Endovenous Laser Ablation (EVLA) of the Anterior Accessory Great Saphenous Vein (AAGSV): Abolition of Sapheno-Femoral Reflux with Preservation of the Great Saphenous Vein

AimDuring surgery for sapheno-femoral junction (SFJ) and anterior accessory great saphenous vein (AAGSV) reflux, many surgeons also strip the great saphenous vein (GSV). This study assesses the short-term efficacy (abolition of reflux on Duplex ultrasound) of endovenous laser ablation (EVLA) of the AAGSV with preservation of a competent GSV in the treatment of varicose veins occurring due to isolated AAGSV incompetence.MethodThirty-three patients (21 women and 12 men) undergoing AAGSV EVLA alone (group A) and 33 age/sex-matched controls undergoing GSV EVLA (Group B) were studied. Comparisons included ultrasound assessment of SFJ competence, successful axial vein ablation, Aberdeen Varicose Vein Symptom Severity Scores (AVVSS) and a visual analogue patient-satisfaction scale.ResultsAt the 1-year follow-up, EVLA had successfully abolished the target vein reflux (AAGSV: median length 19 cm (inter-quartile range, IQR: 14–24 cm) vs. GSV: 32 cm (IQR 24–42 cm)) and had restored SFJ competence in all patients. Twenty of the 33 patients (61%) in group A and 14 of the 33 (42%) in group B (p = 0.218) required post-ablation sclerotherapy at 6 weeks post-procedure for residual varicosities. The AVVSS at 12 months follow-up had improved from the pre-treatment scores in both the groups (group A: median score 4.1 (IQR 2.1–5.2) vs. 11.6 (IQR: 6.9–15.1) p < 0.001; group B: median score 3.3 (IQR 1.1–4.5) vs. 14.5 (IQR 7.6–20.2), p < 0.001), with no significant difference between the groups. Patient-satisfaction scores were similar (group A: 84% and group B: 90%).Previous intervention in group A included GSV EVLA (n = 3) or stripping (n = 9). Thus, the GSV was preserved in 21 patients. The AVVSS also improved in this subgroup (4.4 (2.0–5.4) vs. 11.4 (6.0–14.1), p < 0.001) and SFJ/GSV competence was found to be restored at the 1-year follow-up.ConclusionsAAGSV EVLA abolishes SFJ reflux, improves symptom scores and is, therefore, suitable for treating varicose veins associated with AAGSV reflux.     

曲张大隐静脉管壁病理形态学特征研究

目的检测曲张大隐静脉管壁各参数,并探讨曲张大隐静脉管壁发生、发展过程中组织形态学特征与临床病期之间的关系。方法回顾性分析我院2008年7月至2009年7月期间收治的49例高位结扎剥脱加旋切治疗的大隐静脉曲张患者的临床资料,按临床CEAP分级分为单纯静脉曲张组(C2~C3级,简称单纯曲张组),24例;静脉曲张并皮肤改变组(C4~C6级,简称皮肤改变组),25例;另选6例因外伤行截肢术但大隐静脉正常无损伤者作为对照组。采用Masson染色测量静脉内膜和中膜厚度,以测量静脉截面的最大直径作为管腔内径值,采用免疫组织化学SP法观察静脉管壁的结构变化。结果管腔内径:与对照组比较,单纯曲张组及皮肤改变组上、中、下三段静脉管腔内径均明显增大(P<0.05);皮肤改变组上、中段静脉管腔内径较下段也明显增大(P<0.05);单纯曲张组三段静脉管腔内径变化差异无统计学意义(P>0.05)。单纯曲张组和皮肤改变组的静脉管壁结构改变大致相似,主要表现为内膜不均匀增厚,管壁厚薄不等,以胶原纤维和细胞外基质增生为主,伴有平滑肌增生,中膜厚度略增加,平滑肌束排列紊乱,部分萎缩、凋亡,部分局灶增生,肌束间纤维胶原间质增生,两者相互穿插,排列混乱,弹力纤维断裂。皮肤改变组还可见内膜继发性改变,包括黏液变性、玻璃样变性、内膜炎、血栓形成等。单纯曲张组和皮肤改变组上、中、下三段静脉内膜厚度明显大于对照组(P<0.05);单纯曲张组上、下段静脉内膜厚度明显小于中段(P<0.05);单纯曲张组中段内膜厚度明显大于皮肤改变组中段(P<0.05)。中膜厚度单纯曲张组、皮肤改变组和对照组之间以及同一组内上、中、下三段间比较差异均无统计学意义(P>0.05)。结论下肢曲张静脉管腔扩张,内膜增厚,内膜改变以中段出现较早且显著,上、下二段血管壁的重塑与临床病期之间无关。     

A Prospective Study of Cutaneous Nerve Injury Following Long Saphenous Vein Surgery

