої та малої підшкірних вен у різні періоди онтогенезу людини. Мета. З’ясувати топографо-анатомічні взаємовідношення великої та малої підшкірних вен у плодів людини 4-8 місяців. Методи. Дослідження проведено на препаратах нижніх кінцівок 26 плодів людини 81,0-310,0 мм тім’яно-куприкової довжини (ТКД ) без зовнішніх ознак анатомічних відхилень чи аномалій розвитку кісткових, фасціально-м’язових і судинно-нервових структур нижніх кінцівок за допомогою макромікроскопічного препарування, ін’єкції судин та морфометрії. Результати. У плодів людини 4-8 місяців велика підшкірна вена проходить безпосередньо під фасцією гомілки, частково у підшкірній клітковині, оскільки формування останньої на цій стадії онтогенезу ще продовжується. У більшості досліджених плодів спостерігався класичний варіант топографії великої та малої підшкірних вен правої і лівої нижніх кінцівок. У деяких випадках виявлено варіабельність кількості приток підшкірних вен, додаткові підшкірні вени, різноманітні анастомози між додатковими та великою і малою підшкірними венами. Найбільш цікавими, з нашої точки зору, були анатомічні варіанти підшкірних вен гомілкової ділянки у плодів 180,0, 195,0, 220,0 і 265,0 мм ТКД . Висновки. У плодовому періоді онтогенезу людини встановлено анатомічну мінливість підшкірних вен нижніх кінцівок, яка харак- теризується варіабельністю форми, топографії і білатеральною асиметрією приток великої і малої підшкірних вен та формування венозних анастомозів. В одному випадку виявлена ліва передня додаткова підшкірна вена і у двох плодів ліва задня додаткова підшкірна вена. Співпадання топографії підшкірних вен правої і лівої нижніх кінцівок відзначено у 87,5% плодів. Істотних статевих відмінностей у топографії великої та малої підшкірних вен у плодів людини не виявлено. Виявлені варіанти фетальної топографії великої і малої підшкірних вен важливі для правильної інтерпретації даних флебографічних досліджень та індивідуального вибору найбільш раціонального способу оперативного втручання.
... The varicose veins management started with ligation of the saphenofemoral junction, stripping of the great saphenous veins, phlebectomy, and perforator vein surgery and progressed to the minimally invasive procedures, such as foam sclerotherapy, radiofrequency ablation, and endovenous laser therapy. The advantages of minimal invasiveness for these procedures, showed equivalent short-term outcomes and even better long-term results which have influence our everyday practice [19] . ...
... Human beings have dealt with varicose veins since time immemorial [1] . There are records of ancient Greek methods for treating varicose veins as early as 16th century BC in Ebers papyrus. ...
Article
Introduction Both High Ligation/ Stripping and Radiofrequency ablation have been accepted as a standard in the management of varicose veins and are being performed by general and vascular surgeons. Objectives To compare the postoperative outcome in terms of timing of return to daily activities, post-operative pain scoring, incidence of hematoma, thrombophlebitis and improvement in Venous Severity scores among patients undergoing High Ligation/ Stripping and Radiofrequency Ablation Methodology This study was conducted in JSS Hospital in the departments of general and vascular surgery. A total of 72 patients with Duplex confirmed truncal varicosities were included in the study and 36 underwent High Ligation/ Stripping while 36 underwent Radiofrequency Ablation. Follow up was done at POD1, 3, 5, 7, 30 and at the end of 3 months. Results There was no recurrence in the two groups but RFA group had significantly lesser duration of hospital stay (P value <0.0001), lesser postoperative Visual Analogue Score for pain (1.17 ± 0.94 on day 7) and earlier return to work (3.56 ± 1.87 days), P <0.0001. Conclusion Patients who underwent RFA had lesser post-operative pain scores, lesser duration of hospitalization, early return to work but there was no recurrence in both groups at the end of 3 months.
... The traditional surgery of flush ligation of the great saphenous vein (GSV) with the femoral vein combined with stripping of the GSV was considered to be the gold standard for the treatment of varicose veins until recently. 1 The need for spinal or general anaesthesia, the wound-related complications, longer recovery time and need for a hospital stay has made surgery less attractive and has led to the search for minimally invasive methods such as radiofrequency ablation, endovenous laser ablation and ultrasound-guided foam sclerotherapy, which are proven to be as effective as surgery in the treatment of GSV incompetence. [2][3][4][5] These new procedures can be conducted on an outpatient basis with ultrasound guidance under tumescent anaesthesia, and hence return to work is significantly earlier. ...
Article
Introduction Flush ligation at the saphenofemoral junction and stripping of the great saphenous vein is being increasingly replaced by endovenous methods such as radiofrequency or endovenous laser ablation for the treatment of varicose veins. These modalities are expensive and not widely available. A minimally invasive ultrasound-guided surgery with non-flush ligation and stripping under local anaesthesia is a cost-effective alternative with similar postoperative outcomes. Materials and methods A total of 62 limbs (58 patients) with saphenofemoral junction incompetence underwent clinical evaluation including the CEAP clinical score, the venous clinical severity score, the venous disability score and venous doppler. Patients were randomly assigned to either group A (radiofrequency ablation) or group B (ultrasound-guided non-flush ligation and stripping of the great saphenous vein) for procedures under tumescent anaesthesia and ultrasound guidance. Patients were followed-up on days 7, 30 and 90 to assess primary (obliteration rates) and secondary (venous clinical severity score and venous disability score) outcomes. Results Both the groups showed 100% obliteration of the great saphenous vein at day 90. The venous clinical severity and venous disability scores significantly improved from day 0 to day 90 in both the groups (p = 0.0001). There were no major complications. Group A showed significantly lower minor complications (p = 0.001). None required conversation to general anaesthesia. Conclusions The ultrasound-guided non-flush ligation and stripping of the great saphenous vein are as efficacious as radio frequency ablation, with similar obliteration rates, improvement in disability scores and complication profile at a lower cost. It has the potential for wider availability in the community as most surgeons are conversant with the surgical procedure.
... Chronic venous insufficiency (CVI) is a prevalent issue, affecting an average of 10-15% of men and 20-25% of women worldwide 1 . Surgical treatment of lower limb CVI has progressed greatly since the days of open ligation and stripping to more minimally invasive procedures such as foam sclerotherapy and most recently endothermal ablation technologies such as endovenous laser therapy (EVLT) and endovenous radiofrequency ablation (RFA) 2 . EVLT and RFA have recently been recommended as first-line interventions for CVI by 2013 NICE guidelines 3 and have been shown to be superior to open surgery and foam sclerotherapy 4 . ...
... Impairment of return of venous blood to the heart against gravity as a result of the erect position results in the development of chronic venous insufficiency. [1] Varicose veins constitute a progressive disease that becomes steadily worse. During most of instances, varicose veins remain asymptomatic. ...
... In order to manage venous insufficiency effectively it is necessary to ablate all incompetent superficial veins, as well as incompetent perforators [3,4]. Currently, low-invasive endovenous thermal ablation techniques have become the preferred treatment modality for this purpose [5][6][7], not only because of low invasiveness of such a procedure, but also due to the possibility of conducting the treatment in an outpatient basis. Importantly, the use of intraoperative sonography improves efficacy and safety of treatment. ...
Article
Objectives: Low-invasive endovenous thermal ablation techniques have become the preferred modality for the treatment of incompetent perforating veins. Material and methods: We managed 210 varicose-vein patients (268 limbs) presenting with coexisting superficial and perforator incompetence. We utilised bipolar radiofrequency ablation for the treatment of incompetent superficial veins and monopolar diathermal ablation under protective tumescence to manage incompetent perforators. To ablate incompetent perforating veins with monopolar diathermy we used a modified peripheral intravenous catheter with a long needle for administration of tumescence. Results: The success rate of thermal ablation of incompetent perforating veins, defined as completely occluded perforators demonstrated by Doppler sonography at one-year follow-up, was 95%. A similarly defined success rate of radiofrequency closure of incompetent superficial veins was 97%. There were no serious intraoperative complications such as deep vein thrombosis, peripheral nerve injuries, skin burns or persistent hyperpigmentations. There were transient hypoesthesias in 20% of patients presenting with incompetent Cockett I and Cockett II perforators. In addition, 96% of patients presenting with active ulcers had their ulcers healed 30-60 days after the procedure. Conclusions: Monopolar diathermy with the use of protective tumescence enables minimally invasive, effective, and precise ablation of incompetent perforators. This method is also safe, with no associated injury to adjacent anatomical structures or thromboembolic complications.
