Polidocanol Sclerotherapy in Pyogenic Granulomas.

BACKGROUND: Polidocanol is a safe sclerosing agent with anesthetic properties and minimal skin toxicity. OBJECTIVE: To evaluate the efficacy, safety, and recurrence rates with polidocanol sclerotherapy in the treatment of pyogenic granulomas (PGs). METHODS AND METHODS: Thirty-nine patients with PG were injected with polidocanol 1% solution. Repeat injections were given weekly in case of incomplete clinical/dermoscopic resolution, until a maximum of 3 sittings. A higher strength (3%) was used for subsequent sessions in those with a minimal response to 1% solution. A final assessment for relapses was performed at 3, 6, and 12 months. RESULTS: All 39 patients achieved complete resolution (100% clearance rate), with most (n = 26) lesions resolving after the first sitting. Side effects noted were postprocedure pain (22), erythema (2), superficial ulceration (2), paresthesias (1), prominent edema (4), thrombophlebitis (1), cyanotic discoloration (1), purpuric staining around injection site (4), and mild local pruritus (1). The procedure was well tolerated across the age spectrum (4-63 years) included. CONCLUSION: We report polidocanol to be a highly effective, safe, and cost-effective sclerosant for treatment of PGs with no recurrences or need for special postprocedure care.

[Analysis on clinical efficacy, safety and economy of Shaobei injection and elastic band ligation in the treatment of grade II or III hemorrhoids].

Objective: Currently, various treatments such as hemorrhoidectomy, ligation and sclerotherapy injection can be applied in grade II or III hemorrhoids. This study aims to compare the clinical efficacy, safety and economy between Shaobei injection and elastic band ligation in treating patients with grade II or grade III hemorrhoids. Methods: A retrospective cohort study was used. Clinical data of 60 patients with grade II or grade III hemorrhoids at Department of Anorectal Surgery of the Sixth Affiliated Hospital, Sun Yat-sen University between January 2019 and October 2019 were collected. Patients were divided into two groups according to surgical methods. Patients in the Shaobei group received Shaobei injection (n=28), and those in the ligation group received elastic band ligation (n=32). Inclusion criteria: (1) diagnosis of grade II or III hemorrhoid; (2) application of Shaobei injection or elastic band ligation; (3) age between 18-75 years old. Exclusion criteria: (1) comorbidity with anal fissure, anal fistula, anal sinusitis or other perianal diseases; (2) patients with mental disorder or poor compliance; (3) incomplete clinical or follow-up data. Recurrent rate, postoperative pain, anal edema, anal distension, total cost of hospitalization, length of hospitalization, and postoperative life quality EQ-5D-3L score were compared between the two groups at postoperative 6-month. Results: No significant difference was observed in the baseline data (including Nystrom hemorrhoid symptom score) between the two groups (all P>0.05), except gender ratio [male proportion: Shaobei 75% (21/28) vs. ligation 37.5%(12/32), χ(2)=8.485, P=0.004]. No significant difference in recurrent rate was found between the two groups [14.3% (4/28) vs. 9.4% (3/32), χ(2)=0.035, P=0.851]. Compared to the ligation group, Shaobei group showed less pain at postoperative day 1 [VAS median (range): 2 (1-6) vs. 3 (1-7), Z=2.814, P=0.005] and postoperative day 7 [VAS median (range): 0 (0-2) vs. 1 (0-4), Z=3.149, P=0.002]; lower anal edema ratio at postoperative day 1 [10.7% (3/28) vs. 34.4% (11/32), Z=4.673, P=0.037]; lower anal distension ratio at postoperative day 1 [7.1% (2/28) vs. 28.1% (9/32), Z=4.391, P=0.048]; less hospitalization cost [(6343.5±1444.1) yuan vs. (10 587.1± 1719.0) yuan, t=12.515, P<0.001] and shorter postoperative hospital stay [median (range): 1 (1-5) days vs. 3 (1-6) days, Z=5.879, P<0.001]. The EQ-5D-3L scores of two groups were significantly improved six months after treatment [Shaobei group: (0.90±0.16) vs. (0.73±0.14); ligation group: (0.91±0.13) vs. (0.74±0.10); both P<0.001], while there was no statistically significant difference between the two groups (t=0.130, P=0.897). No complications such as massive hemorrhage, infection, iatrogenic anal fistula, rectal stricture and local induration occurred after the injection. Conclusions: Shaobei injection is effective and safe in treating grade II or III hemorrhoids. Compared with elastic band ligation, it can reduce morbidity of complications and hospitalization expenses.

