Pharmacological Thromboprophylaxis for VTE Post-Endovenous Ablation of Varicose Veins: Network Meta-Analysis.

OBJECTIVE: Endovenous ablation has revolutionized treatment of varicose vein surgery but is associated with a risk of venous thromboembolism. There is no consensus regarding anticoagulation protocols for these patients. This network meta-analysis (NMA) aims to identify which anticoagulant is optimal in this cohort for clot prevention with minimal risk of adverse bleeding events. METHODS: Library databases were searched for studies where patients were treated with one or more anticoagulants following endovenous ablation for varicose veins. The methodological quality of included studies was quantified using the Risk of Bias (ROB) assessment tools. Findings were reported using the meta-analysis of observational studies in epidemiology (MOOSE) checklist. Statistical analysis was carried out using metainsight (rpackage). RESULTS: Observational data on just under 1500 patients prescribed post ablation anticoagulation (Rivaroxaban, Enoxaparin, Fondaparinux) were analyzed. Patient characteristics were comparable across the cohorts. 81 thrombotic and 40 minor bleeding events occurred in total. Overall rivaroxaban is found to be superior to the other agents. CONCLUSIONS: This NMA indicates that prophylactic rivaroxaban is the highest ranked anticoagulant for thromboprophylaxis in patients post endovenous ablation for varicose veins, with a low risk of adverse bleeding. The choice whether to anticoagulate these patients is likely to remain at the discretion of the treating clinician.

Safety and efficacy of endovenous ablation in patients with a history of deep vein thrombosis.

OBJECTIVE: Endovenous ablation is the standard of care for patients with symptomatic superficial venous insufficiency. For patients with a history of deep vein thrombosis (DVT), concern exists for an increased risk of postprocedural complications, particularly venous thromboembolism. The objective of this study was to evaluate the safety and efficacy of endovenous thermal ablation in patients with a history of DVT. METHODS: The national Vascular Quality Initiative Varicose Vein Registry was queried for superficial venous procedures performed from January 2014 to July 2021. Limbs treated with radiofrequency or laser ablation were compared between patients with and without a DVT history. The primary safety end point was incident DVT or endothermal heat-induced thrombosis (EHIT) II-IV in the treated limb at <3 months of follow-up. The secondary safety end points included any proximal thrombus extension (ie, EHIT I-IV), major bleeding, hematoma, pulmonary embolism, and death due to the procedure. The primary efficacy end point was technical failure (ie, recanalization at <1 week of follow-up). Secondary efficacy end points included the risk of recanalization over time and the postprocedural change in quality-of-life measures. Outcomes stratified by preoperative use of anticoagulation (AC) were also compared among those with prior DVT. RESULTS: Among 33,892 endovenous thermal ablations performed on 23,572 individual patients aged 13 to 90 years, 1698 patients (7.2%) had a history of DVT. Patients with prior DVT were older (P < .001), had a higher body mass index (P < .001), were more likely to be male at birth (P < .001) and Black/African American (P < .001), and had greater CEAP classifications (P < .001). A history of DVT conferred a higher risk of new DVT (1.4% vs 0.8%; P = .03), proximal thrombus extension (2.3% vs 1.6%; P = .045), and bleeding (0.2% vs 0.04%; P = .03). EHIT II-IV, pulmonary embolism, and hematoma risk did not differ by DVT history (P = NS). No deaths from treatment occurred in either group. Continuing preoperative AC in patients with prior DVT did not change the risk of any complications after endovenous ablation (P = NS) but did confer an increased hematoma risk among all endovenous thermal ablations and surgeries (P = .001). Technical failure was similar between groups (2.0% vs 1.2%; P = .07), although a history of DVT conferred an increased recanalization risk over time (hazard ratio, 1.90; 95% confidence interval, 1.46, 2.46; P < .001). The groups had comparable improvements in postprocedural venous clinical severity scores and Heaviness, Aching, Swelling, Throbbing, and Itching scores (P = NS). CONCLUSIONS: Endovenous thermal ablation for patients with a history of DVT was effective. However, appropriate patient counseling regarding a heightened DVT risk, albeit still low, is critical. The decision to continue or withhold AC preoperatively should be tailored on a case-by-case basis.

Sub-ulcer Foam Sclerotherapy in Patients with Venous Leg Ulcer, Analysis and Technical Aspects of 134 Consecutive Patients.