... This is less in comparison to most of the patients in western world where most patients present in their late 50s and early 60s. 14,15 As more males are involved in heavy labor, the fact may explain predominantly younger and male patients suffering from the disease. ...
... For decades, open surgery was the gold standard of treating patients with venous disease in the lower limb attributable to saphenous vein insufficiency (SVI). However, minimally invasive techniques have changed the clinical landscape for varicose vein treatment tremendously [ Van den Bremer 2010]. In 2001, Navarro and colleagues first reported on endovenous laser to eliminate insufficient great saphenous vein (GSV) segments, and this has been revolutionary for treatment of SVI [Navarro 2001]. ...
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Background: The purpose of this study was to present early-term outcomes of VariClose® Vein Sealing System, which is a novel, non-thermal, and non-tumescent percutaneous embolization technique for treatment of saphenous vein insufficiency. Methods: Between March 2014 and July 2015, 189 saphenous veins in 141 patients were treated with Variclose Vein Sealing System containing n-butyl cyanoacrylate. Pre-, intra-, post-procedural, and follow-up data of patients were collected and retrospectively reviewed. Results: Mean age of patients was 42.5 ± 14.0 years, of which 53% were female. Technical success rate of intervention was 98.9%. Mean procedure time was 14.3 ± 7.5 minutes. Eighty-nine percent of patients (n = 126/141) were available at mean follow-up time of 6.7 months. Mean Venous Clinical Severity Score was significantly improved from 8.3 ± 2.2 at pre-procedure period to 3.3 ± 1.8 at follow-up. No complete recanalization was observed, but 2 patients were presented with partial recanalization during follow-up. The complete occlusion rate was 98.4%. No serious adverse event related to procedure was observed. Conclusion: Variclose Vein Sealing System appears to be safe and effective in treatment of saphenous vein insufficiency. Further randomized studies with long-term outcomes are required for determining optimal treatment modality in patients with saphenous vein insufficiency.
... The combination of high ligation, division and stripping with multiple stab avulsions is described as the gold standard for varicose vein surgery [12,14,37] and also by standard guidelines in India [23]. This was done in 5.9% cases in the present study and in 42.8%e 75% in other studies [2,12]. ...
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Background: Varicose vein is a common surgical problems in India. This study was done to assess the clinico-epidemiological profile, risk factors and management practices in varicose veins. Materials and methods: Medical records of 170 varicose vein cases admitted in tertiary care hospitals in Mangalore between May 2011 to April 2014 were reviewed retrospectively. Results: Majority of cases 53(31.2%) were of the age group 41–50 years. Majority were males 127(74.7%) and majority were unskilled workers 101(59.4%). Superficial veins were involved in 123(72.4%) cases. Perforator followed by great saphenous vein were most frequently involved. Veins on the left side were more involved than on the right. Common symptoms at the time of presentation was ulceration 98(57.6%) followed by pain in the legs 96(56.5%). Ulceration was seen significantly more among females (p = 0.027) and among house wives (p = 0.004). Complications like eczema 46(27.1%), non-healing ulcers 21(12.3%) and deep vein thrombosis 10(5.9%) were reported among cases. Eczema was present significantly more among elderly patients aged above 60 years (p = 0.019). Risk factors like prolonged standing was observed in 86(50.6%) cases. This history was significantly seen among males (p = 0.001) and among those involved in unskilled occupations (p
... De Measeneer concluded by highlighting that the cases of works that assure a surgeon's appropriate training reduce relapses by 5%. to compare, 3, 4 each case will require individualized therapy or a combination of treatments depending on the specific clinical condition, the findings leading to an accurate diagnosis, and the principles guiding therapeutic choices. [1][2][3][4] As recently reported by Hickey and Cooper,5 it is important to standardize the know-how through appropriate and reproducible clinical and instrumental diagnostic criteria that allow to compare the results regardless of the technique used. ...
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Aim. Varicose veins are not just a cosmetic problem of the legs but also a major component in the pathogenesis of lower limb chronic venous insufficiency (CVI). The venous hemodynamic map (MEVec) is a software application that enables users to record and collect clinical and diagnostic data on hemodynamic disorders underlying CVI. Map-assisted reporting allows for more uniform comparison of outcomes after CVI treatments. In so doing, MEVec may facilitate consultation between phlebologists working in various different specialties, including vascular surgery, angiology, dermatology, primary care, cosmetic plastic surgery, radiology, and cardiology among others. Because specialists speak different languages when talking about veins, they don't understand each other. The demonstration of this phlebologic Tower of Babel is the extreme variability in the long-term results of a myriad of methods and the inevitably ensuing low scientific reliability. Methods. We analyzed patients affected by internal saphenous varicose veins caused by incontinence of the saphenous-femoral junction without other refluxes. Doppler ultrasound assessment and interventions were performed by experienced doctors, all teachers at the School of Excellence in Phlebology (SEF), of the Italian Society of Clinical and Experimental Phlebology (SIFCS) study group on MEVeC. Results and conclusions. Currently, there exists no uniform standard for analysis of outcomes after treatment for chronic venous disease (CVD). With the use of MEVec, however, comparable clinical pictures can be reproduced, independently of the treatment method applied to the disorder. MEVeC can be used to create an objective hemodynamic database of CVI and to retrieve clinical and diagnostic data for standardized comparison of the outcomes of treatments for CVD.
... During the late 1990s various thermo-ablation techniques have been introduced to treat saphenous vein incompetence on the basis of endovenous laser therapy (EVLT) and radio frequency ablation (RFA). 1 Numerous papers have been published reporting on ELVT and RFA. These studies reported better outcomes, compared to classical stripping, in terms of fewer complications, post procedural pain and return to daily activities, with comparative rates of reflux abolishment. ...
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Objectives: The ClariVein® system is an endovenous technique that uses mechano-chemical ablation to treat incompetent truncal veins. This study was conducted to identify the ideal Polidocanol dosage and form for mechano-chemical ablation in order to occlude the great saphenous vein. When adhering to safe dosage levels, sclerosants with higher concentrations potentially limit the extent of treatment. It has been demonstrated that this problem may be overcome by using Polidocanol as a microfoam. This paper was established on findings of a preliminary analysis. Material and methods: The initial study was a single-blinded multicenter randomized controlled trial where patients are allocated to three treatment arms. Group 1 consisted of mechano-chemical ablation +2% Polidocanol liquid, group 2: mechano-chemical ablation +3% Polidocanol liquid and group 3: mechano-chemical ablation +1% Polidocanol foam Results: Eighty-seven, 34 males and 53 females (60.9%), mean age 55 years s.d. 16.0 (range 24-84), were enrolled in the study. Treatment length was 30 cm (range 10-30) for 95.2% of the patients. Mean operating time was 16 minutes (range 5-70). The mean saphenofemoral junction diameter (7.7 mm) was similar in all three groups. At 6 weeks post-treatment duplex ultrasound showed that 25 out of 25 = 100%, 27 out of 28 = 96.4% and 13 out of 23 = 56.5% were occluded in the mechano-chemical ablation + 2% Polidocanol liquid, mechano-chemical ablation + 3% Polidocanol liquid and mechano-chemical ablation + 1% Polidocanol microfoam respectively (p < 0.001). However, stricter scrutiny showed that the anatomical success rate defined as occlusion of at least 85% of the treated length to be 88.0%, 85.7% and 30.4% respectively (p < 0.001). Conclusion: Mechano-chemical ablation using ClariVein® combined with 1% Polidocanol microfoam is significantly less effective and should not be considered as a treatment option of incompetent truncal veins. Further investigation to determine the ideal Polidocanol liquid dosage with mechano-chemical ablation is advocated and is being conducted accordingly.
