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Endovenous Approach to Recurrent Varicose Veins
C H A P T E R
11
Endovenous Approach to Recurrent Varicose Veins Jose I. Almeida
HISTORICAL BACKGROUND Recurrence rates of varicose veins of 20% are common, with rates as high as 70% at 10 years.1–3 Up to 25% of procedures for varicose veins are performed for recurrent disease,4 thus placing considerable demands on health care resources. Note that recurrent varicose vein surgery carries a much greater morbidity risk to the patient than primary surgery.3 This risk seems to be reduced with endovenous techniques.
ETIOLOGY AND NATURAL HISTORY OF DISEASE Patients who have had previous high ligation and stripping (HL/S) typically present with recurrent varicose veins; anatomic distribution of these veins is variable. Neovascularization is commonly seen following traditional stripping procedures and is thought to be secondary to “frustrated” venous drainage from the abdominal wall and perineum.5 Regardless of the mechanism, the result is recurrent reflux in the thigh or lower leg veins. Multiple factors contribute in the development of recurrent disease. The weight of each factor has not yet been determined because there are no prospective studies with adequate sample size. The following descriptions are common etiologies seen at Miami Vein Center after clinical and color flow duplex imaging (CFDI) examinations are performed in patients presenting with recurrent varicose veins. 307
C H A P T E R 1 1 n Endovenous Approach to Recurrent Varicose Veins
Abstract
Keywords
Recurrent varicose veins are common, and up to 25% of procedures are performed for recurrent disease. Multiple factors contribute in the development of recurrent disease, but regardless of the mechanism, the result is recurrent reflux in the thigh or lower leg veins. This chapter describes techniques to treat common scenarios seen in practice: (1) previous high ligation and stripping, (2) previous phlebectomy without GSV stripping, (3) previous laser or radiofrequency ablation without phlebectomy, and (4) previous GSV ablation resulting in clinical improvement. Cochrane systematic reviews for endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus open surgery for great and small saphenous vein varices are also summarized.
recurrent varicose veins endovenous ablation radiofrequency laser foam sclerotherapy great saphenous vein small saphenous vein
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PEARLS AND PITFALLS Previous High Ligation and Stripping All patients with recurrent varicose veins should be evaluated with CFDI. Usually, findings include neovascularity in the groin from which one or more tributary veins are found to descend the thigh. The tributary may attach to another tributary, a perforator, or a remnant of the great saphenous vein (GSV) in the thigh or calf (Fig. 11.1). The reflux extends into dilated tributaries of the skin; these vessels bulge and are palpable. In most cases, our approach is to enter any straight, incompetent, axial, venous segments deep to the skin with a micropuncture access kit. These kits usually contain 4-Fr microsheaths, through which we place a 400-µm-diameter or 600-µm-diameter laser fiber. Perivenous,
Femoral vein
Previous stripping of GSV
Neovascularity
Perforator vein
GSV remnant
A ■
Fig. 11.1
Ultrasoundguided sclerotherapy
Area of perforating vein
Ablation of saphenous vein remnant
B
C ■ Fig. 11.1, cont’d (B) Treatment of recurrent varicose vein with the use of combination endovenous laser and foam scleropathy. (C) Cross-sectional view of a subcutaneous tortuous tributary. These tortuous veins are ideal candidates for ultrasound-guided foam sclerotherapy treatment. Continued
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D ■ Fig. 11.1, cont’d (D) Incompetent midthigh perforating vein is the source of the recurrent varicose veins, which is most effectively treated with thermal ablation if anatomically in a straight orientation. If oriented in a tortuous manner, however, ultrasound-guided foam sclerotherapy treatment is preferred. GSV, Great saphenous vein.
tumescent anesthesia is placed, and the vein or veins are ablated in the usual manner. Because tortuous incompetent venous segments below the level of the skin do not allow the passage of guidewires, these are treated with ultrasound-guided foam sclerotherapy (UGFS) (Fig. 11.2). Finally, all bulging varicose veins that are palpable on the skin receive treatment with ambulatory phlebectomy. These three techniques, used concomitantly, yield very satisfactory results. These types of patients are told that the treatments are palliative, and they will likely need “touch-up” treatments in the future.