Ethanol Sclerotherapy versus Laparoscopic Surgery for Endometrioma Treatment: A Prospective, Multicenter, Cohort Pilot Study.

STUDY OBJECTIVE: To compare the cost-effectiveness of ultrasound (US)-guided aspiration and ethanol sclerotherapy versus laparoscopic surgery for benign-appearing ovarian endometrioma. DESIGN: Prospective, cohort pilot study. SETTING: Multiple centers, Spain. PATIENTS: Forty patients with suspected ovarian endometrioma identified by US, with a maximum diameter of 35 to 100 mm, of whom 33 met inclusion criteria. INTERVENTIONS: The study group (n = 17) underwent US-guided aspiration plus sclerotherapy with ethanol, and the control group (n = 14) underwent laparoscopic cystectomy. MEASUREMENTS AND MAIN RESULTS: Recurrence, complications, and direct costs were compared. One of 17 sclerotherapy patients recurred (5.9%) compared with 4 of 14 laparoscopic surgery patients (28.6%) (odds ratio 0.18, 0.01-1.53). No serious adverse effects (Clavien-Dindo ≥ III) were observed in the sclerotherapy group; 1 patient in the surgery group had a Clavien-Dindo IIIb complication. Median hospital direct costs were significantly lower in the sclerotherapy group than those in the surgery group-266 euros versus 2189 euros. CONCLUSION: Ethanol sclerotherapy seems to be cost-effective for endometrioma and also appears to reduce complications. In this pilot study, recurrence was not higher than with conventional surgery.

A Comparative Study of Percutaneous Aspiration with Sclerotherapy and Laparoscopic Marsupialization for Symptomatic Simple Renal Cysts.

Background: Percutaneous aspiration with sclerotherapy (PAS) and laparoscopic marsupialization (LM) are minimally invasive treatment modalities for renal cysts. We aimed to compare the efficacy and cost/effectiveness of LM and PAS for the treatment of simple symptomatic renal cysts. Methods: Data were prospectively collected from three health care institutions in which 80 patients with symptomatic simple renal cysts underwent a single session of PAS with 95% ethanol (PAS group, n = 40) or underwent LM under general anesthesia (LM group, n = 40) between March 2012 and May 2016. We compared the patient profile, duration of procedure, duration of hospital stay, radiological and symptomatic success rates, treatment costs, and incidence of complications between the two groups. Results: At the 6-month follow-up, the radiological success rate in the LM group was significantly greater than that in the PAS group (97.5% versus 60%; P < .001). The symptomatic success rate was comparable in the two groups (95% versus 90%; P = .675). The treatment failure rate did not significantly differ between the two groups (5.0% versus 17.5%, P = .154). The mean total cost in the PAS and LM groups was 1256 USD and 2343 USD, respectively (P = .001). No significant between-group difference was noted regarding the overall complication rate (P = .615). Conclusions: Both LM and PAS are effective and safe procedures for the treatment of symptomatic simple renal cysts. A single session of PAS seems to be a cost-effective method for the management of symptomatic simple renal cysts.

Five-Year Outcomes of a Randomized Trial of Treatments for Varicose Veins.