... Various treatment modalities were tried in subsequent centuries, but the disease remains an unsolved enigma. Trendelenburg's operation (1882) and the stripping of vein are still the gold standard [1,2]. The crude method of stripping has been replaced by various newer modifications like laser, radio frequency, or sclerotherapy. ...
Article
Varicose veins (VVs) are generally characterized by their elongated, twisted, bulging, superficial appearance on the lower extremities and usually present with acute or chronic venous diseases. Despite diagnostic and surgical advances in the management of VV, patients suffer from post-therapeutic complications and recurrence. We present findings from a retrospective study of a modified treatment modality in patients with varicose veins who attended St. Thomas Institute of Research on Venous Diseases, Changanassery, Kerala. The hospital caters to patients from India and outside. Out of 14,707 patients treated from 1997 till May 2013, 6,350 patients from January to March 2011 were selected for the study from the routine clinical practice (mid-segment) to facilitate follow-up. They were categorized according to Clinical Etiologic Anatomic Pathophysiologic (CEAP) clinical classification system. Baseline data were accrued using a questionnaire. Patients were treated by microfoam sclerotherapy giving a maximum importance to smaller veins, depicting a modified technique of microfoam sclerotherapy (MMFST). This is based on the significance of microscopic venous valves (MVVs) in the development of chronic venous disease (CVD). Follow-up was according to a predefined schedule, and improvements and complications were recorded. A positive family history of VVs was reported in 85.23 % of patients. Half the study population belonged to CEAP clinical class IV. There were no significant complications in patients throughout the 2 to 6 years of follow-up. Recurrence was rarely reported during follow-up and was corrected by repeating the procedure as required during follow-up. MMFST is an innovation in the treatment of VVs based on new principles, with the potential to control and revert the symptoms of CVD, with minimal complications.
Article
Varicose vein disease of the lower extremities is a common problem today. In various countries, approximately 25–30% of women and 10–15% of men sufferfrom this condition. Surgical methods hold a special place in the treatment of such patients. Currently, despite the development of effective minimally invasive endovenous techniques, doctors still face recurrences of the disease due to insufficiency of radical surgery, as well as the natural progression of varicose vein disease as genetically determined, which necessitates further exploration for solutions to improve treatment outcomes. The article describes the history of the development of surgical methods, including the first mentions of this disease, vessel ligation, phlebectomy, minimally invasive techniques, and others.
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Venous leg ulcers (VLUs) are the most severe complication caused by the progression of chronic venous insufficiency. They account for approximately 70–90% of all chronic leg ulcers (CLUs). A total of 1% of the Western population will suffer at some time in their lives from a VLU. Furthermore, most CLUs are VLUs, defined as chronic leg wounds that show no tendency to heal after three months of appropriate treatment or are still not fully healed at 12 months. The essential feature of VLUs is their recurrence. VLUs also significantly impact quality of life and could cause social isolation and depression. They also have a significant avoidable economic burden. It is estimated that the treatment of venous ulceration accounts for around 3% of the total expenditure on healthcare. A VLU-free world is a highly desirable aim but could be challenging to achieve with the current knowledge of the pathophysiology and diagnostic and therapeutical protocols. To decrease the incidence of VLUs, the long-term goal must be to identify high-risk patients at an early stage of chronic venous disease and initiate appropriate preventive measures. This review discusses the epidemiology, socioeconomic burden, pathophysiology, diagnosis, modes of conservative and invasive treatment, and prevention of VLUs.
Article
Introduction: Chronic venous disease is a common clinical problem with an increasing incidence that constitutes a financial burden for healthcare. Minimal invasive techniques and procedures in an outpatient basis may help decompressing the healthcare system. The aim of this study is to evaluate the effectiveness and safety of endovenous closure of the truncal veins with n butylcyanoacrylate adhesive on an outpatient basis. Methods: We treated 100 cases of venous insufficiency with endovenous NBCA glue closure of the truncal veins on an outpatient basis. Patients were usually admitted to the vascular surgery department at the time of the procedure. The surgery took place in the general operation room, under local anesthesia. We didn’t use compression stockings and patients were instructed to walk immediately after the operation. Results: There was a 100% successful obliteration of the target vein in day 0, 2weeks, 3-months and one year. The majority of patients (98%) reported improvement of the symptoms, whereas 60 patients (60%) had complete elimination of symptoms. The appearance of varicose veins improved in 96% of the cases. There were no major adverse effects observed during follow-up. A percentage of 28% presented erythema and tenderness along GSV and 15 of those patients were treated with anti-inflammatory drugs (Ibuprofen) and 5 with antibiotics (Amoxicillin-Clavulanic acid). Conclusion: Outpatient treatment of venous insufficiency with endovenous glue closure is a safe and efficient method. It increases patient satisfaction, permits rapid return to normal activities and reduces the risk of hospital transmission of infectious diseases and hospitalization costs.
Thesis
We explore the effectiveness of using foam in its application within a minimally invasive treatment for varicose veins called foam sclerotherapy. The foam is injected into a varicose vein where it aims to displace the blood and deliver the surfactant to the veins’ endothelial cells. This leads to the collapse of the vessel. Foam is used in the treatment due to its yield stress, which allows an effective displacement of blood. The value of the yield-stress of the foam can be empirically estimated in terms of its surface tension, liquid fraction and bubble radius [Princen and Kiss, 1989]. Further investigation is carried out on the average bubble radius R32 thus the value of the yield stress τ0, allowing us to estimate the yield stress for both the Varethina® and Physician-compounded foams using the data from Carugo et al. [2016]. In order to analyse the effectiveness of the treatment, we conduct finite element simulations of yield-stress fluid through two dimensional channels of various geometries. Due to the nature of the microfluidic flows, we solve the Stokes equations inunison with the Papanastasiou model [Papanastasiou, 1987], treating the foam as a generalised Newtonian fluid with a shear rate dependent viscosity. The algorithms are validated by comparing the numerical velocities with the respective analytical velocity profile. This is done through both straight and curved channel geometries. In order to validate the latter geometry, we produce an analytical velocity profile for a pressure-driven Bingham fluid. The effect of curvature on the channel flow provides added complexity as the yield surfaces are derived as functions of yield-stress, pressure gradient and additionally channel curvature. Once the simulation has been validated, we consider more complex geometries such as a sinusoidal channel. This allows us to explore the effect of deviating from the straight channel case and increasing the channel amplitude has on the size of the rigid plug regions, which is the essential region of the foam in displacing blood.
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Background: Varicose veins of lower limb are multiple elongated dilated and tortuous veins. It is a progressive disease that worsens as the day passes. The treatment modalities available are conservative, surgical and endovenous therapies. It is accepted that surgical treatment is required for symptomatic varicose veins, to relieve symptoms and to prevent the long-term sequelae of eczema, lipodermatosclerosis and venous ulceration. Different surgical interventions may be used, but most preferred treatment applied is saphenofemoral flush ligation and ligation of incompetent perforators. Methods: This prospective comparative study was conducted on 60 patients in the department of general surgery, Mamata general hospital from July 2020 to June 2022. 60 patients were allocated into two groups of 30 patients each, who underwent flush ligation of saphenofemoral junction with stripping of long saphenous varicose vein and Trendelenburg surgery alone (flush ligation of sapheno femoral junction) respectively. Results: The hematoma formation in the thigh was seen in 23.33% of patients who underwent venous stripping whereas it was seen only in 3.33% who underwent Trendelenburg procedure alone. These wounds were examined in the postoperative period. Delayed wound healing was observed in 26.66% in patients with venous stripping and it was 10% with Trendelenburg procedure alone. There was no significant difference in postoperative ambulation, hospital stay and pain relief after 2 months. Conclusions: From this study with the observed variables, it is concluded that the Trendelenburg procedure with incompetent perforators ligation without venous stripping appears to be better than Trendelenburg procedure with incompetent perforators ligation with venous stripping.