OBJECTIVE: For this retrospective study, we analyzed the sub-ulcer foam sclerotherapy technique in patients with venous leg ulcer (VLU). METHODS: This study included 134 patients treated with sub-ulcer foam sclerotherapy at the Oulu University Hospital vascular outpatient clinic from January 2012 to December 2021. All included patients received sub-ulcer foam sclerotherapy as part of the treatment strategy for superficial venous insufficiency. Compression therapy and local wound care were organized for VLU treatment. A follow-up visit was scheduled for one month after the sub-ulcer foam sclerotherapy. Change in ulcer size, local (skin necrosis, infection) or systemic (deep vein thrombosis, pulmonary embolism) complications, and time to ulcer healing were monitored. The occurrence of major limb-related complications (amputation, surgical revision) was monitored for one year postoperatively. RESULTS: One month after sub-ulcer treatment, ulcers were smaller or completely healed in 108 (81%) patients. Ulcer healing was completed in 123 (92%) patients at one year and 131 (98%) patients at two years. Complications were recorded in four (3%) patients, three (2%) who were diagnosed with erysipelas requiring antibiotic treatment and one (1%) patient diagnosed with local dermatitis. During the one-year follow-up, no major limb-related complications (surgical revisions or amputations) arose. CONCLUSIONS: Sub-ulcer foam sclerotherapy may be a feasible addition to superficial vein reflux elimination in patients with VLU and a low risk for complications.

Venous ablation procedures by provider type, including advanced practice providers.

OBJECTIVE: The necessary training and certification of providers performing venous ablation has become a topic of debate in recent years. As venous interventions have shifted away from the hospital, the diversity of provider backgrounds has increased. We aimed to characterize superficial venous ablation practice patterns associated with different provider types. METHODS: We analyzed Medicare Fee-For-Service data from 2010 through 2018. Procedures were identified by their Current Procedural Terminology code and included radiofrequency ablation, endovenous laser ablation, chemical adhesive ablation (ie, VenaSeal; Medtronic, Inc), and mechanochemical ablation. These procedures were correlated with the practitioner type to identify provider-specific trends. RESULTS: Between 2010 and 2018, the number of ablation procedures increased by 107% from 114,197 to 236,558 per year (P < .001). Most procedures were performed by surgeons without vascular board certification (28.7%; 95% confidence interval [CI], 28.7%-28.8%), followed by vascular surgeons (27.1%; 95% CI, 27.0%-27.2%). Traditionally noninterventional specialties, which exclude surgeons, cardiologists, and interventional radiologists, accounted for 14.1% (95% CI, 14.1%-14.2%), and APPs accounted for 3.5% (95% CI, 3.4%-3.5%) of all ablation procedures during the study period. The total number of ablations increased by 9.7% annually (95% CI, 9.7%-9.8%), whereas procedures performed by APPs increased by 62.0% annually (95% CI, 61.6%-62.4%). There were significant differences between specialties in the use of nonthermal ablation modalities: APPs had the highest affinity for nonthermal ablation (odds ratio [OR], 2.60; 95% CI, 2.51-2.69). Cardiologists were also more likely to use nonthermal ablation (OR, 1.62; 95% CI, 1.59-1.66). Similarly, the uptake of new nonthermal technology (ie, chemical adhesives) was greatest among APPs (OR, 3.57; 95% CI, 3.43-3.70) and cardiologists (OR, 1.86; 95% CI, 1.81-1.91). Vascular surgeons were less likely to use nonthermal modalities (OR, 0.95; 95% CI, 0.92-0.97), including new nonthermal technology in the first year of availability (OR, 0.93; 95% CI, 0.90-0.95). CONCLUSIONS: The use of venous procedures has increased rapidly during the past decade, particularly as endovenous ablations have been performed by a wider practitioner base, including APPs and noninterventionalists. Practice patterns differ by provider type, with APPs and cardiologists skewing more toward nonthermal modalities, including more rapid uptake of new nonthermal technology. Provider-specific biases for specific ablation modalities might reflect differences in training, skill set, the need for capital equipment, clinical privileges, or reimbursement. These data could help to inform training paradigms, the allocation of resources, and evaluation of appropriateness in a real-world setting.

Long-term results and predictors of failure after mechanochemical endovenous ablation in the treatment of primary great saphenous vein incompetence.

BACKGROUND: Mechanochemical endovenous ablation (MOCA) was introduced to treat superficial venous insufficiency of the lower leg with less pain and haematoma. Long-term outcome is still lacking. The purpose was to report long-term outcome and to analyse possible predictors for failure. METHODS: The study was a retrospective pooled analysis of two prospective cohorts previously reported, but with prolonged long-term outcome up to 5-years follow-up. RESULTS: 163 treated legs were analysed. Mean follow-up was 5.4±0.6 years, in which 33 total failures occurred. Four procedures were partially successful. VCSS improved significantly and remained stable after 1 and 2-years, but significantly rose again after 5-years. AVVQ dropped significantly, but increased after 1 year to 4.3 and 6.1 at 5-years follow-up. CONCLUSION: MOCA was effective with minimal pain perioperative. However, anatomical success deteriorated after 1-year and showed even less results after 5-years, mainly due to partly recanalization, while clinical results were less affected. There were no clear clinical predictors for failure.