Previous Phlebectomy Without Great Saphenous Vein Stripping Also common in our practice are patients presenting with recurrent varicose veins previously treated with phlebectomy only at an outside facility. These limbs, once examined with CFDI, usually have a large incompetent GSV descending from the groin and terminating ultimately in the calf at a site where large varicosities are noted. These patients do very well with routine GSV ablation using either radiofrequency or laser and using ambulatory phlebectomy for associated varicosities.
C H A P T E R 1 1 n Endovenous Approach to Recurrent Varicose Veins
Ultrasound-guided foam sclerotherapy for the treatment of recurrent varicose veins
Ultrasound
Neovascularity
Foam sclerosant
A ■
Fig. 11.2 Continued
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B ■ Fig. 11.2, cont’d (B) Ultrasound-guided foam sclerotherapy for the treatment of recurrent varicose veins; tortuous veins seen on ultrasound are in the background.
Previous Laser or Radiofrequency Ablation Without Phlebectomy There are individuals who have seen other physicians and come to our practice with a history of GSV ablation that “worked temporarily.” That is, the venous cluster on the medial calf improved shortly after the procedure, but with time, the same cluster began filling and dilating. CFDI performed in our office usually shows successful ablation of the target GSV. However, the cluster of varicose veins in these cases has found a connection with an incompetent perforating vein. This is usually a Boyd perforating vein in the upper calf. This concept of an untreated “venous reservoir” dictates that other sources of reflux will eventually connect because of low venous resistance. Treatment involves either ultrasound-guided sclerotherapy or thermal ablation of the perforator (function of size) and ambulatory phlebectomy of the varicose clusters.
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We have also seen cases in which two sources of venous hypertension from superficial axial vein reflux were identified preoperatively but only one was treated. In these cases, usually only the incompetent GSV was ablated, and the incompetent anterior accessory saphenous vein was left untreated. There may be temporary improvement of the varicosities in direct continuity with the GSV; less direct varicosities may respond with minimal or no improvement. Our approach with these patients is thermal ablation of the anterior accessory saphenous vein, followed by ambulatory phlebectomy at the same stage.
Previous Great Saphenous Vein Ablation With No Improvement When a patient has a history of previous GSV ablation performed at an outside facility and no improvement was observed by the patient, this should be a red flag that the patient was initially misdiagnosed. The majority of these cases were straightforward, with classic small saphenous vein (SSV) incompetence in the limbs. However, the original physician failed to view the posterior calf with CFDI. Ablation of the SSV with laser or radiofrequency energy in combination with ambulatory phlebectomy will quickly rectify this problem. Gastrocnemial vein incompetence has a prevalence of up to 30% in patients with varicose veins. Most practitioners do not treat this vein. Also incompetent perforators connecting through this vein at the posteromedial calf may be overlooked or missed. We have seen these as sources of recurrent varicose veins. Depending on the severity of the signs and symptoms of the disease, we may elect to treat gastrocnemius veins with ultrasound-guided sclerotherapy. Obviously, this adds controversy to the dearth of clinical information referable to this vein. The aforementioned techniques are self-taught techniques, applying standard endovenous principles. The adage developed by the author is “If an incompetent vein is straight—burn it; if it is tortuous—foam it; if the vein is palpable on the skin (straight or tortuous)—remove it with phlebectomy.” Depicted in Fig. 11.3 is an endovenous sheath inside a saphenous vein remnant (to deliver laser energy) with a syringe prepared with a foamed sclerosant attached to the sheath side-arm to deliver foam into an area of neovascularization, and the patient is marked for phlebectomy. We have had no complications with this approach in several thousand recurrent varicose vein cases. Recurrences after endovenous treatment develop secondary to progression of disease and are retreatable with the same approach.