Article
In the management of saphenous vein reflux, endovenous laser ablation (EVLA) has emerged as a very popular minimally invasive substitute in recent years. The development of this field benefits from a thorough understanding of its state of development and bibliometric analysis may help this. However, no bibliometric analysis has adequately summed up this field. We sought to analyze decades' worth of EVLA literature. The purpose of this study was to retrieve information from journals listed in the Web of Science (WOS) search engine with the dataset "TI=(EVLA) or TI=(Endovenous Laser Ablation)". We searched the Web of Science core collection. There were 471 publications (70.701% articles). They were cited 8062 times totally and 17.12 times per article. The mean Hirsch (H) index of the published documents was 49. Over the past 20 years, there has been a gradual rise in the number of publications and citations in EVLA research, showing that the field has gained attention. The United State of America (USA) (n=99), England (n=48), Netherlands (n=48), Turkey (n=46), and Germany (n=40) were the top 5 publishing countries on EVLA research. It was found that the number of published documents was limited. And the contribution was only from 46 countries. The number of publications and the number of broadcasting countries should be increased.
Article
Background: Varicose veins are a common disease that cause edema, heaviness, pigmentation, and skin ulcers, ultimately affecting the quality of life. Various treatments have recently been developed; therefore, clinicians need to understand the anatomy, pathophysiology, risk factors, and symptoms of varicose veins to provide optimal treatment.Current Concepts: Lower extremity veins are composed of deep, superficial, perforating, and communicating vein systems, and the main axial superficial veins are composed of the great and small saphenous veins. Venous circulation primarily relies on muscle pumps in the foot and calf. Pressure on the sole and contraction of calf muscles compress the veins, sending blood upward or to the deep vein system. Varicose veins are caused by valvular abnormalities, muscle pump failure, etc., and associated risk factors include age, pregnancy, obesity, and family history. The main symptoms include heaviness, fatigue, and edema.Discussion and Conclusion: Varicose veins have complex anatomical structures and are developed by various factors. Therefore, appropriate treatments should be selected considering patients’ symptoms, anatomical structure, and economic aspects.
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Chronic venous disease is a worldwide problem associated with significant morbidity and is expected to increase in prevalence as the current population ages. This is a comprehensive review of the anatomy, pathophysiology, genomics, clinical classification, and treatment modalities of chronic venous disease.
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The literature review focuses on the significant aspects of epidemiology, analysis of risk factors and modern principles of surgical treatment of varicose veins. Literature data show that considering pathology in recent years has a tendency to increase the frequency and the significant factors at risk of its development are the inheritance, overweight, as also pregnancy and childbirth of two or more. In recent years, new thermal catheter techniques have become more frequent in the treatment of varicose veins, which demonstrate their advantages and high efficiency. The literature analysis shows that the use of a 1470 nm laser wavelength with a radial type of optical fibers has the highest coagulating effect compared to other types of laser. The authors of the article provided detailed coverage of the endovascular laser ablation technique, showing its advantages over other methods, and its role and place in the comprehensive treatment of the varicose veins.
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Background: With more than 10 million cases occurring annually in India, varicose veins can sometimes result in severe discomfort and pain besides disfiguration of skin. The objective of the study was to assess the most viable treatment options for varicose veins between the traditional Trendelenburg procedure and microphlebectomy. Methods: This was an interventional study conducted at a tertiary center in South India. Patients above 18 years of age, presenting with varicose veins due to saphenofemoral junction (SFJ) incompetence and scheduled for surgical management, were included in a sample size of 46. Subjects were randomized into two groups – Group 1 underwent micro phlebectomy and Group 2 underwent Trendelenburg operation with stripping of great saphenous vein (GSV). Postoperative pain was assessed on day of surgery, day after, and postoperative day 7. A venous Doppler ultrasound was conducted 6 weeks after the surgical procedure, to look for reflux at SFJ. Results: Group 1 subjects reported lesser immediate postoperative pain and incurred significantly less cost as determined by an independent sample t-test. Chi-square test found no significant difference in the rate of occurrence of local complications (P > 0.05), and no recurrence was noted among both groups. Conclusion: Microphlebectomy is a more feasible treatment option than Trendelenburg operation with GSV stripping on account of lower costs. It is also a patient friendly alternative due to immediate reduction in pain.
Article
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This study aimed to review the pathophysiology of varicose veins and chronic venous insufficiency and the recent surgical treatment trend. Varicose veins are tortuous, twisted, or lengthened veins in the lower extremities. It is part of the spectrum of chronic venous disease. Primary pathogenesis is increased chronic venous hypertension caused by valvular insufficiency, venous outflow obstruction, and calf muscle pump failure. Some patients complain of no symptoms, except report cosmetic concerns. If the varicose vein progresses to chronic venous insufficiency, it may cause edema of the lower limb. The skin lesion can present as hyperpigmentation of the median part of the ankle, congestive dermatitis, and even a skin ulcer. The varicose vein can be diagnosed easily by visual inspection after identifying the skin lesions. For non-surgical treatment, elastic stocking, Unna boots, and pneumatic compression devices are recommended to reduce venous pressure. High ligation with stripping has been the standard treatment for varicose veins to achieve symptom relief and improve cosmetic effects. Endovenous laser ablation, radiofrequency ablation, mechanochemical ablation, and the VenaSeal closure system have been introduced as surgical treatment methods. Recently, endovenous thermal/non-thermal ablations are recommended for treatment because both are less invasive techniques. The appropriate therapy should be selected after considering the patients’ symptoms and signs, anatomical structure, and economic burden of the treatment.
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Background Venous ulceration is a common and costly health-care issue worldwide, with poor healing rates greatly affecting patient quality of life. Compression bandaging has been shown to improve healing rates and reduce recurrence, but does not address the underlying cause, which is often superficial venous reflux. Surgical correction of the reflux reduces ulcer recurrence; however, the effect of early endovenous ablation of superficial venous reflux on ulcer healing is unclear. Objectives To determine the clinical effectiveness and cost-effectiveness of compression therapy with early endovenous ablation of superficial venous reflux compared with compression therapy with deferred endovenous ablation in patients with venous ulceration. Design A pragmatic, two-arm, multicentre, parallel-group, open randomised controlled trial with a health economic evaluation. Setting Secondary care vascular centres in England. Participants Patients aged ≥ 18 years with a venous leg ulcer of between 6 weeks’ and 6 months’ duration and an ankle–brachial pressure index of ≥ 0.8 who could tolerate compression and were deemed suitable for endovenous ablation of superficial venous reflux. Interventions Participants were randomised 1 : 1 to either early ablation (compression therapy and superficial endovenous ablation within 2 weeks of randomisation) or deferred ablation (compression therapy followed by endovenous ablation once the ulcer had healed). Main outcome measures The primary outcome measure was time from randomisation to ulcer healing, confirmed by blinded assessment. Secondary outcomes included 24-week ulcer healing rates, ulcer-free time, clinical success (in addition to quality of life), costs and quality-adjusted life-years (QALYs). All analyses were performed on an intention-to-treat basis. Results A total of 450 participants were recruited (224 to early and 226 to deferred superficial endovenous ablation). Baseline characteristics were similar between the two groups. Time to ulcer healing was shorter in participants randomised to early superficial endovenous ablation than in those randomised to deferred ablation [hazard ratio 1.38, 95% confidence interval (CI) 1.13 to 1.68; p = 0.001]. Median time to ulcer healing was 56 (95% CI 49 to 66) days in the early ablation group and 82 (95% CI 69 to 92) days in the deferred ablation group. The ulcer healing rate at 24 weeks was 85.6% in the early ablation group, compared with 76.3% in the deferred ablation group. Median ulcer-free time was 306 [interquartile range (IQR) 240–328] days in the early ablation group and 278 (IQR 175–324) days in the deferred endovenous ablation group ( p = 0.002). The most common complications of superficial endovenous ablation were pain and deep-vein thrombosis. Differences in repeated measures of Aberdeen Varicose Vein Questionnaire scores ( p < 0.001), EuroQol-5 Dimensions index values ( p = 0.03) and Short Form questionnaire-36 items body pain ( p = 0.05) over the follow-up period were observed, in favour of early ablation. The mean difference in total costs between the early ablation and deferred ablation groups was £163 [standard error (SE) £318; p = 0.607]; however, there was a substantial and statistically significant gain in QALY over 1 year [mean difference between groups 0.041 (SE 0.017) QALYs; p = 0.017]. The incremental cost-effectiveness ratio of early ablation at 1 year was £3976 per QALY, with a high probability (89%) of being more cost-effective than deferred ablation at conventional UK decision-making thresholds (currently £20,000 per QALY). Sensitivity analyses using alternative statistical models give qualitatively similar results. Limitations Only 7% of screened patients were recruited, treatment regimens varied significantly and technical success was assessed only in the early ablation group. Conclusions Early endovenous ablation of superficial venous reflux, in addition to compression therapy and wound dressings, reduces the time to healing of venous leg ulcers, increases ulcer-free time and is highly likely to be cost-effective. Future work Longer-term follow-up is ongoing and will determine if early ablation will affect recurrence rates in the medium and long term. Trial registration Current Controlled Trials ISRCTN02335796. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 23, No. 24. See the NIHR Journals Library website for further project information.