A systematic review of endovenous ablation for the treatment of small saphenous varicose veins.

Insufficiency of the small saphenous vein causes 15% of varicose veins in the lower extremities. Endovenous ablation for the treatment of small saphenous vein varices has become a trend, and an increasing number of studies have reported the effects of different types of endovenous ablation in patients with small saphenous varicose veins. The purpose of this systematic review is to summarize the results of existing studies on endovenous ablation for the treatment of small saphenous varicose veins, compare its role and efficacy, and provide insights into the future development of endovenous ablation for treating small saphenous varicose veins. A systematic review of literature published from January 1, 2002 to January 1, 2022 was conducted from PubMed, Embase, and China Academic Journals full-text databases. The pre-determined inclusion criteria were clinical literature of endovenous ablation for treating small saphenous varicose veins. Keywords included "ablation", "small saphenous vein", "lesser saphenous vein", "short saphenous vein", "xiaoyinjingmai" and "xiaorong". Of the 506 articles screened, 33 articles were included in this review: 19 articles were related to endovenous laser ablation, five were related to mechanochemical ablation, seven were related to radiofrequency ablation, and two were related to both endovenous laser ablation and radiofrequency ablation. The anatomical success rate of endovenous laser ablation, radiofrequency ablation, and mechanochemical ablation were 94.3%, 96.0%, and 88.1%, respectively, and the heterogeneities were all moderate. Most of the current studies are of a low-quality level of research. Hence, long-term follow-up studies and large-scale randomized controlled trials are required to obtain high-quality evidence. Although the gold standard for the treatment of small saphenous vein insufficiency remains unclear, endovenous ablation is still the recommended method.

Combined Management of Wound Ulcers With Focus on Interventional Techniques.

This review provides a summary of current practice patterns in managing venous ulcers. The authors will describe the workup for venous ulcers, including differentiation of symptoms, physical examination, and imaging to guide the most effective treatment course for each patient. An overview of conservative management and minimally invasive treatment options for venous ulcers will be provided with a specific focus on periulcer foam sclerotherapy to aid in preventing ulcer recurrence and promoting healing. We will give interventional troubleshooting techniques for challenging patient presentations.

Severe adverse reactions after cyanoacrylate endovenous ablation.

Hypersensitivity reactions after endovenous ablation with cyanoacrylate are relatively common, mild, and self-limited. However, rare cases of severe hypersensitivity reactions have occurred. To date and to the best of our knowledge, only two other cases requiring vein excision have been reported, and we present the third. Even rarer are cases with severe reactions featuring cyanoacrylate extravasation with skin perforation. In the present report, we describe the second case of skin perforation after successful cyanoacrylate endovenous glue embolization. The mechanism of these severe hypersensitivity reactions is unknown. Clinicians should to consider this as a possible complication when using cyanoacrylate. Although rare, patients should also be advised of this adverse event when considering this alternative.

A comparison of patient-reported outcome measures following technical success and technical failure in the treatment of great saphenous vein incompetence using ClariVein: A subanalysis of a multicenter randomized controlled trial comparing 2% and 3% polidocanol.

OBJECTIVE: This study aimed to compare patient-reported outcomes after technical success (TS) and technical failure (TF) in treating great saphenous vein incompetence (GSV) with ClariVein. METHODS: A subanalysis of a previous trial was conducted on symptomatic GSV incompetence patients who received ClariVein treatment with 2% or 3% polidocanol (POL) and were followed for 6 months. Blinding was implemented for observers and patients, and data from both POL groups were combined. TS was defined as at least 85% occlusion of the treated vein, while TF indicated failure to meet TS criteria. Secondary outcomes included Venous Clinical Severity Score (VCSS), Aberdeen Varicose Vein Questionnaire (AVVQ), and Short-Form 36 Health Survey Questionnaire (SF-36). RESULTS: Among the 364 patients included, the TS rate was 64.5%. Comparison of VCSS, AVVQ, and SF-36 scores between TS and TF groups did not yield significant differences. CONCLUSION: This study indicates no significant variation in VCSS, AVVQ, and SF-36 scores between patients experiencing TS and TF following ClariVein treatment for GSV insufficiency.

A network meta-analysis on the efficacy and safety of thermal and nonthermal endovenous ablation treatments.