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Previous stripping of GSV
Neovascularity
GSV remnant
A ■
Fig. 11.3
These bulging varicose veins will be treated with phlebectomy. Injecting transcatheter foam sclerosant Proximal aspect of laser ablation
Sheath in saphenous vein remnant
Squiggly lines are neovascularity
B
C Fig. 11.3, cont’d (B) Recurrent varicose veins from neovascularity in upper thigh and a refluxing saphenous vein remnant. Treatment with a combination of ultrasound foam sclerotherapy, endovenous laser ablation, and ambulatory phlebectomy. (C) Arrow points to saphenous vein remnant. ■
Continued
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D ■ Fig. 11.3, cont’d (D) Arrow points to foam-filled varicose veins just below skin surface. GSV, Great saphenous vein.
COMPARATIVE EFFECTIVENESS OF EXISTING TREATMENTS FROM COCHRANE DATABASE 1. Endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus open surgery for great saphenous vein varices.6 All randomized controlled trials (RCTs) of UGFS, endovenous laser therapy (EVLT), radiofrequency ablation (RFA), and HL/S were considered for inclusion. Primary outcomes were recurrent varicosities, recanalization, neovascularization, technical procedure failure, patient quality-of-life (QoL) scores, and associated complications. A total of 13 studies with a combined total of 3081 randomized patients were included. Three studies compared UGFS with surgery, eight compared EVLT with surgery, and five compared RFA with surgery (two studies had two or more comparisons with surgery). For the comparison of UGFS versus surgery, the findings may have indicated no difference in the rate of recurrences in the surgical group when measured by clinicians, and no difference between the groups for symptomatic recurrence (odds ratio [OR] 1.74; 95% confidence interval [CI], 0.97–3.12; P = .06 and OR, 1.28; 95% CI, 0.66–2.49, respectively). Recanalization and neovascularization were only evaluated in a single study. Recanalization at less than 4 months had an OR of 0.66 (95% CI, 0.20–2.12), recanalization at greater than 4 months an OR of 5.05 (95% CI, 1.67–15.28), and for neovascularization, an OR of 0.05 (95% CI,
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0.00–0.94). There was no difference in the rate of technical failure between the two groups (OR 0.44; 95% CI, 0.12–1.57). For EVLT versus surgery, there were no differences between the treatment groups for either clinician noted or symptomatic recurrence (OR 0.72; 95% CI, 0.43–1.22; P = .22 and OR 0.87; 95% CI, 0.47–1.62; P = .67, respectively). Both early and late recanalization were no different between the two treatment groups (OR 1.05; 95% CI, 0.09–12.77; P = .97 and OR 4.14; 95% CI, 0.76–22.65; P = .10). Neovascularization and technical failure were both statistically reduced in the laser treatment group (OR 0.05; 95% CI, 0.01–0.22; P < .0001 and OR 0.29; 95% CI, 0.14–0.60; P = .0009, respectively). Long-term (5-year) outcomes were evaluated in one study so no association could be derived, but it appeared that EVLT and surgery maintained similar findings. Comparing RFA versus surgery, there were no differences in cliniciannoted recurrence (OR 0.82; 95% CI, 0.49–1.39; P = .47); symptomatic-noted recurrence was only evaluated in a single study. There were also no differences between the treatment groups for recanalization (early or late) (OR 0.68; 95% CI, 0.01–81.18; P = .87 and OR 1.09; 95% CI, 0.39–3.04; P = .87, respectively), neovascularization (OR 0.31; 95% CI, 0.06–1.65; P = 0.17) or technical failure (OR 0.82; 95% CI, 0.07–10.10; P = .88). QoL scores, operative complications, and pain were not amenable to metaanalysis; however, QoL generally increased similarly in all treatment groups, and complications were generally low, especially major complications. Pain reporting varied greatly between the studies but, in general, pain was similar between the treatment groups. Currently available clinical trial evidence suggests that UGFS, EVLT, and RFA are at least as effective as surgery in the treatment of great saphenous varicose veins. Because of large incompatibilities between trials, and different time point measurements for outcomes, the evidence is lacking in robustness. Further randomized trials are needed, which should aim to report and analyze results in a congruent manner to facilitate future metaanalysis. 