Article
Objective: Varicose vein (VV) surgery is frequently performed by surgeons without formal vascular training. We aimed to compare the outcomes of the procedure based on the background of the surgeon. Methods: All patients registered with VV surgery between 2004 and 2016 in Portuguese public hospitals were included in the study. Intrahospital outcomes were assessed from this administrative database. A random multicenter sample of 315 patients submitted to saphenous high ligation and stripping (175 patients from six vascular surgery departments and 140 patients from five general surgery divisions) were further queried over the phone, whereby additional nonregistered outcomes were evaluated: preoperative venous ultrasound, impact on quality of life by the 14-item Chronic Venous Insufficiency Quality of Life Questionnaire, visual analogue scale evaluation (score of 1 to 5) of the aesthetic results and general satisfaction, work absence days, and time to return to physical activities. Results: In 13 years, there were 153,382 patients submitted to VV surgery. Of these, 49% were operated on by general surgeons and 40% by vascular surgeons; in 11%, it was not possible to identify the specialty performing the operation. Twenty-three deaths were registered (no differences between groups). In the general surgery group, 14% of patients were hospitalized for more than one night compared with 3% in the vascular group (P < .001). Reintervention rate during the period analyzed was significantly higher in the general surgery group (13.5% vs 8.2%; P < .001). Rate of outpatient surgery was higher in the vascular surgery group (60% vs 36%; P < .001). Phone query revealed similar overall satisfaction and improvement in quality of life in both groups (4.2 vs 4.0 [P = .275] and 35% vs 36% [P = .745], respectively). However, patients operated on by general surgeons reported worse surgical scars (2.8 vs 2.1; P = .007), higher number of residual VVs (2.4 vs 1.7; P = .006), and higher number of days absent from work (40 vs 27 days; P = .005) and took longer to resume physical activities (60 vs 41 days; P = .001). Conclusions: Despite that the majority of VV surgery in Portugal is executed by general surgeons, this study highlights important advantages when it is performed by surgeons with vascular training.
Article
Objective: The objective of this study was to assess the association between provider characteristics and intensity of endovenous therapy (EVT) utilization in the Medicare population. Methods: The Medicare Provider Utilization and Payment Data Public Use Files (2012-2014) were queried to construct a database of providers performing EVT using laser or radiofrequency ablation techniques for treatment of lower extremity venous reflux. A utilization index (UI; EVT procedure per patient treated per year) was calculated for each provider, and median services per county were determined. Provider specialty, geographic region, and site of service (facility vs outpatient) were determined for each patient. Multivariate regression analysis was used to identify provider characteristics associated with a UI above the 75th percentile. Results: There were 6599 providers who performed EVT in 405,232 Medicare beneficiaries during the study period. Intensity of EVT use by providers was assessed by the calculated UI, the average number of EVT procedures performed in treated patients per year (range, 1-4). Vascular surgeons had the lowest UI among all provider specialties (1.32). By multivariate analysis, the likelihood of a provider's UI being >1.8 (top 25%) was associated with provider training in a field other than surgery, cardiology, or radiology (odds ratio [OR], 3.35; 2.74-4.09); services performed in an outpatient setting (OR, 2.62; 1.97-3.47); and providers who perform high annual volume of EVT (OR, 8.68; 7.59-9.91). A high annual volume provider was defined as one whose EVT volume was ≥75th percentile nationally. Conclusions: There is great variation in intensity of vein ablation procedures performed on Medicare beneficiaries by geographic location and provider specialty. High-volume providers and those with a specialty not traditionally associated with the management of lower extremity chronic venous disease are more likely to perform more EVT procedures per patient.
Article
Background: Chronic venous disease (CVD) is extremely common worldwide. The prevalence is increasing with age and is associated with a reduced quality of life, particularly in relation to pain, physical function and mobility. Symptomatic chronic venous insufficiency (CVI) with venous ulcer at its' endpoint, indicates interventional surgery to cure venous reflux therewith promoting wound healing and preventing recurrence. To our knowledge up to now no coherent study has been undertaken in patients with CVI who underwent an open venous surgery concerning complications, venous hemodynamics and perioperative symptomology in one study population. This was undertaken in our retrospective, single-centre, consecutive case-control study in a single patient population of a university clinic in northern Germany. Part I covers postoperative complications in relation with co-morbidities, co-medication and clinical presentation. Part II will focus on pre- and postoperative hemodynamics and evolution of symptoms. Methods: Records of n = 429 (467 extremities) patients from 2009-2013 treated with open surgery were analysed. Number and type of complication were evaluated with regards to demographic parameters, co-existing medical conditions and procedure related aspects. Complications were grouped as no events (NE), neglectable adverse events (NAE), non-neglectable adverse events (NNAE) and severe (life-threatening) adverse events (SAE). Results: In 467 extremities of 429 patients with CVI 130 (27,84%) postoperative complications were observed after open surgery, thereof 64(13,7%) NAE, 66(14,14%) NNAE and 0 SAE. 29 (6,76%) patients developed a postoperative surgical site infection, thereof 4 (0,9%) with consecutive septicaemia. Except one case with nerval lesion and paraesthesia and hypoesthesia not resolving after 12 month all complications resolved within surveillance time span of 12 month. Patients developing NAE had a higher BMI (p = 0.003), were more likely to have diabetes mellitus (p < 0.001), and co-morbidities leading to the intake of anti-platelet or anticoagulation drugs (p < 0.001). Metabolic syndrome (p < 0.001) and anti-platelet or anticoagulation (p < 0.001) could be defined as independent risk factors for the development of complications. Patients receiving open surgery of small saphenous veins had 8 times higher risk of calf muscle venous thrombosis (p = 0.001). Conclusion: Patients with a metabolic syndrome or receiving anti-platelet therapy or anticoagulation medication should undergo open venous surgery under hospital conditions with routine postinterventional surveillance visits. Patients undergoing an open surgery of SSV are definite candidates for postoperative subcutaneous heparin thromboprophylaxis. In general Stripping below knee increases the risk of postoperative sensory deficit. This resolves in almost all patients within one year.