OBJECTIVE: We assessed the mid-term efficacy and safety of thermal and nonthermal endovenous ablation for the treatment of lower limb superficial venous insufficiency. METHODS: We performed a systematic review in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) statement and a Bayesian network meta-analysis. The primary end points were great saphenous vein (GSV) closure and venous clinical severity score (VCSS) improvement. A meta-regression using GSV diameter as a covariate was undertaken for the two primary end points. RESULTS: We included 14 studies and 4177 patients, with a mean follow-up of 25.7 months. Radiofrequency ablation (RFA; odds ratio [OR], 3.99; 95% confidence interval [CI], 1.82-10.53), cyanoacrylate ablation (CAC; OR, 3.09; 95% CI, 1.35-8.37), and endovenous laser ablation (EVLA; OR, 2.72; 95% CI, 1.23-7.38) displayed increased odds for GSV closure compared with mechanochemical ablation (MOCA). MOCA inferiority compared with RFA (mean difference [MD], 0.96; 95% CI, 0.71-1.20), EVLA (MD, 0.94; 95% CI, 0.61-1.24), and CAC (MD, 0.89; 95% CI, 0.65-1.15) was also depicted regarding VCSS improvement. EVLA resulted in an increased risk of postoperative paresthesia compared with MOCA (risk ratio [RR], 9.61; 95% CI, 2.32-62.29), CAC (RR, 7.90; 95% CI, 2.44-38.16), and RFA (RR, 6.96; 95% CI, 2.31-28.04). Although the overall analysis identified nonstatistically significant differences for Aberdeen varicose vein questionnaire score improvement, thrombophlebitis, ecchymosis, and pain, further investigation revealed an increase pain profile for EVLA at 1470 nm compared with RFA (MD, 3.22; 95% CI, 0.93-5.47) and CAC (MD, 3.04; 95% CI, 1.05-4.97). A sensitivity analysis displayed a persistent underperformance of MOCA compared with RFA (OR, 4.33; 95% CI, 1.15-55.54) for GSV closure and both RFA (MD, 0.99; 95% CI, 0.22-1.77) and CAC (MD, 0.84; 95% CI, 0.08-1.65) regarding VCCS improvement. Although no regression model reached statistical significance, the GSV closure regression model revealed a trend for considerably decreased efficacy for both CAC and MOCA with larger GSV diameters compared with RFA and EVLA. CONCLUSIONS: Although our analysis has produced skepticism regarding the efficacy of MOCA in the mid-term period for VCSS improvement and GSV closure rates, CAC showed equivalent results compared with both RFA and EVLA. Additionally, CAC displayed a decreased risk of postprocedural paresthesia and pigmentation and induration compared with EVLA. Also, both RFA and CAC had an improved pain profile compared with EVLA 1470 nm. The potential underperformance of nonthermal, nontumescent ablation modalities in ablating large GSVs necessitates further research.

Endovenous radiofrequency ablation using a new bipolar electrode in a canine model: a new endovenous radiofrequency electrode.

Purpose: This study aimed to determine the effectiveness and safety of a newly developed endovenous radiofrequency (RF) catheter compared with that of the existing RF catheter in a canine model. Methods: Seven dogs underwent ablation using 1 control catheter (ClosureFAST, CF; Covidien) and 1 experimental catheter (VENISTAR, VS; STARmed Co., Ltd.) in the femoral and cephalic veins. The ablated vein was evaluated macroscopically (2,3,5-triphenyltetrazolium chloride staining, TTC), microscopically (hematoxylin and eosin staining), and ultrasonographically. Vessel injury score was used to evaluate the ablating effect objectively. Veins from 1 dog were evaluated on the day of ablation, while in the remaining 6 dogs, the ablated veins were evaluated 2 weeks later. Results: A total of 23 veins (CF, 11 veins; VS, 12 veins) were ablated in 7 dogs. Non-TTC-stained vein wall areas were identified in all ablated veins. No significant difference was observed in the mean vessel injury score (2.54 ± 1.16 vs. 2.42 ± 1.13, P = 0.656) and the mean vessel wall thickness (0.32 ± 0.03 mm vs. 0.31 ± 0.05 mm, P = 0.212) between CF and VS. There was no blood flow in all veins ablated with VS, whereas there was remaining blood flow in 1 vein ablated with CF. Perivenous complication was not observed. Conclusion: Endovenous RF ablation using a newly developed VS RF catheter seems to provide comparable occlusion rate and degree of vein wall injury without perivenous adverse events compared to the most commonly used RF catheter (CF).

Effect of Endovenous Laser Ablation Along With Compression Therapy on Chronic Venous Ulcer Healing.