2. Endovenous ablation therapy (laser or radiofrequency) or foam sclerotherapy versus conventional surgical repair for short saphenous varicose veins.7 All RCTs comparing EVLA, endovenous RFA, or UGFS with conventional surgery in the treatment of SSV varices were included. There were three RCTs, all of which compared EVLA with surgery; one also compared UGFS with surgery. There were no trials comparing RFA with surgery. The EVLA versus surgery comparison included 311 participants: 185 received EVLA and 126 received surgery. In the UGFS comparison, each treatment group contained 21 subjects. For the EVLA versus surgery comparison, recanalization or persistence of reflux at 6 weeks occurred less frequently in the EVLA group than in the surgery group (OR 0.07; 95% CI, 0.02–0.22; I2 = 51%; 289 participants, three studies, moderatequality evidence). Recurrence of reflux at 1 year was also less frequent in the EVLA group than in the surgery group (OR 0.24; 95% CI, 0.07–0.77; I2 = 0%; 119 participants, two studies, low-quality evidence). For the outcome clinical evidence of recurrence (i.e., presence of new visible varicose veins) at 1 year, there was no difference between the two treatment groups (OR 0.54; 95% CI, 0.17–1.75; 99 participants, one study, low-quality evidence). Four participants each in the EVLA and surgery groups required reintervention because of technical failure (99 participants, one study, moderate-quality evidence). There was no difference between the two treatment groups for disease-specific QoL (Aberdeen Varicose Veins Questionnaire) either at 6 weeks (mean difference [MD], 0.15; 95% CI, −1.65–1.95; I2 = 0%; 265 participants, two studies, moderate-quality evidence), or at 1 year (MD, −1.08; 95% CI, −3.39–1.23; 99 participants, one study, low-quality evidence). Main complications reported at 6 weeks were sural nerve injury, wound infection, and deep venous thrombosis (DVT) (one DVT case in each treatment group; EVLA: 1/161, 0.6%; surgery 1/104, 1%; 265 participants, two studies, moderate-quality evidence). For the UGFS versus surgery comparison, there were insufficient data to detect
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clear differences between the two treatment groups for the two outcomes, recanalization or persistence of reflux at 6 weeks (OR, 0.34; 95% CI, 0.06–2.10; 33 participants, one study, low-quality evidence), and recurrence of reflux at 1 year (OR, 1.19; 95% CI, 0.29–4.92; 31 participants, one study, low-quality evidence). No other outcomes could be reported for this comparison because the study data were not stratified according to saphenous vein. Moderate-quality to low-quality evidence exists to suggest that recanalization, or persistence of reflux at 6 weeks, and recurrence of reflux at 1 year, are less frequent when EVLA is performed, compared with conventional surgery. For the UGFS versus conventional surgery comparison, the quality of evidence is assessed to be low; consequently, the effectiveness of UGFS compared with conventional surgery in the treatment of SSV varices is uncertain. Further RCTs for all comparisons are required with longer follow-up (at least 5 years). In addition, measurement of outcomes such as recurrence of reflux, time taken to return to work, duration of procedure, pain, and so on, and choice of time points during follow-up should be standardized, such that future trials evaluating newer technologies can be compared efficiently. REFERENCES 1. Negus D. Recurrent varicose veins: a national problem. Br J Surg. 1993;80:823–824. 2. Rivlin S. The surgical cure of primary varicose veins. Br J Surg. 1975;62:913–917. 3. Royle JP. Recurrent varicose veins. World J Surg. 1986;10:944–953. 4. Hayden A, Holdsworth J. Complications following re-exploration of the groin for recurrent varicose veins. Ann R Coll Surg Engl. 2001;83:272–273. 5. Chandler JG, Pichot O, Sessa C, et al. Treatment of primary venous insufficiency by endovenous saphenous vein obliteration. Vasc Surg. 2000;34:201–214. 6. Nesbitt C, Bedenis R, Bhattacharya V, et al. Endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus open surgery for great saphenous vein varices. Cochrane Database Syst Rev. 2014;(7):CD005624. 7. Paravastu SC, Horne M, Dodd PD. Endovenous ablation therapy (laser or radiofrequency) or foam sclerotherapy versus conventional surgical repair for short saphenous varicose veins. Cochrane Database Syst Rev. 2016;(11):CD010878.