Chapter
The incorporation of the various endovenous techniques in the treatment of the superficial vein incompetence has limited the space for the open techniques. According to the current guidelines, the thermal ablation techniques, and the nonthermal ablation techniques secondarily, have been proposed as the main treatment options. Nevertheless, open surgical procedures (high ligation with or without stripping and phlebectomies) still remain an equal alternative. Additionally, there are specific situations that the ablation techniques cannot be used. In these cases, the standard surgical treatments remain a prudent option. Similar to primary varicose vein disease, the role of traditional open surgery for the management of recurrent varicose veins has been significantly limited by the development of the endovenous techniques. However, in the unusual circumstances where the endovenous techniques are either unavailable or contraindicated, a re-exploration of the groin may be considered. In the current chapter, a detailed description of the open surgical technique used today and suggested treatment algorithms for the primary and recurrent superficial vein incompetence are presented.
Article
Chronic venous disease (CVD) is a highly prevalent pathology that compromises patient’s quality of life, and has an important impact socioeconomically. Its treatment passes through the adoption of hygiene-dietetic measures, pharmacological therapy and elastic compression, as well as approaches that are able to ablate venous reflux and hypertension such as mechanical, thermic or chemical ablations. Due to the multiplicity of therapeutic approaches available nowadays, it is important to search for the more effective ones. The objective of this work is to establish a systematic clinical orientation for patients with chronic venous disease, taking into account the CEAP classification, the published results and the recommendations available, in a way to achieve clinical improvement and to answer patient’s expectations. English articles were searched in Medline in concern to the treatment of chronic venous disease. Articles cited by others contained in the initial research were also included. It was possible to understand that chronic venous disease treatment must be individualized and established according to the clinical state. Hygiene-dietetic measures must be adopted by all patients and the different compressions degrees adjusted to the CEAP classification. Pharmacological therapy induces symptomatic relieve and improves complications. All ablation techniques can be performed in an ambulatory setting. Thermal ablation is a promising treatment although there is lack of long term results for recurrence, whereas the chemical ablation, despite being the cheapest, is the mayor cause of pigmentation and recanalization. Mechanical approaches can be performed without general anesthesia and patients are able to return to work the day after the procedure.
Article
INTRODUCTION The management of superficial and deep venous reflux and obstruction that leads to the development of varicose veins (VV) and the post-thrombotic syndrome (PTS) forms a large part of the workload for most vascular and endovascular specialists and is likely to increase as the population ages. However, the epidemiology, genetics and pathophysiology of these conditions remains incompletely defined and many clinicians lack a clear understanding of the underlying anatomy and vascular biology. As a result, treatment outcomes are not infrequently sub-optimal. ANATOMY Venous blood from the lower limbs returns to the right heart against gravity through the superficial and deep venous systems. The superficial venous system comprises the great saphenous veins (GSV) and small saphenous veins (SSV) and their tributaries. The GSV originates from the medial end of the dorsal venous arch, passes anterior to the medial malleolus, and continues up the medial aspect of the calf and then the thigh to enter the common femoral vein in the groin at the saphenofemoral junction (SFJ). The SSV originates from the lateral end of the dorsal venous arch, passes posterior to the lateral malleolus and then continues up the back of the calf between the heads of gastrocnemius to enter the popliteal fossa. It is joined variably by gastrocnemius veins and then usually enters the popliteal vein at the sapheno-popliteal junction (SPJ). The SPJ may be absent in which case the SSV continues up the postero-medial aspect of the thigh (Giacomini vein) and often joins the GSV.
Article
Aim: In the last 10 years, endovascular procedures have taken over on saphenous stripping in rich countries. The recent literature is full of scientific papers that magnify the results of endovascular procedures, and guidelines in many countries attribute to them the role of a new golden standard in the treatment of varicose disease. But surely in the world there are still some surgeons who perform saphenous stripping in patients in which the indication is placed after preoperative ultrasound analysis. Therefore stripping is not dead and cannot yet be buried. Methods: In our experience the traditional ablative surgery in the treatment of patients with varicose veins of the lower limbs (CEAP 2-6) is always in the first place and continues to be performed in a percentage that approaches 70% compared to the total of phlebological interventions performed annually. Over the past 3 years on a total of 858 patients (554 F and 304 M) aged between 22 and 84 years, 590 patients (68.7%) underwent saphenectomy by stripping, often associated with multiple phlebectomies of the thigh and/or leg. Results: With the various techniques used there was neither mortality, nor infectious complications. We complain about a case of hematoma in the thigh in a subject operated by stripping in anticoagulant treatment, because of serious heart disease. No thrombotic complication, neither immediate nor at 3-month follow-up, has been documented. Conclusion. Our current experience makes us conclude that surgery still represents for long-term efficacy the therapeutic strategy of reference, but it is undeniable that the endovascular procedures for their minimally invasiveness, fewer complications, reduced need for general anesthesia, quicker return to work and equivalent recurrence rates, are destined to become in the near future the gold standard for treatment of varicose disease. However, due to the heterogeneity of the diseases, it is not possible to perform only one type of operation for all varicose patients, and probably saphenous stripping will always have a role, though reduced over time.
Article
Prehistoric man was able to perform injections using poultry bones as a needle and his mouth or an animal bladder as the reservoir for fluids. Varicose veins have been known at least since the days of Hippocrates (-400 b.c.e.). Piston-action metal syringes have been found in the ruins of Pompei. Transparent syringes and metal needles date from the nineteenth century. In the twentieth century, foam and echographic monitoring revolutionized the treatment of varicose saphenous veins. In the early 21st century, surgeons abandoned the "dogma of crossectomy" and attempted to replace stripping with thermal endovenous treatments (laser, radiofrequencies, steam ablation). New pharmaco-mechanical techniques are currently being assessed for the treatment of large-diameter varicose saphenous veins.
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High venous pressure in leg from walking in erect position can lead the development of defective valves and reflux, and superficial veins may become elongated and tortuous. Women are more prone to varicose vein due to hormonal influences and pregnancy. Besides long standing occupation and female gender, there are other risk factors including age, family history, obesity, and prior deep vein thrombosis. Recently developed health related quality of life has contributed to concern more about varicose vein and develop the treatment modalities of varicose vein. Because of the chronicity of the development of varicose vein, most patients are usually accustomed to high venous pressure of their leg and feel minor or no discomfort. Among the reasons to seek for the treatment of varicose vein, cosmetic purpose is the most common. Most patients prefer non-surgical treatment including sclerotheraphy to surgical intervention. High ligation and stripping of varicose vein has remained as the standard treatment of varicose vein with excellent long term results. Minimal invasive non-surgical treatments including radiofrequency ablation and endovenous laser treatment have shown less scars and earlier mobility. Newer treatment modalities have to prove comparable long term results, not merely better cosmetic and short term results. We reviewed about the development of varicose vein and the treatment modalities including preventive measures. Correct comprehension of the patient and proper application of the treatment modality are essential for the good result without recurrence after the treatment of varicose vein.
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The aim of this study was to compare two different approaches to surgical treatment of varicose veins in the lower limbs, too often characterized by recurrence or persistent varicose veins. In our retrospective study, we analyzed how superficial epigastric vein sparing in saphenous-femoral crossectomy might influence the incidence of recurrence. We analyzed 200 patients, and we noticed a trend characterized by a reduction of recurrence or persistent varicose veins in the group treated with selective crossectomy (superficial epigastric vein sparing).
Article
The American Society for Dermatologic Surgery (ASDS) periodically develops consensus documents for its members concerning various aspects of dermatologic surgery. Unwanted and painful leg veins are a very widespread problem. Many advances in sclerotherapy of varicose and telangiectatic leg veins have occurred since the previous consensus documents. In 2013, the ASDS Board of Directors voted to have a committee of experts in the field to develop consensus documents on sclerotherapy. An expert panel reviewed the literature on sclerotherapy and discussed the findings. A consensus was reached with evidence-based recommendations on diagnostic evaluation and treatment of varicose and telangiectatic leg veins. The consensus documents include discussion of indications for treatment, patient selection, contraindications, diagnostic testing, treatment approaches, use of compression, and expected outcome. Common sclerosants and their mechanisms of action, advantages and disadvantages of foam sclerotherapy, and minimizing and treating complications are presented. The ASDS consensus documents on sclerotherapy will be helpful in educating their members on safe and effective sclerotherapy of varicose and telangiectatic leg veins.