Introduction Chronic venous insufficiency is a major cause of morbidity, and there is a paucity of data regarding its epidemiology due to the lack of a central wound registry. In this study, we aimed to study the time for healing of the ulcer and compliance with compression therapy (CT) following endovenous laser ablation (EVLA) ± ultrasound-guided foam sclerotherapy (UGFS) along with CT in patients with chronic venous ulcers. Methods This prospective observational study was conducted from January 2020 to June 2021 after obtaining institutional ethical committee clearance. Patients with chronic venous ulcers (>six weeks to 4 cm in 10% of patients. A total of 38% of patients underwent only EVLA, and EVLA+UGFS were done in 62% of participants. The healing rate at six months follow-up was 92%, with the average time taken being 2.55±1.38 months. Those who remained with an unhealed ulcer at six months follow-up had an ulcer size of >5 cm and an age of >50 years. Ninety-six percent of the patients were compliant with CT after an endovenous intervention. The recurrence rate at two years post-ablation was 6%. VCSS was 19.66±3.23 at presentation and 5.5±2.82 at six months of follow-up. Conclusion Endovenous ablation of superficial venous reflux along with CT is associated with a shorter healing time of venous ulcerations and reduced chances of recurrence. There is an improvement in VCSS score over the period of six months follow-up.

Outcomes of cyanoacrylate closure of the truncal varicose vein insufficiency: A comparison between young and elderly patients.

OBJECTIVES: Cyanoacrylate closure (CAC) procedure has become an alternative treatment method that has become increasingly popular in the treatment of chronic venous insufficiency (CVI) in recent years. The present study was designed to assess the feasibility, tolerance, results, and efficacy of CAC for truncal varicosities in elderly population. METHODS: In this retrospective single-center observational cohort study, CAC procedure was performed in 160 patients (184 limbs) with truncal varicose vein insufficiency. The patients were divided into two groups: elderly group, and younger group. The primary outcome of this study was to assess the feasibility, tolerance, and safety of the CAC procedure for truncal varicosities in elderly population over 70 years. The Venous Clinical Severity Score (VCSS), visual analogue scale of pain (VASP) and occlusion rate of the treated target veins of the patients were evaluated and compared among groups. The secondary outcomes were to evaluate and compare technical success, mortality, major adverse events, and other postoperative complications between the groups. RESULTS: All operations were carried out under local anesthesia. There were no technical failures or device-related complications. Anatomic success rate was 100% after procedures. The occlusion rate for the elderly group at 2 weeks, 6 months, and 12 months was 100%, 92.3%, and 92.3%, respectively, while the occlusion rate for the younger group was 100%, 97%, and 94.7%, respectively. There was no significant difference in occlusion rates between two groups (p > .05) (Log Rank = 0,231). Improvement in the VCSSs was statistically significant between baseline and 12 months after procedure in both groups (p < .001). Improvement in the VASPs was statistically significant between baseline and 2 weeks after procedure in both groups (p < .001). There were no symptoms or signs of sural nerve injury, hematoma, or phlebitis in either group. CONCLUSIONS: Although it has some potential risks, it is conceivable that the CAC procedure may be applied in selected fit elderly patients for the treatment of CVI. Age appeared to have no effect on the early and mid-term prognosis of the CAC procedure performed in the study cohort.

Early results of cyanoacrylate adhesive ablation versus laser ablation for the treatment of great saphenous vein insufficiency in the Chinese mainland population.

OBJECTIVE: In this study, we present our early outcomes of cyanoacrylate ablation (CA) versus endovenous laser ablation (EVLA) for the treatment of great saphenous vein (GSV) insufficiency in the Chinese mainland population. METHODS: We retrospectively analyzed 108 patients (53 patients in the CA group and 55 patients in the EVLA group) with GSV insufficiency who were treated with CA and EVLA between May 2020 and May 2021. The Venous Clinical Severity Score and Aberdeen Varicose Vein Questionnaire were used to assess clinical symptoms and quality of life, respectively. Total closure rates and procedure-related adverse events were also recorded in both groups. RESULTS: There was no significant difference between patients treated with CA or EVLA in terms of demographic and clinical characteristics. The average procedure time was 17 min in the CA group and 35 min in the EVLA group (p < 0.001). The CA group had lower pain scores during the procedure and 3 days afterward than the EVLA group (p < 0.001). At month 12, the CA group had a 90.4% closure rate, while the EVLA group had an 83.0% closure rate, with no significant difference between the two groups (p > 0.05). There was no significant difference in the Venous Clinical Severity Score or Aberdeen Varicose Vein Questionnaire score between the groups (p > 0.05). During follow-up, neither group experienced any significant adverse events, such as pulmonary embolism or deep venous thrombosis. The incidence of ecchymosis and paresthesia was significantly lower in the CA group than in the EVLA group (p < 0.05). CONCLUSIONS: Cyanoacrylate ablation has a high feasibility profile and is an effective approach to accomplish complete GSV target vein closure at early follow-up in the Chinese patients. Compared to EVLA, the improvement in quality-of-life outcomes is also sustained and similar, with less pain and fewer complications due to the absence of tumescence anesthesia and postprocedural compression stockings.

