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The Association Between PICC Use and Venous Thromboembolism in Upper and Lower Extremities
Abstracts Gregory L. Moneta, MD, SECTION EDITOR
Patterns of Failure of a Standardized Perioperative Venous Thromboembolism Prophylaxis Protocol Cassidy MR, Macht RD, Rosenkranz P, et al. J Am Coll Surg 2016;222:1074-81. Conclusion: Emergency and multiple operations result in increased hazards for VTE despite standard prophylaxis. These factors are not currently captured in the Caprini model and should prompt reassessment of the Caprini model with perhaps weighted numerical values and enhanced prophylaxis. Summary: In response to analysis of National Surgical Quality Improvement Program (NSQIP) data, the authors implemented a mandatory venous thromboembolism (VTE) risk calculation for every patient on their general surgical service by integrating the Caprini grading system into their electronic medical record (EMR). Electronic reminders about appropriate VTE prophylaxis were automatically regenerated before and after operations and at discharge. Depending on risk level both mechanical and pharmacologic prophylaxis were utilized. Use of this protocol reduced the author’s rates of VTE events markedly compared to their previous data. However, VTE events still occurred even if prophylaxis was administered. In this study they sought to analyze patients who failed their mandatory standardized prophylaxis system in hopes of identifying hazards that might not be captured in the current Caprini scoring system. They reviewed all non- trauma, general surgery patients who had evidence of VTE after inception of the VTE risk assessment and prophylaxis program that utilized the Caprini score. Recorded characteristics included demographics, diagnosis, operations, risk profile, prophylaxis prescribed and regime compliance. Twenty-seven patients failed the protocol and manifested VTE with an overall VTE rate of 0.3%. Of these patients, 63% had emergency operations and 52% underwent multiple operations compared with 13% and 2% of the non-trauma general surgery population in whom VTE did not develop (P < .001). Of the patients with VTE, 52% had pre-existing or postoperative infection, 22% had malignancy and 15% missed 1 or more doses of pharmacologic prophylaxis during hospitalization. Five of the VTEs manifested after discharge. One of those patients had extended prophylaxis prescribed beyond hospitalization while an extended course of prophylaxis was not provided to 3 patients who were eligible. One other patient had underestimation of VTE risk by the Caprini score due to lack of awareness of a family history of VTE. Comment: Data indicate emergency and multiple operations confer a dramatic increased hazard for VTE despite standard prophylaxis. These particular factors are not currently captured in the Caprini model. They appear to be significant modifiers of risk that perhaps should be incorporated into the Caprini model or serve as additional factors to the Caprini model indicating enhanced need for VTE prophylaxis.
Compression of the Right Iliac Vein in Asymptomatic Subjects and Patients With Iliofemoral Deep Vein Thrombosis Chen F, Deng J, Hu XM, Zhou WM. Phlebology 2016:31;471-80. Conclusions: Right iliac vein compression is a frequent finding with CT imaging and represents a normal anatomic pattern. However, patients with right leg deep vein thrombosis (DVT) have more severe iliac vein compression than left leg DVT patients. Summary: Compression of the left iliac vein by the right iliac artery is well known as a risk factor for chronic venous disease and acute venous thrombosis, so-called May-Thurner syndrome. Whereas it is known that the right iliac vein can also occasionally be compressed it has not been well studied systematically. The authors’ goal was to evaluate right iliac vein and left iliac vein compression in asymptomatic subjects and in patients with right sided and left sided iliofemoral DVT. This is a retrospective analysis of records and computer tomography (CT) images from 200 asymptomatic subjects (male and female 100 each). In addition, a prospective analysis was conducted in 79 consecutive DVT patients (left:right DVT, 47:32) who had also undergone contrast-enhanced CT evaluations. The diameter and percentage of compression of the iliac veins were evaluated. In asymptomatic subjects, 13.5% had >50% right
iliac vein compression, 2% had right iliac vein compression >70%. Mean right iliac vein compression was 23.45%. Left iliac vein compression >50% was present in 45% of subjects and 17% had left iliac compression >70% with mean left iliac vein compression of 47.58%. The most common mechanism of right iliac vein compression was sandwiching of the vein between the right external iliac artery and the right internal iliac artery (59.3%). Males had greater iliac vein compression than females (male, 26.29%; female, 20.68%; P < .001). Mean percent compression of the right iliac vein was higher in right lower extremity DVT patients than in left lower extremity DVT patients (right leg DVT right iliac vein compression, 48.5% vs left leg DVT iliac vein compression, 22.3%; P < .001). Comment: Data indicate that although not as widely recognized as left iliac vein compression, right iliac vein compression is also likely a contributor to DVT. The corollary is right iliac vein compression may be a contributor to chronic venous disease of the right lower extremity as left iliac vein compression it increasingly considered a contributor to chronic venous disease in the left lower extremity.