Article
Background: Patient-reported outcomes are increasingly recognized as important to understanding outcomes of medical interventions such as varicose vein surgery (VVS). Our aim was to compare positive outcomes of VVS as defined by several patient-reported measures, and to identify baseline characteristics associated with positive outcomes of VVS. Methods: A secondary analysis of the UK Patient-Reported Outcome Measures database was conducted on patients undergoing VVS, in the period 2009-2011 who completed the generic EQ-5D (index and visual analog scale [VAS] summary scores) and disease-specific Aberdeen varicose vein questionnaire (AVVQ). Surgical outcome was defined as positive if pre/post change scores exceeded half a standard deviation of mean baseline scores. Logistic regression models were used to identify significant predictors of positive outcomes, including age, gender, and baseline health. Results: Of 9,113 patients analyzed (71 % females, 57 % aged >50 years), positive outcomes were identified in 62 % using the AVVQ, 43 % based on EQ-5D index scores, and 24 % according to EQ-VAS; 10 % improved on all three measures. Patients with poorer baseline functioning (AVVQ scores ≥11) were more likely to have a positive outcome based on the EQ-5D index (odds ratio [OR] 1.23, 95 % confidence interval [CI] 1.11-1.36) and EQ-VAS (OR 1.30, 95 % CI 1.14-1.47). Conclusions: Defining surgery as successful will clearly depend on how health-related quality of life (HRQL) is operationalized and the criteria used to identify meaningful change. Across a range of criteria, a consistently greater proportion of patients had positive outcomes in terms of VV-related functioning (via AVVQ) compared with those who improved in terms of generic health (via EQ-index), or self-rated health (EQ-VAS).
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Radiofrequency obliteration (RFO), endovenous laser therapy (EVLT) and foam sclerotherapy (FS) are potential treatments for varicose veins. A systematic review was undertaken to assess their safety and effectiveness and to compare these endoluminal therapeutic options with conventional ligation and vein stripping. An electronic health database search was performed on all studies published between 1970 and 2007 describing RFO, EVLT, and FS for treating varicose veins. Twenty-nine EVLT studies, 32 RFO studies and 22 FS trials were included. RFO was associated with the worst short and long-term safety and efficacy results compared to EVLT and FS regarding ''complete occlusion at the end of follow-up'', ''phlebitis'', ''deep vein thrombosis'', and ''paraesthesia''. EVLT had the best results concerning the long-term effectiveness parameters for ''occlusion at the end of follow-up'' and ''recanalization, recurrence or development of new veins'', compared to RFO and FS. Foam sclerotherapy of varicose veins is associated with a higher recurrence rate in patients with saphenofemoral incompetence compared to the rates after EVLT or RFO treatment. EVLT, RFO, and FS seem to be safe and effective modalities with good short and mid-term Acquisition of comparative long-term and very long-term data on clinical efficacy (particularly with regard to the formation of recurrent varicose veins), safety, quality of life outcomes and costs is needed by large high-quality prospective randomized trials of endovenous techniques versus each other and versus surgery before considering endovenous techniques as the standard treatment.
Article
In the past many methods for the surgical treatment of varicose veins have been used. Among these, the most favored have been high ligation with retrograde injection and, in more recent years, the complete-stripping procedure. In order to evaluate these two common surgical procedures for varicose veins, we made the comparative study to be reported here.Background Information Certain background information is essential to a proper understanding of the basis of this study. The surgical treatment of varicose veins during the past few decades has gone through a cycle of methods-from radical dissection and extirpation; through extraluminal and intraluminal partial stripping, injections with sclerosing solution, high ligation with or without retrograde injections, and multiple-level ligations, to modern complete stripping. Madelung,1 in 1884, advocated extirpation of the greater saphenous system with ligation of the communicating veins through a long incision in the thigh and leg. This was a formidable procedure
Article
Endovenous laser ablation (ELA) has become a standard treatment of the incompetent great saphenous vein (GSV). Our prospective audit examines the implementation of this new method in a large community hospital with special attention to obstacles, technical results, pain scores, failures and our learning curve. Three hundred and twenty-three patients (403 limbs) with incompetence of the GSV underwent ELA. Patients were assessed by clinical examination and venous duplex ultrasound was performed 6 weeks after operation. Visual analog scale (VAS) pain scores of the first postoperative week were recorded. Operative time and success rate were analysed. After 6 weeks, 301 (74.7%) treated legs were examined by duplex ultrasound imaging. Successful complete occlusion was present in 282 (93.7%) GSVs. Partial occlusion was present in 12 (4.0%) GSVs. In seven (2.3%) limbs the GSV was not occluded. The maximum mean VAS pain score was noted on the 5th postoperative day. From the start of this series, the operation time decreased rapidly for each surgeon, stabilising after 15 limbs. ELA of the incompetent GSV is effective and safe. ELA is simple to perform, well accepted by patients and relatively atraumatic. In our opinion, ELA can be easily implemented in surgical practice.
Article
Minimally invasive techniques such as endovenous laser therapy, radiofrequency ablation, and ultrasound-guided foam sclerotherapy are widely used in the treatment of lower extremity varicosities. These therapies have not yet been compared with surgical ligation and stripping in large randomized clinical trials. A systematic review of Medline, Cochrane Library, and Cinahl was performed to identify studies on the effectiveness of the four therapies up to February 2007. All clinical studies (open, noncomparative, and randomized clinical trials) that used ultrasound examination as an outcome measure were included. Because observational and randomized clinical trial data were included, both the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) and Quality Of Reporting Of Meta-analyses (QUORUM) guidelines were consulted. A random effects meta-analysis was performed, and subgroup analysis and meta-regression were done to explore sources of between-study variation. Of the 119 retrieved studies, 64 (53.8%) were eligible and assessed 12,320 limbs. Average follow-up was 32.2 months. After 3 years, the estimated pooled success rates (with 95% confidence intervals [CI]) for stripping, foam sclerotherapy, radiofrequency ablation, and laser therapy were about 78% (70%-84%), 77% (69%-84%), 84% (75%-90%), and 94% (87%-98%), respectively. After adjusting for follow-up, foam therapy and radiofrequency ablation were as effective as surgical stripping (adjusted odds ratio [AOR], 0.12 [95% CI, -0.61 to 0.85] and 0.43 [95% CI, -0.19 to 1.04], respectively). Endovenous laser therapy was significantly more effective compared with stripping (AOR, 1.13; 95% CI, 0.40-1.87), foam therapy (AOR, 1.02; 95% CI, 0.28-1.75), and radiofrequency ablation (AOR, 0.71; 95% CI, 0.15-1.27). In the absence of large, comparative randomized clinical trials, the minimally invasive techniques appear to be at least as effective as surgery in the treatment of lower extremity varicose veins.
Article
Non-invasive methods of venous assessment were used to assess the procedure of high ligation plus multiple avulsion of varicosities for the treatment of varicose veins in 54 limbs. Duplex scanning before operation confirmed saphenofemoral incompetence and excluded short saphenous incompetence. After operation it revealed that in two limbs the saphenofemoral junction was still patent and incompetent. In the 52 limbs in which the junction had been ligated there was persistent reflux down the long saphenous vein in 24 cases. In only two limbs was this attributable to mid-thigh perforating veins. Photoplethysmography was also performed before and after operation and the venous refilling time measured. Improvement in refilling time produced by application of above knee tourniquets before operation was measured (predicted improvement) and the change in refilling time after operation was also recorded (observed improvement). There was a statistically significant correlation between observed improvement and predicted improvement in refilling times in the limbs with no reflux in the long saphenous vein after operation (Pearson's correlation coefficient, r = 0.6, P less than 0.001). There was no correlation between predicted and observed refilling times in the limbs with persisting reflux in the long saphenous vein after operation. In conclusion, this operation fails to control functionally significant reflux within the long saphenous vein in a high proportion of cases.