11
Endovenous Approach to Recurrent Varicose Veins Jose I. Almeida
HISTORICAL BACKGROUND Recurrence rates of varicose veins of 20% are common, with rates as high as 70% at 10 years.1–3 Up to 25% of procedures for varicose veins are performed for recurrent disease,4 thus placing considerable demands on health care resources. Note that recurrent varicose vein surgery carries a much greater morbidity risk to the patient than primary surgery.3 This risk seems to be reduced with endovenous techniques.
ETIOLOGY AND NATURAL HISTORY OF DISEASE Patients who have had previous high ligation and stripping (HL/S) typically present with recurrent varicose veins; anatomic distribution of these veins is variable. Neovascularization is commonly seen following traditional stripping procedures and is thought to be secondary to “frustrated” venous drainage from the abdominal wall and perineum.5 Regardless of the mechanism, the result is recurrent reflux in the thigh or lower leg veins. Multiple factors contribute in the development of recurrent disease. The weight of each factor has not yet been determined because there are no prospective studies with adequate sample size. The following descriptions are common etiologies seen at Miami Vein Center after clinical and color flow duplex imaging (CFDI) examinations are performed in patients presenting with recurrent varicose veins. 307
C H A P T E R 1 1 n Endovenous Approach to Recurrent Varicose Veins
Abstract
Keywords
Recurrent varicose veins are common, and up to 25% of procedures are performed for recurrent disease. Multiple factors contribute in the development of recurrent disease, but regardless of the mechanism, the result is recurrent reflux in the thigh or lower leg veins. This chapter describes techniques to treat common scenarios seen in practice: (1) previous high ligation and stripping, (2) previous phlebectomy without GSV stripping, (3) previous laser or radiofrequency ablation without phlebectomy, and (4) previous GSV ablation resulting in clinical improvement. Cochrane systematic reviews for endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus open surgery for great and small saphenous vein varices are also summarized.
recurrent varicose veins endovenous ablation radiofrequency laser foam sclerotherapy great saphenous vein small saphenous vein
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PEARLS AND PITFALLS Previous High Ligation and Stripping All patients with recurrent varicose veins should be evaluated with CFDI. Usually, findings include neovascularity in the groin from which one or more tributary veins are found to descend the thigh. The tributary may attach to another tributary, a perforator, or a remnant of the great saphenous vein (GSV) in the thigh or calf (Fig. 11.1). The reflux extends into dilated tributaries of the skin; these vessels bulge and are palpable. In most cases, our approach is to enter any straight, incompetent, axial, venous segments deep to the skin with a micropuncture access kit. These kits usually contain 4-Fr microsheaths, through which we place a 400-µm-diameter or 600-µm-diameter laser fiber. Perivenous,
Femoral vein
Previous stripping of GSV
Neovascularity
Perforator vein
GSV remnant
A ■
Fig. 11.1
Ultrasoundguided sclerotherapy
Area of perforating vein
Ablation of saphenous vein remnant
B
C ■ Fig. 11.1, cont’d (B) Treatment of recurrent varicose vein with the use of combination endovenous laser and foam scleropathy. (C) Cross-sectional view of a subcutaneous tortuous tributary. These tortuous veins are ideal candidates for ultrasound-guided foam sclerotherapy treatment. Continued
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D ■ Fig. 11.1, cont’d (D) Incompetent midthigh perforating vein is the source of the recurrent varicose veins, which is most effectively treated with thermal ablation if anatomically in a straight orientation. If oriented in a tortuous manner, however, ultrasound-guided foam sclerotherapy treatment is preferred. GSV, Great saphenous vein.
tumescent anesthesia is placed, and the vein or veins are ablated in the usual manner. Because tortuous incompetent venous segments below the level of the skin do not allow the passage of guidewires, these are treated with ultrasound-guided foam sclerotherapy (UGFS) (Fig. 11.2). Finally, all bulging varicose veins that are palpable on the skin receive treatment with ambulatory phlebectomy. These three techniques, used concomitantly, yield very satisfactory results. These types of patients are told that the treatments are palliative, and they will likely need “touch-up” treatments in the future.