A Randomized, Double-Blind, PlaceboControlled, Clinical Study on the Efficacy and Safety of Calcium Dobesilate in the Treatment of Chronic Venous Insufficiency Rabel E, Ballarini S, Lehr L. Phlebology 2016;31:264-74. Conclusions: Treatment with calcium dobesilate in patients with chronic venous insufficiency results in a volume decrease of the affected leg. Summary: Calcium dobesilate is advocated as a vasoactive drug with favorable effects on the retinal circulation in patients with diabetes, on hemorrhoids, and in the lower extremities of patients with chronic venous insufficiency. The authors studied the effects of 500 mg of calcium dobesilate v placebo for the reduction of lower extremity edema in patients with chronic venous insufficiency, CEAP classes 3 or 4. There were a total of 351 patients randomized in this study. One hundred seventy-four patients were randomized to calcium dobesilate and 177 to placebo. Active treatment was 500 mg calcium dobesilate, three times daily for 12 weeks with a 12-week follow-up period. At the end of treatment the relative volume change in the most pathological leg was 0.6 6 4.8% with calcium dobesilate compared to 0.3 6 3.3% with placebo (P ¼ .09). At the end of follow-up the relative volume change was 1.01 6 5.4% for calcium dobesilate vs 0.08 6 3.5% for placebo (P ¼ .002). Comment: Obviously, this limited study is not a raging endorsement for the use of this drug to reduce edema in patients with chronic venous insufficiency. Leg volume is decreased but not much. However, a better characterization of the effects of the drug in terms of long-term prognosis of CVI, its effects when combined with various adjuncts such as compression devices or wraps and effects on patient perceived quality of life is needed and requires further study.
The Association Between PICC Use and Venous Thromboembolism in Upper and Lower Extremities Green MT, Flanders SA, Woller SC, et al. Am J Med 2015;128:986-93. Conclusions: Peripherally inserted central venous catheters (PICCs) are associated with upper and lower extremity DVT. Summary: Use of PICCs has grown substantially in hospitalized patients with certain clear clinical advantages in that they help avoid complications associated with central venous catheters in the neck or chest. They can be used for diverse purposes including infusion of antibiotics, chemotherapy or even homodynamic monitoring. Hospital based vascular nursing teams provide cost effective insertion at the bedside. Several studies, however, have identified PICCs as a risk factor for upper extremity venous thromboembolism (VTE). However, it is unknown whether PICCs increase VTE in upper and lower extremities or are associated with pulmonary embolism (PE), and no previous studies have assessed whether PICC lines are independently associated with an increase of lower extremity deep vein thrombosis (DVT). The authors examined the risk of VTE in the deep veins in the arms and legs and of
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Abstracts
Journal of Vascular Surgery: Venous and Lymphatic Disorders January 2017
PE in patients with PICC lines. This was a multicenter retrospective cohort study of 76,242 hospitalized medical patients from 48 Michigan hospitals. PICC line presence, comorbidities, VTE risk factors, and thrombotic events within 90 days from hospital admission were ascertained by phone and record review. Cox proportional hazard models examined the association between PICC line use and 90-day hazard of upper and lower extremity DVT or PE, adjusting for patient characteristics and natural clustering within hospitals. A total of 3790 patients received a PICC line during hospitalization. From hospital admission to 90 days, 876 thrombotic events (208 upper extremity DVTs, 372 lower extremity DVTs, and 296 PEs) were identified. After risk adjustment, PICC line use was independently associated with all VTE (hazard ratio [HR], 3.16; 95% confidence interval [CI], 2.59-3.85), upper extremity DVT (HR, 10.49; 95% CI, 7.79-14.11), and lower extremity DVT (HR, 1.48; 95% CI, 1.02-2.15). PICC lines were not associated with pulmonary embolism (HR, 1.34; 95% CI, 0.86-2.06). Results were also robust to sensitivity analyses incorporating receipt of pharmacologic prophylaxis during hospitalization. Comment: It is unclear why there is an association between PICC lines and lower extremity DVT but it likely reflects the fact that PICC lines are often used in high risk patients that are otherwise inherently predisposed to venous thrombosis. In addition, certain acute inflammatory illnesses such as pneumonia increase risk of lower extremity DVT and treatment often requires a PICC line. However, this was an observational study and thus the results are subject to confounding from many potential unmeasured and/or unknown variables. In addition, data regarding care of PICC lines in individual hospitals was not collected and how this may influence DVT risk is also unknown. The lack of association of PICC lines with PE in this study likely reflects the fact the majority of DVTs were upper extremity DVTs and upper extremity VTE is not as strongly associated with PE as lower extremity DVT. It seems most likely that PICC lines result in DVT from mechanical influence of the catheter combined with an overall increased thrombotic state of these patients.