BACKGROUND: Endovenous laser ablation and ultrasound-guided foam sclerotherapy are recommended alternatives to surgery for the treatment of primary varicose veins, but their long-term comparative effectiveness remains uncertain. METHODS: In a randomized, controlled trial involving 798 participants with primary varicose veins at 11 centers in the United Kingdom, we compared the outcomes of laser ablation, foam sclerotherapy, and surgery. Primary outcomes at 5 years were disease-specific quality of life and generic quality of life, as well as cost-effectiveness based on models of expected costs and quality-adjusted life-years (QALYs) gained that used data on participants' treatment costs and scores on the EuroQol EQ-5D questionnaire. RESULTS: Quality-of-life questionnaires were completed by 595 (75%) of the 798 trial participants. After adjustment for baseline scores and other covariates, scores on the Aberdeen Varicose Vein Questionnaire (on which scores range from 0 to 100, with lower scores indicating a better quality of life) were lower among patients who underwent laser ablation or surgery than among those who underwent foam sclerotherapy (effect size [adjusted differences between groups] for laser ablation vs. foam sclerotherapy, -2.86; 95% confidence interval [CI], -4.49 to -1.22; P<0.001; and for surgery vs. foam sclerotherapy, -2.60; 95% CI, -3.99 to -1.22; P<0.001). Generic quality-of-life measures did not differ among treatment groups. At a threshold willingness-to-pay ratio of £20,000 ($28,433 in U.S. dollars) per QALY, 77.2% of the cost-effectiveness model iterations favored laser ablation. In a two-way comparison between foam sclerotherapy and surgery, 54.5% of the model iterations favored surgery. CONCLUSIONS: In a randomized trial of treatments for varicose veins, disease-specific quality of life 5 years after treatment was better after laser ablation or surgery than after foam sclerotherapy. The majority of the probabilistic cost-effectiveness model iterations favored laser ablation at a willingness-to-pay ratio of £20,000 ($28,433) per QALY. (Funded by the National Institute for Health Research; CLASS Current Controlled Trials number, ISRCTN51995477.).

Cost Analysis of a Multidisciplinary Vascular Anomaly Clinic.

OBJECTIVE: Multidisciplinary vascular anomaly clinics (VACs) offer important value to pediatric patients with complex vascular anomalies whose care overlaps specialties. These clinics are labor intensive and costly to operate since providers see fewer patients compared to their individual specialty clinic. Our North American tertiary care institution's VAC specialists include a pediatric otolaryngologist, pediatric surgeon, pediatric plastic surgeon, pediatric dermatologist, and interventional radiologist. To assess financial feasibility, we conducted a cost analysis of our VACs comprised of 2 half-day multidisciplinary physician attended clinics (5 specialists at our main campus and 2 specialists at a satellite clinic) and a half-day nurse practitioner clinic. METHOD: Assessment of net revenue based on net collections for clinic, professional, operative, hospital setting, and facility charges generated during 12 consecutive monthly VACs beginning July 1, 2015. Expense calculations included provider and staff salaries, benefits, supply costs, and clinic leasing costs. RESULTS: There were 469 clinic visits, of which 202 were new patient evaluations. Sixty-eight patients underwent 93 procedures under general anesthesia, including procedures performed by our interventional radiologist, most commonly sclerotherapy or embolization (n = 37), surgical interventions including endoscopy (n = 36), or laser procedures (n = 20). Three patients were admitted. Fifty-seven patients received a new diagnosis different from that for which they were referred. Gross revenue was $1 810 525, and net revenue was 42.5%, or $783 152. Expenses totaled $453 415 for a net positive revenue of $329 737. CONCLUSION: When including direct downstream revenue, particularly from operative procedures, our VAC program operates on a net positive margin, making the program financially feasible.

Cost-Effectiveness of Current and Emerging Treatments of Varicose Veins.

OBJECTIVES: To analyze the cost-effectiveness of current technologies (conservative care [CONS], high-ligation surgery [HL/S], ultrasound-guided foam sclerotherapy [UGFS], endovenous laser ablation [EVLA], and radiofrequency ablation [RFA]) and emerging technologies (mechanochemical ablation [MOCA] and cyanoacrylate glue occlusion [CAE]) for treatment of varicose veins over 5 years. METHODS: A Markov decision model was constructed. Effectiveness was measured by re-intervention on the truncal vein, re-treatment of residual varicosities, and quality-adjusted life-years (QALYs) over 5 years. Model inputs were estimated from systematic review, the UK National Health Service unit costs, and manufacturers' list prices. Univariate and probabilistic sensitivity analyses were undertaken. RESULTS: CONS has the lowest overall cost and quality of life per person over 5 years; HL/S, EVLA, RFA, and MOCA have on average similar costs and effectiveness; and CAE has the highest overall cost but is no more effective than other therapies. The incremental cost per QALY of RFA versus CONS was £5,148/QALY. Time to return to work or normal activities was significantly longer after HL/S than after other procedures. CONCLUSIONS: At a threshold of £20,000/QALY, RFA was the treatment with highest median rank for net benefit, with MOCA second, EVLA third, HL/S fourth, CAE fifth, and CONS and UGFS sixth. Further evidence on effectiveness and health-related quality of life for MOCA and CAE is needed. At current prices, CAE is not a cost-effective option because it is costlier but has not been shown to be more effective than other options.