Article
Liposuction is now a well-established procedure in dermatologic surgery. The relative advantages and risks of the various forms of primary anesthesia and supplemental analgesia used for liposuction surgery in the office by dermatologic surgeons is described. Effective anesthetic techniques include infiltration of local anesthesia (LA) with or without intramuscular (IM), intravenous (IV), or nitrous oxide sedation, cryoanesthesia, and IV or inhalation general anesthesia (GA). Local anesthesia, using large volumes of dilute anesthetic solution containing lidocaine (0.05%), epinephrine (1:1,000,000), and sodium bicarbonate (12.5 meq/L), is a safe and effective modality for liposuction by dermatologists. In a study of 12 liposuction patients treated with this technique, the average lidocaine dose was 1181 mg (9.4 mg/kg/hr). The highest peak lidocaine blood level among all patients was 0.484 microgram/ml. Dermatologists should not assume the dual responsibility of surgeon and of monitoring patients given IV sedation. Any form of anesthesia has the potential for serious complications. The surgeon and office staff must be well trained and equipped to perform emergency resuscitation.
Article
A curative atrial fibrillation procedure will most likely rely on creating transmural linear ablative lesions. However, it is currently unknown whether endocardial radiofrequency lesions can create lines of conduction block. In six pigs, intracardiac echocardiography was used to guide the positioning of multiple coil array catheters to bridge endocardial structures in three right atrial locations: (1) from the crista terminalis to the tricuspid annulus; (2) from the fossa ovalis to the crista terminalis; and (3) from the inferior vena cava to the tricuspid annulus. Once the catheter was positioned, linear lesions were made by radiofrequency energy applied sequentially to each of the four coils. After 15 days, the chest was opened and a 112-electrode epicardial plaque was positioned over the atrial free wall lesion to determine activation patterns. Three lesions were placed in each animal, with a mean procedure time of 47+/-11 minutes. Once adequate contact was determined by intracardiac echocardiography, a single series of radiofrequency application was required to achieve tissue heating (65+/-4 degrees C) with a power of 21+/-10 W. Epicardial mapping demonstrated complete conduction block across the lesions in all animals, with split potentials and disparate activation times (64+/-16 ms) across the lesion. At autopsy, all lesions were discrete, continuous, and without evidence of charring. The lesions were within 0.3+/-0.5 mm of their targeted anatomic locations and measured 21+/-4 mm long and 2.8+/-0.6 mm wide. Histology revealed transmural fibrosis throughout the length of each lesion. Linear lesions that are electrophysiologically transmural and continuous can be placed in the right atrium of normal pigs. With intracardiac echocardiography, adequate tissue contact over several coil electrodes can be ensured, resulting in short procedure times, efficient energy application, and accurate anatomically linked lesion placement.
Article
The purposes of this article are to describe Byzantine varicose vein surgery and to note its influence on the development of these operations after that time. A study and analysis of the original texts of the Byzantine physicians, written in Greek and containing the now mostly lost knowledge of the earlier Hellenistic and Roman periods, was undertaken. The Byzantines paid special attention to varicosis surgery from the early period of the empire. The famous fourth-century (ce) physician Oribasius meticulously described a number of surgical methods of confronting varicosis, some of which were derived from the texts of earlier Greek surgeons, to which he added his own keen observations. Later, eminent Byzantine physicians developed these techniques further and evaluated their usefulness. The study of Byzantine medical texts proves that several surgical techniques on varicosis were widely practiced in Byzantine times and were derived from the work of ancient Greek and Roman physicians. The techniques described had a great influence on western medieval and later European surgery, thus constituting significant roots of modern angiology.
Article
Endovenous laser (EVL) ablation of the great saphenous vein (GSV) is thought to minimize postoperative morbidity and reduce work loss compared with high ligation and stripping (HL/S). However, the procedures have not previously been compared in a randomized trial with parallel groups where both treatments were performed in tumescent anesthesia on an out-patient basis. Patients with varicose veins due to GSV insufficiency were randomized to either EVL (980 nm) or HL/S in tumescent anesthesia. Miniphlebectomies were also performed. Patients were examined preoperatively and at 12 days, and 1, 3, and 6 months postoperatively. Sick leave, time to normal physical activity, pain score, use of analgesics, Aberdeen score, Medical Outcomes Study Short Form-36 quality-of-life score, Venous Clinical Severity Score (VCSS), and complication rates were investigated. The total cost of the procedures, including lost wages and equipment, was calculated. Cost calculations were based on the standard fee for HL/S with the addition of laser equipment and the standard salary and productivity level in Denmark. A follow-up of 6 months was achieved in 121 patients (137 legs). The groups were well matched for patient and GSV characteristics. Two HL/S procedures failed, and three GSVs recanalized in the EVL group. The groups experienced similar improvement in quality-of-life scores and VCSS score at 3 months. Only one patient in the HL/S group had a major complication, a wound infection that was treated successfully with antibiotics. The HL/S and EVL groups did not differ in mean time to resume normal physical activity (7.7 vs 6.9 calendar days) and work (7.6 vs 7.0 calendar days). Postoperative pain and bruising was higher in the HL/S group, but no difference in the use of analgesics was recorded. The total cost of the procedures, including lost wages, was euro 3084 (3948US)intheHL/Sandeuro3396(3948 US) in the HL/S and euro 3396 (4347 US) in the EVL group. This study suggests that the short-term efficacy and safety of EVL and HL/S are similar. Except for slightly increased postoperative pain and bruising in the HL/S group, no differences were found between the two treatment modalities. The treatments were equally safe and efficient in eliminating GSV reflux, alleviating symptoms and signs of GSV varicosities, and improving quality of life. Long-term outcomes, particularly with respect to recurrence rates, shall be investigated in future studies, including the continuation of the present.
Article
Endovenous laser ablation (EVLA) is a minimally invasive technique for treating varicose veins due to truncal vein incompetence. This randomized trial compared EVLA with conventional surgery in patients with primary saphenofemoral and great saphenous vein (GSV) reflux. Consecutive consenting patients with symptomatic varicose veins were randomized to EVLA 1 (stepwise laser withdrawal), EVLA 2 (continuous laser withdrawal) or surgery (saphenofemoral ligation, GSV stripping, multiple phlebectomies). Principal outcome measures were abolition of GSV reflux and improvement in Aberdeen Varicose Vein Symptom Score (AVVSS) 3 months after treatment. GSV reflux was abolished in 41 of 42 legs treated with EVLA 1, 26 of 29 following EVLA 2 and 28 of 32 after surgery (P = 0.227). The median (interquartile range, i.q.r.) AVVSS improvement was similar: 9.38 (4.54-14.93) with EVLA 1, 10.26 (5.03-15.03) after EVLA 2 and 8.36 (4.54-13.21) following surgery (P = 0.694). Return to normal activity (median (i.q.r.) 2 (0-7) versus 7 (2-26) days; P = 0.001) and work (4 (2-7) versus 17 (7.25-33.25) days; P = 0.005) was quicker after EVLA by either method. Abolition of reflux and improvement in disease-specific quality of life was comparable following both EVLA and surgery. The earlier return to normal activity following EVLA may confer important socioeconomic advantages. Registration number: ISRCTN99270116 (http://www.controlled-trials.com).
Milestones, Pebbles, and Grains of Sand. Diseases of the Veins
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Tratamiento endoluminal de las varices con laser de diodo: estudio preliminary
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Historical development of varicose vein surgery Varicose Veins and Telangiectasia, Diagnosis and Treatment
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Historical aspects The Pathology and Surgery of Veins of the Lower Limb
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Anning ST. Historical aspects. In: Dodd H, Cockett FB eds. The Pathology and Surgery of Veins of the Lower Limb. Edinburgh: Livingstone, 1956. pp 6-28.
Ambulatory Phlebec-tomy, a Practical Guide for Treating Varicose Veins
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The operative treatment of varicose veins, with special reference to a modification of Trendelenburg's operation. Intercolonial Med
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