Effectiveness of Embolization or Sclerotherapy of Pelvic Veins for Reducing Chronic Pelvic Pain: A Systematic Review Daniels JP, Champaneria R, Shah L, et al. J Vasc Interv Radiol 2016;27:1478-86. Conclusions: Embolization appears to provide symptomatic relief of chronic pelvic pain (CPP) in the majority of women and is safe although quality of evidence is low. Summary: Pelvic congestion syndrome (PCS) is described as chronic pelvic pain (CPP) arising from dilated and refluxing incompetent pelvic veins. Diagnosis is based on patient reported symptoms, anatomic features and venagraphic findings. There are no generally accepted or well defined clinic criteria for diagnosis of PCS, likely reflecting difficulty establishing a causal relationship between pelvic vein incompetence and CPP. Since the early 1990’s percutaneous induction of embolic materials in dilated or reflexing veins has become common for treatment of CPP. However, once an incompetent vein has been occluded blood can be diverted to additional veins with recurrence of reflux. The objective of this systematic review was to assess the effectiveness of percutaneous embolization of incompetent pelvic veins in reducing CPP. Secondary objectives were to assess radiologic features, impact on fertility, and adverse events. The authors utilized a comprehensive search strategy incorporating various terms for pelvic congestion, pelvic pain, and embolization in 17 bibliographic databases with no restriction on study design. Methodologic quality was assessed. The varying quality and heterogeneity of the studies precluded meta-analysis. Results were therefore tabulated and described in a narrative fashion. From 21 prospective case series and one poor-quality randomized trial of embolization, a total of 1308 women were identified. In approximately 75% of the women, early substantial relief of pain was observed in those undergoing embolization and pain relief increased over time and was sustained. Significant pain reductions following treatment were observed in all studies that measured pain on a visual analog scale. Repeat intervention rates were generally low. There were few data on the impact on menstruation, ovarian reserve, or fertility but no concerns were noted. There was a 2% or less risk of coil migration.
Comment: Basically the article states that coil embolization of refluxing pelvic veins can be done to treat CPP with an expected 75% response rate in terms of pain improvement following the treatment. While transient pain is common following embolization, the procedure appears safe with a <2% risk of coil migration. Questions appear to be not so much whether embolization provides early pain relief, but whether there are particular presenting characteristics predicting successful outcomes and what are the optimal techniques for coil embolization to eliminate CPP? Preprocedure discussions with women with PCC who select embolization for treatment of PCC should highlight the fact that embolization while safe may still not provide complete relief of symptom and long-term results are unknown.