A 1470-nm laser combined with foam sclerotherapy in day surgery: a better choice for lower limb varicose veins.

Day surgery is being more and more adopted by clinicians. Higher wavelength lasers give patients better experience than lower wavelength lasers, which makes it more suitable for day surgery. This study compares the short- and mid-term efficacy, postoperative morbidity, and patient satisfaction of "1470-nm endovenous laser ablation (EVLA) combining foam sclerotherapy in day surgery" with "810-nm EVLA with high ligation combining foam sclerotherapy in hospital surgery" on great saphenous vein (GSV) insufficiency postoperatively. A single-institution historical cohort study of 194 patients was performed in Shanghai Ninth People's Hospital, China. Ninety-seven patients received 1470-nm EVLA combining foam sclerotherapy in day surgery ("1470-nm group"), and 97 patients received 810-nm EVLA with high ligation combining foam sclerotherapy in hospital surgery recommended by guidelines ("810-nm group"). No significant difference was found between the 1470-nm group and the 810-nm group in terms of GSV occlusion rate (both 100%), complication rate, and recurrence rate (8.2 vs. 11.3%) during the period of 1-12 months after surgery. Serious complications in the 1470-nm group and 810-nm group were 0 and 1.0%. Minor complications in the 1470-nm group and 810-nm group were ecchymosis at 20.6 and 18.6%, edema at 69.1 and 63.9%, and paresthesia around ankle at 0 and 3.1%, respectively. Advantage of the 1470-nm group over the 810-nm group was statistically significant considering the patient perioperative comfort and economic cost. Treatment of 1470-nm EVLA combining foam sclerotherapy in day surgery has similar efficacy as the 810-nm EVLA with high ligation combining foam sclerotherapy in hospital surgery in GSV insufficiency and is more comfortable with less incision, hospitalization procedure, and medical costs. It may be a new option for patients who are afraid or unable to be hospitalized.

Transparent cap-assisted endoscopic sclerotherapy in esophageal varices: a randomized-controlled trial.

BACKGROUND AND AIM: Endoscopic treatment is widely accepted as the first-line therapy selection for esophageal variceal bleeding. Nevertheless, endoscopic injection sclerotherapy requires experienced endoscopists and is associated with a high risk of bleeding. Our study evaluates the feasibility and efficacy of transparent cap-assisted endoscopic sclerotherapy in the management of esophageal varices. PATIENTS AND METHODS: A randomized-controlled trial was conducted in a tertiary referral center from April 2015 to May 2016. Patients who received endoscopic sclerotherapy were randomized in a blinded manner into two groups: the transparent cap-assisted group (n=59) and the control group (n=61). RESULTS: The average injection sites were reduced in the transparent cap-assisted group compared with the control group (1.2±0.4 vs. 1.4±0.05, P=0.000), whereas no difference was observed in the dosage of lauromacrogol (16.97±4.91 vs. 16.85±4.57, P=0.662) and the hemorrhage that occurred during injection made no difference (50.8 vs. 61.0%, P=0.276); yet, salvage hemostasis methods were used in only nine patients in the transparent cap-assisted group compared with 17 patients in the control group (25.0 vs. 38.7%, P=0.0936). The cost of each procedure in the cap-assisted group was ¥2578 (1878-4202), whereas it was ¥3691 for the control group (2506-5791) (P=0.023). Moreover, in both groups, no esophageal constriction was observed during the 6-month follow-up period, whereas the rebleeding rate between two groups showed no statistical significance in 6 months (89.8 vs. 93.4%, P=0.563). CONCLUSION: Transparent cap-assisted sclerotherapy provided a clear field of vision and helped to fix the targeted veins, thus significantly reducing the use of the salvage hemostasis method during sclerotherapy injection hemorrhage. It is also associated with reduced injection sites and endoscopic therapy cost.