OBJECTIVES: The aim of this study was to identify the incidence and distribution of nerve damage in patients undergoing primary venous surgery. METHODS: Patients undergoing primary great saphenous vein surgery between February and November 2003 were enrolled. In all cases the great saphenous vein was 'flush' ligated at the sapheno-femoral junction and stripped to the knee by inversion without using a stripper head; multiple phlebectomies were performed using an Oesch hook. A vascular nurse followed up patients 6 weeks post-operatively. Those reporting altered sensation and/or pain were examined by a doctor to provide an objective assessment of any neurological damage. These patients were again followed up by telephone at 6 and 12 months. RESULTS: Sixty-three limbs from 54 patients were enrolled. Numbness or paraesthesia was identified in 17 (27%) limbs at 6 week follow-up. 11 (17%) limbs were affected below the knee and 7 (11%) limbs were affected at the thigh or groin. One of the limbs was affected above and below the knee. Of these 17 limbs there was resolution in six limbs at 6 months and nine limbs at 12 months. Two patients with persistent nerve lesions regretted undergoing surgery. Patients undergoing bilateral surgery were more likely to report abnormal sensation (chi(2) test, p=0.006). There was no significant difference between the incidence of nerve injury for consultant, SpR or SHO as first operator (chi(2) test, p=0.9). CONCLUSION: This study demonstrates the frequency of nerve injury during primary great saphenous vein surgery. It will be useful for clinicians providing informed consent and may provide a benchmark for comparison with newer techniques.     

小儿大隐静脉穿刺探讨

总结102例小儿大隐静脉穿刺体会,就穿刺点的选择、穿刺方向、穿刺角度及固定方法进行了探讨.     

The Structural Study of the Saphenous Vein

From November, 1971, to September, 1974, 1,179 patients received aortocoronary saphenous vein bypass grafts at the Cleveland Clinic Hospital. Segments of saphenous vein from each patient were sent for microscopical analysis. These vein segments were classified as normal or abnormal (phlebosclerotic). Four hundred ninety-six normal vein grafts in 295 patients were restudied and had a patency of 87.9%. One hundred forty-four abnormal vein grafts in 86 patients were restudied and showed 89.5% patency.This study suggests that histopathological identification of an abnormal (phlebosclerotic) vein segment does not constitute a determining factor as far as late patency is concerned in a vein segment that is not grossly sclerotic.     

Effect of Ticlopidine on Saphenous Vein Bypass Patency Rates: A Double-blind Study

The effects of ticlopidine, a new antiplatelet agent, on graft patency rate was investigated in a group of 150 consecutive patients undergoing aortocoronary bypass graft procedures. In a double-blind study, two groups of 75 patients each received ticlopidine (250 mg twice daily) or a placebo during a three-month period. Graft patency was evaluated by repeat angiography in 38 patients and by rest and stress myocardial scintigraphy in 93. Combined angiographic and scintigraphic analysis was performed in 36 patients. The biological effects of ticlopidine on platelet activity were assessed by bleeding time and appropriate ex vivo tests. Graft patency was evaluated in 131 patients (87%). Evaluation was performed at the end of the three-month therapy period in 77 patients (Groups T₁ [ticlopidine] and P₁ [placebo]) and five months later in 54 patients. The total graft attrition rate was 10.1% in Group T₁ compared with 20.3% in Group P₁ (p < 0.1). Excluding patients with discordant biological data, the attrition rate was 7.1% for Group T₁ compared with 21.8% for Group P₁ (p < 0.02). There was no difference between the subgroups evaluated five months after the end of therapy.Ticlopidine appears to be an effective means of protecting graft patency as long as the biological effects of the drug are present. This protective effect disappears when the drug is discontinued, which suggests that ticlopidine should be prescribed for a longer period, at least for the first year after operation.     

Four-Year Follow-up on Endovascular Radiofrequency Obliteration of Great Saphenous Reflux

BACKGROUND: Endovascular radiofrequency obliteration has been used since 1998 as an alternative to conventional vein stripping surgery for elimination of saphenous vein insufficiency. OBJECTIVE: To demonstrate the long-term efficacy of this treatment modality. METHODS: Data were prospectively collected in a multicenter ongoing registry. Only great saphenous vein above-knee treatments were included in this study. Eight hundred ninety patients (1,078 limbs) were treated prior to November 2003 at 32 centers. Clinical and duplex ultrasound follow-up was performed at 1 week, 6 months, and 1, 2, 3, and 4 years. RESULTS: Among 1,078 limbs treated, 858 were available for follow-up within 1 week, 446 at 6 months, 384 at 1 year, 210 at 2 years, 114 at 3 years, and 98 at 4 years. The vein occlusion rates were 91.0%, 88.8%, 86.2%, 84.2%, and 88.8%, respectively; the reflux-free rates were 91.0%, 89.3%, 86.2%, 86.0%, and 85.7%, respectively; and the varicose vein recurrence rates were 7.2%, 13.5%, 17.1%, 14.0%, and 21.4%, respectively, at each follow-up time point at 6 months, and 1, 2, 3, and 4 years. Patient symptom improvement persisted over 4 years. CONCLUSIONS: Endovascular temperature-controlled radiofrequency obliteration of saphenous vein reflux exhibits an enduring treatment efficacy clinically, anatomically, and hemodynamically up to 4 years following treatment.     