Treatment Modalities for Small Saphenous Vein Insufficiency: Systematic Review and MetaAnalysis Boersma D, Kornmann VNN, van Eekeren RRJP, et al. JEVT 2016;23:199-211. Conclusions: Endovenous thermal ablation is preferred to surgery and preferred to foam sclerotherapy in the treatment of the small saphenous vein (SSV) reflux. Summary: Prevalence of superficial vein reflux in the adult population is 21% (Maurins U et al, J Vasc Surg 2008;48:680-7). The SSV is responsible for about 15% of all varicose vein disease (Almgren B et al, Acta Chirurg Scand 1990;156:69-74). Open techniques for surgical treatment of small saphenous vein incompetence are technically more demanding and associated with higher recurrence and complication rates than those associated with long saphenous vein treatment (Winterborn RJ et al, Eur J Vasc Endovasc Surg 2004;28:400-3). There have been many clinical studies of endothermal ablation of the greater saphenous vein with excellent results. There is, however, less known about optimal therapy for SSV incompetence. In this study, the authors performed a meta-analysis to investigate and compare anatomic success rates and complications of treatment modalities for SSV incompetence. They performed a systematic literature review using PubMed, EMBASE, and the Cochrane Library on therapies for treatment of incompetence of SSVs. These included surgery, endovenous laser ablation (EVLA), radio frequency ablation (RFA), ultrasound guided foam sclerotherapy (UGFS), steam ablation and mechanochemical endovenous ablation (MOCA). The authors search resulted in 49 articles including five randomized control trials and 44 cohort studies. Nine articles evaluated open surgery, 28 EVLA, 9 RFA, 6 UGFS, and 1 MOCA. The authors utilized a random effects model to estimate the primary outcome of anatomic success defined as closure of the treated vein on follow up duplex ultrasound imaging. Secondary outcomes were technical success and major complications (paresthesia and deep vein thrombosis) evaluated as weighted means. Pooled anatomic success rate was 58.0% (95% confidence interval [CI], 40.9%-75%) for surgery in 798 SSVs, 98.5% (95% CI, 97.7%-99.2%) for EVLA in 2950 SSVs, 97.1% (95% CI, 94.3%-99.9%) for RFA in 386 SSVs, and 63.6% (95% CI, 47.1%-80.1%) for UGFS in 494 SSVs. The study reported results of MOCA with anatomic success rate of 94%. Neurological complications were most frequently reported after surgery (mean, 19.6%) compared to thermal ablation (EVLA: mean, 4.8%; RFA: mean, 9.7%). Deep venous thrombosis was a rare complication (0%-1%). Comment: A major limitation of this article is lack of patient reported outcome measures. It is important to notice, however that both open surgical techniques and thermal ablation techniques are associated with neurologic damage with an incidence of paresthesia of 19.6% after surgery and 9.7% after RFA and 4.8% after EVLA. However, nonthermal techniques were not associated with neurologic damage. In addition, the occurrence of paresthesia may be under reported with respect to milder transient complaints because no specific neurologic examination was performed routinely in the studies evaluated. The emerging concept of shared patient decision making seems important here as data do suggest that, despite inferior anatomic results with nonthermal techniques, a discussion with the patient regarding the potential for atomic failure of the procedure vs neurologic damage should be held with patients considering treatment of SSV incompetence.
Patterns of Failure of a Standardized Perioperative Venous Thromboembolism Prophylaxis Protocol Cassidy MR, Macht RD, Rosenkranz P, et al. J Am Coll Surg 2016;222:1074-81. Conclusion: Emergency and multiple operations result in increased hazards for VTE despite standard prophylaxis. These factors are not currently captured in the Caprini model and should prompt reassessment of the Caprini model with perhaps weighted numerical values and enhanced prophylaxis. Summary: In response to analysis of National Surgical Quality Improvement Program (NSQIP) data, the authors implemented a mandatory venous thromboembolism (VTE) risk calculation for every patient on their general surgical service by integrating the Caprini grading system into their electronic medical record (EMR). Electronic reminders about appropriate VTE prophylaxis were automatically regenerated before and after operations and at discharge. Depending on risk level both mechanical and pharmacologic prophylaxis were utilized. Use of this protocol reduced the author’s rates of VTE events markedly compared to their previous data. However, VTE events still occurred even if prophylaxis was administered. In this study they sought to analyze patients who failed their mandatory standardized prophylaxis system in hopes of identifying hazards that might not be captured in the current Caprini scoring system. They reviewed all non- trauma, general surgery patients who had evidence of VTE after inception of the VTE risk assessment and prophylaxis program that utilized the Caprini score. Recorded characteristics included demographics, diagnosis, operations, risk profile, prophylaxis prescribed and regime compliance. Twenty-seven patients failed the protocol and manifested VTE with an overall VTE rate of 0.3%. Of these patients, 63% had emergency operations and 52% underwent multiple operations compared with 13% and 2% of the non-trauma general surgery population in whom VTE did not develop (P < .001). Of the patients with VTE, 52% had pre-existing or postoperative infection, 22% had malignancy and 15% missed 1 or more doses of pharmacologic prophylaxis during hospitalization. Five of the VTEs manifested after discharge. One of those patients had extended prophylaxis prescribed beyond hospitalization while an extended course of prophylaxis was not provided to 3 patients who were eligible. One other patient had underestimation of VTE risk by the Caprini score due to lack of awareness of a family history of VTE. Comment: Data indicate emergency and multiple operations confer a dramatic increased hazard for VTE despite standard prophylaxis. These particular factors are not currently captured in the Caprini model. They appear to be significant modifiers of risk that perhaps should be incorporated into the Caprini model or serve as additional factors to the Caprini model indicating enhanced need for VTE prophylaxis.