Comparison of Ultrasound-Guided Percutaneous Polidocanol Injection Versus Percutaneous Ethanol Injection for Treatment of Benign Cystic Thyroid Nodules.

OBJECTIVES: We compared the efficacy, safety, and cost-effectiveness of ultrasound-guided percutaneous polidocanol injection and percutaneous ethanol injection for the treatment of benign cystic and predominantly cystic thyroid nodules. METHODS: A total of 135 cystic thyroid nodules treated by percutaneous ethanol injection and 136 cystic thyroid nodules treated by percutaneous polidocanol injection were enrolled retrospectively in this study from May 2010 to March 2016. The nodules were followed after 1, 3, 6, and 12 months. Nodule volumes, symptoms scores, and cosmetic scores were assessed before treatment and at follow-up. The therapeutic success rate, safety, and cost-effectiveness between the groups were also compared. RESULTS: No significant differences in the reduction of the nodule volume, volume reduction rate, and therapeutic success were observed between the groups with cystic and predominantly cystic thyroid nodules during follow-up (P > .05). Neither the cosmetic scores (P = .59; P = .42) nor the symptom scores (P = .32; P = .73) in the cystic and predominantly cystic nodules were significantly different between the groups at the last follow-up. The complication rates for ethanol were higher than those for polidocanol (P < .05). However, the cost of polidocanol injection was higher than that of ethanol injection for cystic thyroid nodules (mean ± SD, US$97.18 ± US$22.17 versus US$43.36 ± US$5.51; P < .01). CONCLUSIONS: Ultrasound-guided percutaneous polidocanol injection can be an alternative for sclerotherapy of cystic or predominantly cystic thyroid nodules. However, its cost was higher than that of percutaneous ethanol injection.

Randomized controlled trial of scleroligation versus band ligation alone for eradication of gastroesophageal varices.

BACKGROUND AND AIMS: Gastric varices develop in 5% to 33% of patients with portal hypertension. Their most common form is concomitant gastroesophageal varices. Scleroligation (combined sclerotherapy and band ligation) has been used successfully in management of esophageal varices but has not been evaluated previously in the management of gastroesophageal varices. The aim of this work was evaluation of a new scleroligation technique for management of bleeding gastroesophageal varices regarding efficacy, adverse events, variceal recurrence, and survival. METHODS: This study was conducted on 120 cirrhotic patients with bleeding gastroesophageal varices, whom we divided randomly into 2 groups of 60 patients each-a band ligation group and a scleroligation group. RESULTS: The mean number of sessions was lower in the scleroligation group than in the band ligation group (2.22 ± 0.92 and 3.43 ± 0.67, respectively) (P < .001), as were the duration of treatment and total number of bands used. Cost and survival were comparable in the 2 groups. There was no significant difference between the 2 maneuvers regarding adverse events, recurrence rates, or rebleeding rates after obliteration. Recurrence was significantly higher in patients with larger varices, ulceration, and postprocedure pyrexia. Rebleeding was significantly higher among those who experienced postprocedure pyrexia and developed or had worsening of gastric antral vascular ectasia. CONCLUSIONS: Scleroligation appears to achieve a faster rate of eradication with fewer treatment sessions and total number of bands deployed to achieve variceal obliteration than band ligation and is comparable in cost and in adverse event and recurrence rates. (Clinical trial registration number: NCT02646202.).

Prospective Randomized Study of Ultrasound-Guided Foam Sclerotherapy Combined with Great Saphenous Vein High Ligation in the Treatment of Severe Lower Extremity Varicosis.