Previous Phlebectomy Without Great Saphenous Vein Stripping Also common in our practice are patients presenting with recurrent varicose veins previously treated with phlebectomy only at an outside facility. These limbs, once examined with CFDI, usually have a large incompetent GSV descending from the groin and terminating ultimately in the calf at a site where large varicosities are noted. These patients do very well with routine GSV ablation using either radiofrequency or laser and using ambulatory phlebectomy for associated varicosities.
C H A P T E R 1 1 n Endovenous Approach to Recurrent Varicose Veins
Ultrasound-guided foam sclerotherapy for the treatment of recurrent varicose veins
Ultrasound
Neovascularity
Foam sclerosant
A ■
Fig. 11.2 Continued
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B ■ Fig. 11.2, cont’d (B) Ultrasound-guided foam sclerotherapy for the treatment of recurrent varicose veins; tortuous veins seen on ultrasound are in the background.
Previous Laser or Radiofrequency Ablation Without Phlebectomy There are individuals who have seen other physicians and come to our practice with a history of GSV ablation that “worked temporarily.” That is, the venous cluster on the medial calf improved shortly after the procedure, but with time, the same cluster began filling and dilating. CFDI performed in our office usually shows successful ablation of the target GSV. However, the cluster of varicose veins in these cases has found a connection with an incompetent perforating vein. This is usually a Boyd perforating vein in the upper calf. This concept of an untreated “venous reservoir” dictates that other sources of reflux will eventually connect because of low venous resistance. Treatment involves either ultrasound-guided sclerotherapy or thermal ablation of the perforator (function of size) and ambulatory phlebectomy of the varicose clusters.
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We have also seen cases in which two sources of venous hypertension from superficial axial vein reflux were identified preoperatively but only one was treated. In these cases, usually only the incompetent GSV was ablated, and the incompetent anterior accessory saphenous vein was left untreated. There may be temporary improvement of the varicosities in direct continuity with the GSV; less direct varicosities may respond with minimal or no improvement. Our approach with these patients is thermal ablation of the anterior accessory saphenous vein, followed by ambulatory phlebectomy at the same stage.
Previous Great Saphenous Vein Ablation With No Improvement When a patient has a history of previous GSV ablation performed at an outside facility and no improvement was observed by the patient, this should be a red flag that the patient was initially misdiagnosed. The majority of these cases were straightforward, with classic small saphenous vein (SSV) incompetence in the limbs. However, the original physician failed to view the posterior calf with CFDI. Ablation of the SSV with laser or radiofrequency energy in combination with ambulatory phlebectomy will quickly rectify this problem. Gastrocnemial vein incompetence has a prevalence of up to 30% in patients with varicose veins. Most practitioners do not treat this vein. Also incompetent perforators connecting through this vein at the posteromedial calf may be overlooked or missed. We have seen these as sources of recurrent varicose veins. Depending on the severity of the signs and symptoms of the disease, we may elect to treat gastrocnemius veins with ultrasound-guided sclerotherapy. Obviously, this adds controversy to the dearth of clinical information referable to this vein. The aforementioned techniques are self-taught techniques, applying standard endovenous principles. The adage developed by the author is “If an incompetent vein is straight—burn it; if it is tortuous—foam it; if the vein is palpable on the skin (straight or tortuous)—remove it with phlebectomy.” Depicted in Fig. 11.3 is an endovenous sheath inside a saphenous vein remnant (to deliver laser energy) with a syringe prepared with a foamed sclerosant attached to the sheath side-arm to deliver foam into an area of neovascularization, and the patient is marked for phlebectomy. We have had no complications with this approach in several thousand recurrent varicose vein cases. Recurrences after endovenous treatment develop secondary to progression of disease and are retreatable with the same approach.