Compression of the Right Iliac Vein in Asymptomatic Subjects and Patients With Iliofemoral Deep Vein Thrombosis Chen F, Deng J, Hu XM, Zhou WM. Phlebology 2016:31;471-80. Conclusions: Right iliac vein compression is a frequent finding with CT imaging and represents a normal anatomic pattern. However, patients with right leg deep vein thrombosis (DVT) have more severe iliac vein compression than left leg DVT patients. Summary: Compression of the left iliac vein by the right iliac artery is well known as a risk factor for chronic venous disease and acute venous thrombosis, so-called May-Thurner syndrome. Whereas it is known that the right iliac vein can also occasionally be compressed it has not been well studied systematically. The authors’ goal was to evaluate right iliac vein and left iliac vein compression in asymptomatic subjects and in patients with right sided and left sided iliofemoral DVT. This is a retrospective analysis of records and computer tomography (CT) images from 200 asymptomatic subjects (male and female 100 each). In addition, a prospective analysis was conducted in 79 consecutive DVT patients (left:right DVT, 47:32) who had also undergone contrast-enhanced CT evaluations. The diameter and percentage of compression of the iliac veins were evaluated. In asymptomatic subjects, 13.5% had >50% right
iliac vein compression, 2% had right iliac vein compression >70%. Mean right iliac vein compression was 23.45%. Left iliac vein compression >50% was present in 45% of subjects and 17% had left iliac compression >70% with mean left iliac vein compression of 47.58%. The most common mechanism of right iliac vein compression was sandwiching of the vein between the right external iliac artery and the right internal iliac artery (59.3%). Males had greater iliac vein compression than females (male, 26.29%; female, 20.68%; P < .001). Mean percent compression of the right iliac vein was higher in right lower extremity DVT patients than in left lower extremity DVT patients (right leg DVT right iliac vein compression, 48.5% vs left leg DVT iliac vein compression, 22.3%; P < .001). Comment: Data indicate that although not as widely recognized as left iliac vein compression, right iliac vein compression is also likely a contributor to DVT. The corollary is right iliac vein compression may be a contributor to chronic venous disease of the right lower extremity as left iliac vein compression it increasingly considered a contributor to chronic venous disease in the left lower extremity.
A Randomized, Double-Blind, PlaceboControlled, Clinical Study on the Efficacy and Safety of Calcium Dobesilate in the Treatment of Chronic Venous Insufficiency Rabel E, Ballarini S, Lehr L. Phlebology 2016;31:264-74. Conclusions: Treatment with calcium dobesilate in patients with chronic venous insufficiency results in a volume decrease of the affected leg. Summary: Calcium dobesilate is advocated as a vasoactive drug with favorable effects on the retinal circulation in patients with diabetes, on hemorrhoids, and in the lower extremities of patients with chronic venous insufficiency. The authors studied the effects of 500 mg of calcium dobesilate v placebo for the reduction of lower extremity edema in patients with chronic venous insufficiency, CEAP classes 3 or 4. There were a total of 351 patients randomized in this study. One hundred seventy-four patients were randomized to calcium dobesilate and 177 to placebo. Active treatment was 500 mg calcium dobesilate, three times daily for 12 weeks with a 12-week follow-up period. At the end of treatment the relative volume change in the most pathological leg was 0.6 6 4.8% with calcium dobesilate compared to 0.3 6 3.3% with placebo (P ¼ .09). At the end of follow-up the relative volume change was 1.01 6 5.4% for calcium dobesilate vs 0.08 6 3.5% for placebo (P ¼ .002). Comment: Obviously, this limited study is not a raging endorsement for the use of this drug to reduce edema in patients with chronic venous insufficiency. Leg volume is decreased but not much. However, a better characterization of the effects of the drug in terms of long-term prognosis of CVI, its effects when combined with various adjuncts such as compression devices or wraps and effects on patient perceived quality of life is needed and requires further study.