BACKGROUND: To evaluate the effect of ultrasound-guided foam sclerotherapy (UGFS) in a single session combined with great saphenous vein (GSV) high ligation for severe lower extremity varicosis classified as C4-C6, compared with GSV stripping plus multistab avulsion or transilluminated powered phlebectomy (TIPP). METHODS: From January 2012 to December 2014, 177 patients with primary GSV insufficiency, classified as C4-C6, were randomized into the UGFS group or the control group. The UGFS group was managed by GSV high ligation and foam sclerotherapy in one session under the surveillance of ultrasonography, whereas the control group received GSV high ligation and stripping combined with multistab avulsion or TIPP. The patients were followed up at 1, 6, and 12 months after treatment. Outcome assessments included reflux recurrence rate, procedure-related adverse events, hemodynamic parameters, revised Venous Clinical Severity Score (VCSS), and Aberdeen Varicose Vein Questionnaire (AVVQ) score. The medical cost and operating time of the 2 groups were also compared. RESULTS: In total, 73 patients received UGFS, whereas 90 patients underwent traditional surgery. Sixty-five patients in the UGFS group (89.0%) and 74 patients in the control group (82.2%) completed the follow-up. At the end of 12 months, the cumulative reflux recurrence rate was 13.8% in the UGFS group and 13.5% in the control group (P = 0.955). In the UGFS and control groups, minor complications (27.7% vs. 21.6%, P = 0.406) and major complications (3.1% vs. 2.7%, P = 0.895) were not significantly different. Compared with baseline values, obvious improvements of the venous filling index, VCSS, and AVVQ scores after treatment were confirmed in both groups (P < 0.001). The average operating and recovery times were much shorter (38.3 vs. 81.2 min, 5.4 vs. 9.6 days, P < 0.001, respectively), and the average hospital cost was much lower ($853 vs. $1,575, P < 0.001) in the UGFS group than in the control group. The patient satisfaction rate reached 92.3% in the UGFS group and 89.2% in the control group 12 months after operation (P = 0.270). CONCLUSIONS: Our outcomes indicated that UGFS combined with GSV high ligation was safe and effective for severe lower extremity varicosis.

Practice patterns of endovenous ablation therapy for the treatment of venous reflux disease.

OBJECTIVE: The purpose of this study was to assess practice patterns of endovenous ablation therapy for the treatment of venous reflux disease among the vein specialist members of the American Venous Forum (AVF). METHODS: An online survey was conducted of AVF members designed to identify demographics, treatment practices, and clinical variables in the selection of vein ablation devices. RESULTS: The survey was distributed to 798 practicing physicians, of whom 129 (16%) responded. The specialty distribution of respondents was as follows: vascular surgeons, 54%; phlebologists, 14%; general surgeons, 11%; interventional radiologists, 9%; and other specialties, 6%. The majority (81%) were from the United States, and 65% were self-employed. Almost half (47%) were in practice for >20 years, with 33% of all respondents performing three to five saphenous vein ablations per week. Three-quarters (79%) of respondents preferred radiofrequency ablation (RFA), with 47% believing that it was more cost-effective and more than half (57%) reporting improved patient satisfaction with this technique. Most of them (63%) responded that previous capital investment played a significant role in their choice of vein ablation device along with the associated cost of disposable equipment. A large majority (77%) of physicians responded that they had a significant role in choosing the treatment device, whereas only 17% thought that patients' choice played a major role in device choice. The capital investment affected choice of modality more significantly in newer practices (P < .0.5). CONCLUSIONS: The majority of AVF vein specialists prefer an RFA technique to laser, believing that RFA is associated with improved patient outcomes and is more cost-effective. Advances in technology, device costs, and reimbursement levels may have an impact on such preferences in the future.

What is effective care for varicose veins?