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n
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Previous stripping of GSV
Neovascularity
GSV remnant
A ■
Fig. 11.3
These bulging varicose veins will be treated with phlebectomy. Injecting transcatheter foam sclerosant Proximal aspect of laser ablation
Sheath in saphenous vein remnant
Squiggly lines are neovascularity
B
C Fig. 11.3, cont’d (B) Recurrent varicose veins from neovascularity in upper thigh and a refluxing saphenous vein remnant. Treatment with a combination of ultrasound foam sclerotherapy, endovenous laser ablation, and ambulatory phlebectomy. (C) Arrow points to saphenous vein remnant. ■
Continued
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D ■ Fig. 11.3, cont’d (D) Arrow points to foam-filled varicose veins just below skin surface. GSV, Great saphenous vein.
COMPARATIVE EFFECTIVENESS OF EXISTING TREATMENTS FROM COCHRANE DATABASE 1. Endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus open surgery for great saphenous vein varices.6 All randomized controlled trials (RCTs) of UGFS, endovenous laser therapy (EVLT), radiofrequency ablation (RFA), and HL/S were considered for inclusion. Primary outcomes were recurrent varicosities, recanalization, neovascularization, technical procedure failure, patient quality-of-life (QoL) scores, and associated complications. A total of 13 studies with a combined total of 3081 randomized patients were included. Three studies compared UGFS with surgery, eight compared EVLT with surgery, and five compared RFA with surgery (two studies had two or more comparisons with surgery). For the comparison of UGFS versus surgery, the findings may have indicated no difference in the rate of recurrences in the surgical group when measured by clinicians, and no difference between the groups for symptomatic recurrence (odds ratio [OR] 1.74; 95% confidence interval [CI], 0.97–3.12; P = .06 and OR, 1.28; 95% CI, 0.66–2.49, respectively). Recanalization and neovascularization were only evaluated in a single study. Recanalization at less than 4 months had an OR of 0.66 (95% CI, 0.20–2.12), recanalization at greater than 4 months an OR of 5.05 (95% CI, 1.67–15.28), and for neovascularization, an OR of 0.05 (95% CI,
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0.00–0.94). There was no difference in the rate of technical failure between the two groups (OR 0.44; 95% CI, 0.12–1.57). For EVLT versus surgery, there were no differences between the treatment groups for either clinician noted or symptomatic recurrence (OR 0.72; 95% CI, 0.43–1.22; P = .22 and OR 0.87; 95% CI, 0.47–1.62; P = .67, respectively). Both early and late recanalization were no different between the two treatment groups (OR 1.05; 95% CI, 0.09–12.77; P = .97 and OR 4.14; 95% CI, 0.76–22.65; P = .10). Neovascularization and technical failure were both statistically reduced in the laser treatment group (OR 0.05; 95% CI, 0.01–0.22; P < .0001 and OR 0.29; 95% CI, 0.14–0.60; P = .0009, respectively). Long-term (5-year) outcomes were evaluated in one study so no association could be derived, but it appeared that EVLT and surgery maintained similar findings. Comparing RFA versus surgery, there were no differences in cliniciannoted recurrence (OR 0.82; 95% CI, 0.49–1.39; P = .47); symptomatic-noted recurrence was only evaluated in a single study. There were also no differences between the treatment groups for recanalization (early or late) (OR 0.68; 95% CI, 0.01–81.18; P = .87 and OR 1.09; 95% CI, 0.39–3.04; P = .87, respectively), neovascularization (OR 0.31; 95% CI, 0.06–1.65; P = 0.17) or technical failure (OR 0.82; 95% CI, 0.07–10.10; P = .88). QoL scores, operative complications, and pain were not amenable to metaanalysis; however, QoL generally increased similarly in all treatment groups, and complications were generally low, especially major complications. Pain reporting varied greatly between the studies but, in general, pain was similar between the treatment groups. Currently available clinical trial evidence suggests that UGFS, EVLT, and RFA are at least as effective as surgery in the treatment of great saphenous varicose veins. Because of large incompatibilities between trials, and different time point measurements for outcomes, the evidence is lacking in robustness. Further randomized trials are needed, which should aim to report and analyze results in a congruent manner to facilitate future metaanalysis. 