The Association Between PICC Use and Venous Thromboembolism in Upper and Lower Extremities Green MT, Flanders SA, Woller SC, et al. Am J Med 2015;128:986-93. Conclusions: Peripherally inserted central venous catheters (PICCs) are associated with upper and lower extremity DVT. Summary: Use of PICCs has grown substantially in hospitalized patients with certain clear clinical advantages in that they help avoid complications associated with central venous catheters in the neck or chest. They can be used for diverse purposes including infusion of antibiotics, chemotherapy or even homodynamic monitoring. Hospital based vascular nursing teams provide cost effective insertion at the bedside. Several studies, however, have identified PICCs as a risk factor for upper extremity venous thromboembolism (VTE). However, it is unknown whether PICCs increase VTE in upper and lower extremities or are associated with pulmonary embolism (PE), and no previous studies have assessed whether PICC lines are independently associated with an increase of lower extremity deep vein thrombosis (DVT). The authors examined the risk of VTE in the deep veins in the arms and legs and of
143
144
Abstracts
Journal of Vascular Surgery: Venous and Lymphatic Disorders January 2017
PE in patients with PICC lines. This was a multicenter retrospective cohort study of 76,242 hospitalized medical patients from 48 Michigan hospitals. PICC line presence, comorbidities, VTE risk factors, and thrombotic events within 90 days from hospital admission were ascertained by phone and record review. Cox proportional hazard models examined the association between PICC line use and 90-day hazard of upper and lower extremity DVT or PE, adjusting for patient characteristics and natural clustering within hospitals. A total of 3790 patients received a PICC line during hospitalization. From hospital admission to 90 days, 876 thrombotic events (208 upper extremity DVTs, 372 lower extremity DVTs, and 296 PEs) were identified. After risk adjustment, PICC line use was independently associated with all VTE (hazard ratio [HR], 3.16; 95% confidence interval [CI], 2.59-3.85), upper extremity DVT (HR, 10.49; 95% CI, 7.79-14.11), and lower extremity DVT (HR, 1.48; 95% CI, 1.02-2.15). PICC lines were not associated with pulmonary embolism (HR, 1.34; 95% CI, 0.86-2.06). Results were also robust to sensitivity analyses incorporating receipt of pharmacologic prophylaxis during hospitalization. Comment: It is unclear why there is an association between PICC lines and lower extremity DVT but it likely reflects the fact that PICC lines are often used in high risk patients that are otherwise inherently predisposed to venous thrombosis. In addition, certain acute inflammatory illnesses such as pneumonia increase risk of lower extremity DVT and treatment often requires a PICC line. However, this was an observational study and thus the results are subject to confounding from many potential unmeasured and/or unknown variables. In addition, data regarding care of PICC lines in individual hospitals was not collected and how this may influence DVT risk is also unknown. The lack of association of PICC lines with PE in this study likely reflects the fact the majority of DVTs were upper extremity DVTs and upper extremity VTE is not as strongly associated with PE as lower extremity DVT. It seems most likely that PICC lines result in DVT from mechanical influence of the catheter combined with an overall increased thrombotic state of these patients.
Effectiveness of Embolization or Sclerotherapy of Pelvic Veins for Reducing Chronic Pelvic Pain: A Systematic Review Daniels JP, Champaneria R, Shah L, et al. J Vasc Interv Radiol 2016;27:1478-86. Conclusions: Embolization appears to provide symptomatic relief of chronic pelvic pain (CPP) in the majority of women and is safe although quality of evidence is low. Summary: Pelvic congestion syndrome (PCS) is described as chronic pelvic pain (CPP) arising from dilated and refluxing incompetent pelvic veins. Diagnosis is based on patient reported symptoms, anatomic features and venagraphic findings. There are no generally accepted or well defined clinic criteria for diagnosis of PCS, likely reflecting difficulty establishing a causal relationship between pelvic vein incompetence and CPP. Since the early 1990’s percutaneous induction of embolic materials in dilated or reflexing veins has become common for treatment of CPP. However, once an incompetent vein has been occluded blood can be diverted to additional veins with recurrence of reflux. The objective of this systematic review was to assess the effectiveness of percutaneous embolization of incompetent pelvic veins in reducing CPP. Secondary objectives were to assess radiologic features, impact on fertility, and adverse events. The authors utilized a comprehensive search strategy incorporating various terms for pelvic congestion, pelvic pain, and embolization in 17 bibliographic databases with no restriction on study design. Methodologic quality was assessed. The varying quality and heterogeneity of the studies precluded meta-analysis. Results were therefore tabulated and described in a narrative fashion. From 21 prospective case series and one poor-quality randomized trial of embolization, a total of 1308 women were identified. In approximately 75% of the women, early substantial relief of pain was observed in those undergoing embolization and pain relief increased over time and was sustained. Significant pain reductions following treatment were observed in all studies that measured pain on a visual analog scale. Repeat intervention rates were generally low. There were few data on the impact on menstruation, ovarian reserve, or fertility but no concerns were noted. There was a 2% or less risk of coil migration.