Varicose veins affect one-quarter to one-third of Western adult populations and consume an increasing amount of health care resources. Much of this increased utilization has been driven by the advent of minimally invasive technology including endovenous thermal ablation, foam sclerotherapy, and more recently mechanicochemical and cyanoacrylate glue ablation. This has largely been driven by patient and physician preferences in the absence of robust evidence that one therapy is truly superior to another. This partially arises from misunderstandings about appropriate outcomes measures and what truly constitutes effective treatment of varicose veins. Technical outcomes, such as saphenous closure rates, have frequently been used as surrogates for effective treatment but are poorly correlated with symptom improvement, quality of life, and risk of recurrence. Although there does appear to be a trend towards higher recurrence with ultrasound-guided foam sclerotherapy, the data are occasionally conflicting and there does not appear to be substantial differences between the various modalities. Similarly, there do not appear to be major differences in late quality of life measures between these treatment options. As long-term differences in recurrence and quality of life are small, overall cost effectiveness is driven primarily by initial treatment costs and ultrasound-guided foam sclerotherapy is the most cost-effective strategy in many models. However, there continues to be substantial uncertainty surrounding cost estimates and other factors of importance to the patient may ultimately drive treatment decisions. The benefits of some adjuncts to the treatment of axial superficial reflux, such as the concurrent versus staged management of tributary varicosities, remain ill-defined while that of others, such as routine post-procedural ultrasound surveillance and compression, need critical re-evaluation.

Cost-utility analysis of great saphenous vein ablation with radiofrequency, foam and surgery in the emerging health-care setting of Thailand.

OBJECTIVES: To conduct economic evaluations of radiofrequency ablation, ultrasound-guided foam sclerotherapy and surgery for great saphenous vein ablation. METHOD: A cost-utility and cohort analysis from societal perspective was performed to estimate incremental cost-effectiveness ratio. Transitional probabilities were from meta-analysis. Direct medical, direct non-medical, indirect costs, and utility were from standard Thai costings and cohort. Probabilistic sensitivity analysis was performed to assess parameter uncertainties. RESULTS: Seventy-seven patients (31 radiofrequency ablation, 19 ultrasound-guided foam sclerotherapy, and 27 surgeries) were enrolled from October 2011 to February 2013. Compared with surgery, radiofrequency ablation costed 12,935 and 20,872 Baht higher, whereas ultrasound-guided foam sclerotherapy costed 6159 lower and 1558 Bath higher for outpatient and inpatient, respectively. At one year, radiofrequency ablation had slightly lower quality-adjusted life-year, whereas ultrasound-guided foam sclerotherapy yielded additional 0.025 quality-adjusted life-year gained. Because of costing lower and greater quality-adjusted life-year than other compared alternatives, outpatient ultrasound-guided foam sclerotherapy was an option being dominant. Probabilistic sensitivity analysis resulted that at the Thai ceiling threshold of 160,000 Baht/quality-adjusted life-year gained, ultrasound-guided foam sclerotherapy had chances of 0.71 to be cost-effective. CONCLUSIONS: Ultrasound-guided foam sclerotherapy seems to be cost-effective for treating great saphenous vein reflux compared to surgery in Thailand at one-year results.

Radiofrequency ablation: an assessment of clinical and cost efficacy.

BACKGROUND: Varicose veins are common and frequently cause patient distress. In recent years, Radiofrequency ablation (RFA) has emerged as a minimally invasive alternative to traditional open venous ligation surgery. AIMS: The aim of this study was to directly compare RFA and open saphenofemoral ligation. METHODS: This was a single-centre retrospective cohort study. Consecutive patients undergoing surgical management over a 2-year period commencing from January 2011 were studied. Radiological success, peri-operative serological testing and hospital length of stay were documented. Procedural cost was calculated. A focused cohort analysis was undertaken to compare the initial 50 RFA procedures performed with the last 50. RESULTS: During the study period, 296 patients underwent surgical intervention. A total of 204 patients underwent RFA. Sixty-six percent of all patients were female. RFA was associated with a reduction in overnight hospital stay (18 vs. 78 %, P = <0.001) when compared with open ligation with a success rate of 98 %. No significant inter-group difference was noted for 30-day readmission (p = 0.203). Focused cohort analysis identified an increase in hospital day case activity (74 vs. 90 %, p = 0.002), which contributed to a reduction in procedural cost (€1,024 vs. €971, p = 0.003) over the study period. CONCLUSIONS: Radiofrequency ablation is a viable alternative to open repair offering excellent efficacy. It is however associated with a higher procedural cost than the open surgical option.