The Advantages of the Great Saphenous Vein as a Femoropopliteal Graft: A Report on Its Clinical Use

As a majority of vascular surgeons prefer the autologous saphenous vein as a bypass graft below the inguinal ligament, the need of alternative graft materials or reconstructive techniques is confined to patients with unavailable or unsuitable saphenous veins. The aim of this investigation was to ascertain how often these alternative procedures are necessary. From 1973 to June 1979, the great saphenous vein was used as a femoropopliteal graft without regard to fixed limitations in the diameter and the quality of the vein. During this period, vascular reconstruction was required in 148 limbs due to symptomatic atherosclerotic occlusion of the superficial femoral artery. In 144 of these cases, the ipsilateral (138) or the contralateral (6) great saphenous vein was used for a femoropopliteal bypass reconstruction. Thus, the vein could not be utilized in only 4 of 148 cases (2.7%).

As graft patency rate was not subject to the size and quality of the vein and as cumulative patency rates in the 144 grafts were most satisfactory (97.9, 92.0 and 81.9% at 1 month, 1 year and 5 years, respectively), although all these veins were used regardless of their calibre and quality, we conclude that the great saphenous vein can be used more liberally as a graft for femoropopliteal occlusion In approximately only 3% of patients requiring operation, alternative reconstructive techniques, such as ‘non-vein’ bypass grafts and thrombendarterectomy are needed.     

Great Saphenous Vein Diameter at the Saphenofemoral Junction and Proximal Thigh as Parameters of Venous Disease Class

BackgroundGreat saphenous vein (GSV) incompetence is involved in the majority of cases of varicose disease. Standardised pre-interventional assessment is required to analyse the relative merit of treatment modalities. We weighed GSV diameter measurement at the sapheno-femoral junction (SFJ) against measurement at the proximal thigh 15 cm distal to the groin (PT), established a conversion factor and applied it to selected literature data.MethodsLegs with untreated isolated GSV reflux and varices limited to its territory and control legs were studied clinically, with duplex ultrasound and photoplethysmography. GSV diameters were measured at both the SFJ and the PT. A conversion factor was calculated and used to compare published data.ResultsOf 182 legs, 60 had no GSV reflux (controls; group I), 51 had above-knee GSV reflux only (group II) and 71 had GSV reflux above and below knee (group III). GSV diameters in group I measured 7.5 mm (±1.8) at the SFJ and 3.7 mm (±0.9) at the PT. In groups II and III, they measured 10.9 mm (±3.9) at the SFJ and 6.3 mm (±1.9) at the PT (p < 0.001 each). Measurement at the PT revealed higher sensitivity and specificity to predict reflux and clinical class. Good correlation between sites of measurement (r = 0.77) allowed a conversion factor (SFJ = 1.767 * PT, PT = 0.566*SFJ) to be applied to pre-interventional data of published studies.ConclusionsGSV diameter correlates with clinical class, measurement at the PT being more sensitive and more specific than measurement at the SFJ. Applying the conversion factor to published data suggests that some studies included patients with minor disease.     

高流体静力压和缺氧对大隐静脉和脾静脉滋养血管超微结构的影响

目的观察大隐静脉和脾静脉滋养血管内皮细胞超微结构变化,探讨高流体静力压和缺氧对滋养血管内皮细胞的影响。方法收集曲张大隐静脉和高压性脾静脉管壁标本34例,另设对照组为正常大隐静脉和脾静脉34例。采用HE染色光镜下观察大隐静脉和脾静脉外膜层滋养血管,半薄切片定位。再采用超薄切片,透射电镜下观察滋养血管内皮细胞的超微结构变化。结果大隐静脉曲张组和病脾静脉组滋养血管内皮细胞细胞核结构完整,染色质分布正常;部分线粒体基质深染,嵴模糊、嵴断裂。结论高流体静力压和缺氧下大隐静脉和脾静脉管壁滋养血管内皮细胞的超微结构会出现重塑现象,二者改变相同。     

Intravascular 1320-nm Laser Closure of the Great Saphenous Vein: A 6- to 12-Month Follow-up Study

OBJECTIVE: The objective was to determine the safety and efficacy of an intravascular laser with a novel wavelength to close the great saphenous vein. METHODS: Twenty-four cases of an incompetent great saphenous vein (0.5-1.2 cm in diameter) associated with distal varicose veins were treated with a 1320-nm intravascular laser at 5 W with an automatic pullback mechanism at 1 mm/s. Patients were evaluated with duplex ultrasound to determine efficacy of treatment at various time periods to at least 6 months after the procedure. RESULTS: All patients demonstrated complete closure of the incompetent great saphenous vein. In most cases, the treated great saphenous vein was not identifiable 6 months postoperatively. There was no recurrence of any varicose veins. All preoperative symptoms resolved after treatment, and no complications were noted. All patients were very pleased with the outcome of the procedure. CONCLUSIONS: At 6 months or greater follow-up, a 5-W, 1320-nm intravascular laser with 1 mm/s automatic pullback, delivered through a diffusion-tip fiber, is safe and effective in treating an incompetent great saphenous vein up to 1.2 cm in diameter.