Comment: Basically the article states that coil embolization of refluxing pelvic veins can be done to treat CPP with an expected 75% response rate in terms of pain improvement following the treatment. While transient pain is common following embolization, the procedure appears safe with a <2% risk of coil migration. Questions appear to be not so much whether embolization provides early pain relief, but whether there are particular presenting characteristics predicting successful outcomes and what are the optimal techniques for coil embolization to eliminate CPP? Preprocedure discussions with women with PCC who select embolization for treatment of PCC should highlight the fact that embolization while safe may still not provide complete relief of symptom and long-term results are unknown.
Treatment Modalities for Small Saphenous Vein Insufficiency: Systematic Review and MetaAnalysis Boersma D, Kornmann VNN, van Eekeren RRJP, et al. JEVT 2016;23:199-211. Conclusions: Endovenous thermal ablation is preferred to surgery and preferred to foam sclerotherapy in the treatment of the small saphenous vein (SSV) reflux. Summary: Prevalence of superficial vein reflux in the adult population is 21% (Maurins U et al, J Vasc Surg 2008;48:680-7). The SSV is responsible for about 15% of all varicose vein disease (Almgren B et al, Acta Chirurg Scand 1990;156:69-74). Open techniques for surgical treatment of small saphenous vein incompetence are technically more demanding and associated with higher recurrence and complication rates than those associated with long saphenous vein treatment (Winterborn RJ et al, Eur J Vasc Endovasc Surg 2004;28:400-3). There have been many clinical studies of endothermal ablation of the greater saphenous vein with excellent results. There is, however, less known about optimal therapy for SSV incompetence. In this study, the authors performed a meta-analysis to investigate and compare anatomic success rates and complications of treatment modalities for SSV incompetence. They performed a systematic literature review using PubMed, EMBASE, and the Cochrane Library on therapies for treatment of incompetence of SSVs. These included surgery, endovenous laser ablation (EVLA), radio frequency ablation (RFA), ultrasound guided foam sclerotherapy (UGFS), steam ablation and mechanochemical endovenous ablation (MOCA). The authors search resulted in 49 articles including five randomized control trials and 44 cohort studies. Nine articles evaluated open surgery, 28 EVLA, 9 RFA, 6 UGFS, and 1 MOCA. The authors utilized a random effects model to estimate the primary outcome of anatomic success defined as closure of the treated vein on follow up duplex ultrasound imaging. Secondary outcomes were technical success and major complications (paresthesia and deep vein thrombosis) evaluated as weighted means. Pooled anatomic success rate was 58.0% (95% confidence interval [CI], 40.9%-75%) for surgery in 798 SSVs, 98.5% (95% CI, 97.7%-99.2%) for EVLA in 2950 SSVs, 97.1% (95% CI, 94.3%-99.9%) for RFA in 386 SSVs, and 63.6% (95% CI, 47.1%-80.1%) for UGFS in 494 SSVs. The study reported results of MOCA with anatomic success rate of 94%. Neurological complications were most frequently reported after surgery (mean, 19.6%) compared to thermal ablation (EVLA: mean, 4.8%; RFA: mean, 9.7%). Deep venous thrombosis was a rare complication (0%-1%). Comment: A major limitation of this article is lack of patient reported outcome measures. It is important to notice, however that both open surgical techniques and thermal ablation techniques are associated with neurologic damage with an incidence of paresthesia of 19.6% after surgery and 9.7% after RFA and 4.8% after EVLA. However, nonthermal techniques were not associated with neurologic damage. In addition, the occurrence of paresthesia may be under reported with respect to milder transient complaints because no specific neurologic examination was performed routinely in the studies evaluated. The emerging concept of shared patient decision making seems important here as data do suggest that, despite inferior anatomic results with nonthermal techniques, a discussion with the patient regarding the potential for atomic failure of the procedure vs neurologic damage should be held with patients considering treatment of SSV incompetence.