Prospective randomized trial of antithrombotic strategies following great saphenous vein ablation using injectable polidocanol endovenous microfoam (Varithena).

OBJECTIVE: Postablation deep vein thrombosis (DVT) represents a potentially serious complication after Varithena polidocanol endovenous microfoam (PEM) ablation. The following primary outcomes were assessed: whether (1) adjunctive apixaban anticoagulation or (2) mechanical deep venous system (DVS) saline flushing could decrease saphenofemoral junction (SFJ) thrombus extension (postablation superficial thrombus extension [PASTE]) and/or DVT compared with compression alone, after great saphenous vein (GSV) PEM ablation. METHODS: Varithena 1% PEM ablation patients were randomized to (1) SFJ compression, (2) compression and DVS saline flushing, or (3) compression, DVS saline flushing, and 5 days of postprocedural 5 mg oral apixaban anticoagulation twice daily. Duplex imaging was obtained 7 to 10 days after PEM ablation and PASTE/DVT incidence (primary end point) was compared between groups at this time point. RESULTS: We treated 304 limbs in 257 patients with PEM. Overall, 103 limbs received SFJ compression (group C, 33.8%), 101 received compression and deep venous flushing (group D, 32.9%), and 100 received compression, deep flush, and anticoagulation (group A, 33.2%). Mean ultrasound follow-up time was 9.7 days (all patients) with a primary GSV closure rate of 92.4%. SFJ PASTE (II-IV) occurred in 0.9%, 1.0%, and 0% (groups C, D, and A, respectively). DVT occurred in 16.7%, 14.7%, and 1.98% (groups C, D, and A; χ2, P = .002). Patients in group A receiving apixaban anticoagulation had a significant reduction in DVT compared with patients in group C (1.98% vs 16.7%, χ2; P < .001); likewise, patients in group A had a significantly decreased DVT occurrence compared with group D (14.7% vs 1.98%; χ2, P = .00162), whereas patients in groups C and D were not statistically different (16.7% vs 14.7%; χ2, P = .60). CONCLUSIONS: (1) Neither adjunctive DVS flushing nor anticoagulation decreased clinically relevant SFJ PASTE (II-IV) incidence, which remained similarly low across all groups and ranged between 0% and 1%, regardless of adjunctive DVS flushing or anticoagulation. This rate was significantly lower than prior reports (2.3%-4.1%). (2) DVS flushing had no influence on the rate of DVT. Observed PEM-induced DVT incidence using SFJ compression alone or compression with DVS flushing (16.7% and 14.7%, respectively) was significantly higher than prior reports (2.5%-9.6%). This finding may relate to the greater extent of AK/BK GSV territory treated in the present study. (3) Five days of postprocedural oral apixaban anticoagulation, 5 mg given twice daily, significantly decreased DVT occurrence to 1.98%, compared with nonanticoagulated patients (16.7%). This finding is comparable with the DVT rates reported after endovenous thermal ablation (0.7-1.7%). (4) Postprocedural apixaban anticoagulation may have a significant preventive role in decreasing DVT occurrence after PEM ablation.

One-year duplex ultrasound-assessed closure outcomes of percutaneous endovenous microwave ablation for the treatment of varicose veins of the lower limbs.

PURPOSE: This study aims to investigate the safety and efficacy of a new device using microwave technology for the endovenous ablation of the great saphenous vein (GSV) causing symptomatic lower limb varicose veins (LLVV). MATERIALS AND METHODS: This prospective, single-arm, single-center, cohort study investigated the safety and effectiveness of endovenous microwave ablation for the treatment of symptomatic LLVV. Enrollment period was set between January and December 2020. Primary safety endpoint was the occurrence of procedure-related complications and primary efficacy endpoint was anatomical success defined as the duplex ultrasound (DUS)-proven GSV occlusion at 1 year follow-up. Secondary endpoints included 1-year clinical success (CEAP classification improvement), repeat procedures rate due to GSV recanalization, and pain assessment at 24 h post treatment. RESULTS: In total, 50 patients (42 female; mean age: 62 ± 12 years) with 64 limbs were treated. No procedure-related complications were noted. Technical success was 95.3% (61/64 GSVs), as three cases of GSV recanalization were detected. Clinical success was 100%, as in all cases symptoms improvement by at least one grade according to CEAP classification, was achieved. Mean CEAP grade significantly improved from 3.3 ± 0.72 (median: 3) at baseline to 1.8 ± 0.85 (median: 2) at 1-year (p < 0.0001). There were no repeat procedures due to GSC recanalization. The median 24-h VAS value was 2 (mean: 1.9 ± 1.4). CONCLUSIONS: Endovenous microwave ablation was safe and effective for the treatment of varicose veins, achieving high 1-year GSV occlusion rates.