2. Endovenous ablation therapy (laser or radiofrequency) or foam sclerotherapy versus conventional surgical repair for short saphenous varicose veins.7 All RCTs comparing EVLA, endovenous RFA, or UGFS with conventional surgery in the treatment of SSV varices were included. There were three RCTs, all of which compared EVLA with surgery; one also compared UGFS with surgery. There were no trials comparing RFA with surgery. The EVLA versus surgery comparison included 311 participants: 185 received EVLA and 126 received surgery. In the UGFS comparison, each treatment group contained 21 subjects. For the EVLA versus surgery comparison, recanalization or persistence of reflux at 6 weeks occurred less frequently in the EVLA group than in the surgery group (OR 0.07; 95% CI, 0.02–0.22; I2 = 51%; 289 participants, three studies, moderatequality evidence). Recurrence of reflux at 1 year was also less frequent in the EVLA group than in the surgery group (OR 0.24; 95% CI, 0.07–0.77; I2 = 0%; 119 participants, two studies, low-quality evidence). For the outcome clinical evidence of recurrence (i.e., presence of new visible varicose veins) at 1 year, there was no difference between the two treatment groups (OR 0.54; 95% CI, 0.17–1.75; 99 participants, one study, low-quality evidence). Four participants each in the EVLA and surgery groups required reintervention because of technical failure (99 participants, one study, moderate-quality evidence). There was no difference between the two treatment groups for disease-specific QoL (Aberdeen Varicose Veins Questionnaire) either at 6 weeks (mean difference [MD], 0.15; 95% CI, −1.65–1.95; I2 = 0%; 265 participants, two studies, moderate-quality evidence), or at 1 year (MD, −1.08; 95% CI, −3.39–1.23; 99 participants, one study, low-quality evidence). Main complications reported at 6 weeks were sural nerve injury, wound infection, and deep venous thrombosis (DVT) (one DVT case in each treatment group; EVLA: 1/161, 0.6%; surgery 1/104, 1%; 265 participants, two studies, moderate-quality evidence). For the UGFS versus surgery comparison, there were insufficient data to detect
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clear differences between the two treatment groups for the two outcomes, recanalization or persistence of reflux at 6 weeks (OR, 0.34; 95% CI, 0.06–2.10; 33 participants, one study, low-quality evidence), and recurrence of reflux at 1 year (OR, 1.19; 95% CI, 0.29–4.92; 31 participants, one study, low-quality evidence). No other outcomes could be reported for this comparison because the study data were not stratified according to saphenous vein. Moderate-quality to low-quality evidence exists to suggest that recanalization, or persistence of reflux at 6 weeks, and recurrence of reflux at 1 year, are less frequent when EVLA is performed, compared with conventional surgery. For the UGFS versus conventional surgery comparison, the quality of evidence is assessed to be low; consequently, the effectiveness of UGFS compared with conventional surgery in the treatment of SSV varices is uncertain. Further RCTs for all comparisons are required with longer follow-up (at least 5 years). In addition, measurement of outcomes such as recurrence of reflux, time taken to return to work, duration of procedure, pain, and so on, and choice of time points during follow-up should be standardized, such that future trials evaluating newer technologies can be compared efficiently. REFERENCES 1. Negus D. Recurrent varicose veins: a national problem. Br J Surg. 1993;80:823–824. 2. Rivlin S. The surgical cure of primary varicose veins. Br J Surg. 1975;62:913–917. 3. Royle JP. Recurrent varicose veins. World J Surg. 1986;10:944–953. 4. Hayden A, Holdsworth J. Complications following re-exploration of the groin for recurrent varicose veins. Ann R Coll Surg Engl. 2001;83:272–273. 5. Chandler JG, Pichot O, Sessa C, et al. Treatment of primary venous insufficiency by endovenous saphenous vein obliteration. Vasc Surg. 2000;34:201–214. 6. Nesbitt C, Bedenis R, Bhattacharya V, et al. Endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus open surgery for great saphenous vein varices. Cochrane Database Syst Rev. 2014;(7):CD005624. 7. Paravastu SC, Horne M, Dodd PD. Endovenous ablation therapy (laser or radiofrequency) or foam sclerotherapy versus conventional surgical repair for short saphenous varicose veins. Cochrane Database Syst Rev. 2016;(11):CD010878.