Superficial venous incompetence: low-cost outpatient minisurgery, sclerotherapy and combined procedure as a management plan. Costs and efficacy. A 20-year, follow-up registry.

BACKGROUND: This registry study evaluated low-cost outpatient surgery (mini-S) for venous insufficiency as an alternative to stripping. METHODS: This 20-year follow-up is focused on the recurrence of varices and on the long-term efficacy of the mini-S (group 1) in comparison with controls (2, stripping), sclerotherapy (3) or a combination of mini-S+sclerotherapy (4). Costs were compared. RESULTS: At 20-years of follow-up, considering recurrence/development of new varicose veins, 24.05% of the limbs treated with mini-S developed new varices in comparison with 64.4% in group 2, 24.1% in group 3 and 15.4% in group 4 (P<0.05). New surgical procedures were needed in 18.9% of mini-S patients vs. 58.5% in group 2, 21.9% in group 3 and 19.7% in group 4 (P<0.05 between group 2 and the other groups). Sclerotherapy (in the years following the initial treatment) was used in 37.9% of mini-S patients in comparison with 67.7% of subjects in group 2 patients, 33.1% in group 3 and 22.8% in group 4 (P<0.05 between outpatient treatment and group 2). The superficial venous system was incompetent in 21% of mini-S patients in comparison with 38.8% in group 2 (P<0.05), 20.7% in group 3 and 17.9% of group 4. At 20 years edema was present in 10.5% of limbs in group 2 in comparison with a <3% (range 2.2-2.1%) in the other groups. Edema was more significant after stripping. Ambulatory venous pressure measurements in subgroups was lower in groups 1, 3 and 4 with a lower refilling time (P<0.05). The cost of in-hospital, daily surgical treatments were €1978 (covered by the heathcare provider). The cost of mini-S was on average €488 per limb (covered by patients). CONCLUSIONS: Outpatients procedures, in particular the mini-S management plan, were cheaper than stripping and more effective at 20-years follow-up. They could be a model for emerging contries with restricted budgets for vein surgery. Also being cheaper more people may have benefits from treatment when/where hospital procedures are not covered by an healthcare provider.

Foam sclerotherapy.

Foam sclerotherapy is a minimally invasive treatment for lower limb varicose veins. Current evidence indicates that its efficacy may not be as high as surgery or endovenous ablation. The minimally invasive nature of the treatment however means that it has a wide application, and it can be particularly useful in patients who are not suitable for other types of treatment. NICE guidelines recommend its use as a second line after endovenous ablation. Complication rates are low and most of these are of little clinical consequence.

A Cost-effectiveness Analysis of Surgery, Endothermal Ablation, Ultrasound-guided Foam Sclerotherapy and Compression Stockings for Symptomatic Varicose Veins.

OBJECTIVE: The aim was to investigate the cost-effectiveness of interventional treatment for varicose veins (VV) in the UK NHS, and to inform the national clinical guideline on VV, published by the National Institute of Health and Care Excellence. DESIGN: An economic analysis was constructed to compare the cost-effectiveness of surgery, endothermal ablation (ETA), ultrasound-guided foam sclerotherapy (UGFS), and compression stockings (CS). The analysis was based on a Markov decision model, which was developed in consultation with members of the NICE guideline development group (GDG). METHODS: The model had a 5-year time horizon, and took the perspective of the UK National Health Service. Clinical inputs were based on a network meta-analysis (NMA), informed by a systematic review of the clinical literature. Outcomes were expressed as costs and quality-adjusted life years (QALYs). RESULTS: All interventional treatments were found to be cost-effective compared with CS at a cost-effectiveness threshold of £20,000 per QALY gained. ETA was found to be the most cost-effective strategy overall, with an incremental cost-effectiveness ratio of £3,161 per QALY gained compared with UGFS. Surgery and CS were dominated by ETA. CONCLUSIONS: Interventional treatment for VV is cost-effective in the UK NHS. Specifically, based on current data, ETA is the most cost-effective treatment in people for whom it is suitable. The results of this research were used to inform recommendations within the NICE guideline on VV.