Women benefit from endovenous ablation with fewer complications: Analysis of the Vascular Quality Initiative Varicose Vein Registry.

OBJECTIVE: To evaluate the association between gender and long-term clinician-reported and patient-reported outcomes after endovenous ablation procedures. METHODS: This retrospective cohort study of prospectively collected data from the Vascular Quality Initiative's Varicose Vein Registry included patients undergoing endovenous ablation procedures on truncal veins with or without treatment of perforating veins between 2015 and 2019. A univariate analysis included comparisons of preprocedural, postprocedural, and periprocedural change in Venous Clinical Severity Score (VCSS) and total symptom score by gender. Rates of complications including deep vein thrombosis, endovenous heat-induced thrombosis, leg pigmentation, blistering, paresthesia, incisional infection, and any postprocedural complications were reported by gender. Multivariable analysis leveraged linear regression to examine how gender affected the relationships between patient characteristics, complication rates, and periprocedural change in VCSS score and total symptom score. RESULTS: Of 9743 patients who met the inclusion criteria, 3090 (31.7%) were men and 6653 (68.2%) were women. The perioperative change in VCSS score was greater for men than women (average -4.46 for men vs -4.13 for women; P < .0001). Perioperative change in total symptom score was greater for women than for men (average -10.64 for women vs -9.64 for men; P < .0001). Women had lower incidence of any leg complication (6.1% vs 8.6%; P = .001) endovenous heat-induced thrombosis (1.1% vs 2.2%; P = .002), and infection (0.4% vs 0.7%; P = .001). In multivariable analysis, among patients with a body mass index of more than 40, presence of deep reflux, and preoperative Clinical, Etiologic, Anatomic, and Physiologic classification of 2, women had a greater periprocedural change in VCSS score than men. CONCLUSIONS: Women benefited from endovenous ablation similarly as men, with a lower incidence of postprocedural complications. Gender may be useful for patient selection and counseling for endovenous ablation, with particular usefulness among patients with a high body mass index, presence of deep reflux, and preoperative Clinical, Etiologic, Anatomic, and Physiologic classification of 2.

Treatment and contemporary outcomes associated with adjunct tourniquet use during phlebectomy of complex, voluminous truncular varicosities.

OBJECTIVE: Phlebectomy of large voluminous varicose veins comes with a risk of substantial blood loss. The purpose of the present study was to investigate the outcomes associated with the use of an adjunct tourniquet during varicose vein surgery of complex and large truncular varicosities. METHODS: The prospectively collected registry data included anatomic and outcomes details for patients who presented with complex and large truncular varicosities with a CEAP clinical class of C2, or higher (indicating more serious venous disease) from December 2014 to December 2021. Of all patients, those treated with an adjunct tourniquet for large complex varicosities (largest diameter varicosity ≥1 cm by visual inspection) were selected for analysis. The venous clinical severity scores (VCSSs) and patient-reported outcomes (PROs) were obtained. Additional parameters, including operative time, tourniquet time, and blood loss, were obtained retrospectively via a review of the medical records. Univariate descriptive statistics of the demographic and procedural data were performed pre- and postoperatively, with comparisons performed using the Student two-tailed t test. RESULTS: The data from 19 patients (22 limbs; 7 women and 12 men) were analyzed. Of the 22 limbs, 11 (50%) had advanced venous disease of C4 or higher preoperatively. A review of the preoperative duplex ultrasound scans confirmed the presence of large varicosities (average, 1.0 ± 0.54 cm; n = 18). All the limbs were treated using radiofrequency ablation of axial reflux and phlebectomy (a combination of powered and stab) under tourniquet control (82%) or phlebectomy under tourniquet control alone (18%). The average tourniquet time was 40 ± 12 minutes, with a median blood loss of 50 mL (interquartile range, 30-100 mL). The average follow-up was 332 ± 422 days after 19 procedures for 16 patients (2 patients moved out of state during the immediate postoperative period and 1 patient was lost to follow-up). Of the patients who completed >3 months of follow-up, 14 limbs experienced improvement in the CEAP class, 5 limbs had no change, and 3 were limbs of patients who moved or were lost to follow-up. The VCSSs significantly improved (8.8 ± 2.8 vs 3.9 ± 1.9; P < .0001). The PROs also improved significantly (16.1 ± 5.0 vs 2.2 ± 2.3; P < .0001). CONCLUSIONS: Tourniquet use in the treatment of varicosities has only been described in the setting of high ligation and stripping. Our data suggest that in the modern era of minimally invasive endovenous treatment of axial reflux and phlebectomy, adjunct tourniquet use during the treatment of large complex varicosities can result in significant improvements in the VCSSs and PROs, with minimal blood loss.

Does eradication of superficial vein incompetence after superficial vein thrombosis reduce the risk of recurrence and of deep vein thrombosis? A pilot study evaluating clinical practice in Örebro county, Sweden.

BACKGROUND: Elective eradication of superficial vein incompetence (SVI) is advocated after superficial vein thrombosis (SVT) to prevent venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), and to prevent recurrent SVT. However, this practice currently lacks evidence and not all SVT patients are referred. METHOD: Pilot study based on retrospective review of medical records for patients in Örebro county, Sweden; diagnosed with SVT during 2019. Patients in primary care without venous intervention were compared with patients from a vascular service treated with eradication for SVI, regarding prevalence of VTE and recurrent SVT during one-year follow-up. RESULTS: Out of 236 records reviewed, 97(41%) were included, 44 in the vascular care, and 53 in primary care. Erroneous diagnosis and coding were common causes for exclusion. The groups differed in ultrasound verified SVT 25(47.2%) and 35(79.5%) (p = .001), LMWH treatment 13(24.5%) and 24(54.5%) (p = .002), and history of prior SVT 19(35.8%) and 31(70.5%) (p = .001).There was no difference in the incidence of VTE during follow-up, 1(1.9%) and 1(2.3%) (p = 1.000), or recurrent SVT, 7(13.2%) and 6(13.6%), respectively (p = .951). CONCLUSIONS: This pilot study cannot confirm if elective eradication of SVI after SVT reduces the risk of VTE and recurrent SVT, however, the incidence of VTE was low in both groups. Limitations of the study are the small sample size and the lack of duplex ultrasound in all cases in both groups at diagnosis and at follow-up. Further prospective studies on homogenous populations are needed.

[Truncal mechanochemical versus thermal endovenous ablation for varicose vein disease: a systematic review and meta-analysis]. / Sistematicheskii obzor i metaanaliz rezul'tatov primeneniya stvolovoi mekhanokhimicheskoi i termal'noi obliteratsii u patsientov s varikoznoi bolezn'yu.

OBJECTIVE: To compare the outcomes of thermal and mechanochemical endovenous ablative techniques in patients with varicose veins. MATERIAL AND METHODS: We searched the PubMed, EMBASE and Cochrane Library databases for studies devoted to mechanochemical and thermal endovenous ablative techniques from inception until July 2021. The primary outcome was anatomical success. Secondary endpoints were intraoperative pain syndrome, complications, modification of disease severity and quality of life. RESULTS: This meta-analysis enrolled 10 comparative studies and 1.252 participants after truncal ablations. The follow-up period ranged from 4 weeks to 36 months. With regard to overall anatomical success, 245 out of 267 (91.8%) patients after mechanochemical ablation and 249 out of 266 (93.6%) patients after thermal ablation had favorable results after a month (low-quality evidence; odds ratio [OR] 0.79; 95% CI 0.40-1.55). No statistical heterogeneity was identified (χ2=1.48; df=2; p=0.48; I2=0%). Further analysis identified different incidence of total occlusion after 12 months or later (OR 0.36; 95% CI 0.11-1.21; p=0.05; I2=68%). Mechanochemical ablation resulted less intraoperative pain. Mean difference was -1.3 (95% CI -2.53- -0.07; p=0.00001). MOCA was followed by fewer incidence of nerve injury, hematoma, deep vein thrombosis and phlebitis. There were more cases of skin pigmentation compared to thermal ablation (low-quality evidence, p>0.05). Subsequent assessment of disease severity identified significant between-group difference of means (-0.64 (95% CI -1.82-0.53; p=0.004) and -0.16 (95% CI -0.43-0.11; p=0.005) after 6 and 12 months, respectively). Further assessment of quality of life revealed no between-group differences. These data were characterized by moderate methodological quality. CONCLUSION: Mechanochemical ablation is as effective as standard TA within the first postoperative month. However, this approach is associated with lesser anatomical success after 12 months. In most studies, pain syndrome was less severe in case of mechanochemical ablation. These data suggest that mechanochemical ablation is a safe alternative for varicose veins. However, further large-scale trials are required to define the role of MOCA.