Transcatheter Duplex Ultrasound-Guided Sclerotherapy for Treatment of Greater Saphenous Vein Reflux: Preliminary Report

Background. Surgical ligation and stripping of the greater saphenous vein has been the gold standard for treatment of saphenofemoral junction incompetence for several years. Although sclerotherapy of the greater saphenous vein has also been advocated by some phlebologists, the procedure can be technically challenging and has resulted in inadvertent nontarget injection.
Objective. The purpose of this study was to assess the effectiveness and safety of transcatheter duplex-guided sclerotherapy for the treatment of varicose veins due to saphenofemoral junction reflux.
Methods. Fifty-one greater saphenous veins in 50 patients were treated with transcatheter sclerotherapy. Using local anesthesia and ultrasound guidance, the greater saphenous vein was entered 15–45 cm below the saphenofemoral junction. An infusion catheter was placed over a guidewire and positioned under ultrasound guidance, and 3% sodium tetradecyl sulfate was administered below the saphenofemoral junction and along the course of an "empty" greater saphenous vein via the catheter.
Results. Catheter placement and treatment was possible in all patients, with 2–5 ml of 3% sodium tetradecyl sulfate administered per session. At the 24-hour and 1-week follow-ups, all treated greater saphenous vein segments were closed following initial treatment, with no flow detectable by continuous wave or color Doppler interrogation. No patients required re-treatment, with all veins remaining closed at 2- to 12-months follow-up. There have been no adverse reactions.
Conclusion. Transcatheter duplex ultrasound-guided sclerotherapy should improve both the safety and efficacy of treatment compared to conventional ultrasound-guided sclerotherapy and offers an alternative to surgical ligation and stripping for those patients wishing to avoid surgery.     

限制性内翻剥脱联合TriVex旋切及泡沫硬化剂治疗下肢静脉曲张（附132例报告）

目的 探讨限制性内翻剥脱联合TriVex旋切及泡沫硬化剂治疗下肢静脉曲张的手术方法及技巧.方法 2010年2月~2012年2月,应用该方法治疗132例下肢静脉曲张,临床病因病理生理解剖分类系统（CEAP）分级为C2~5 Ep/As/Pr的患者.内翻剥脱大隐静脉主干至膝下水平,小腿曲张静脉团结合透光旋切（transilluminated powered phlebectomy,TIPP）及泡沫硬化剂治疗（foam sclerotherapy）.观察术后瘀斑、隐神经缺失、症状改善情况及术后复发率.结果 所有患者术后下肢静脉曲张消失,临床症状缓解,无严重并发症.术后1个月随访,6.1%（8/132）有隐神经缺失症状.术后1年随访,1.7%（2/117）有隐神经缺失症状.无复发病例.结论 限制性内翻剥脱联合TriVex旋切及泡沫硬化剂治疗下肢静脉曲张简单,微创,有效.     

Crossectomy and great saphenous vein stripping

Crossectomy and stripping have been the standard of care for primary great saphenous varicose veins since the high failure rates of sclerotherapy became apparent in the 1970s. As the specialty of venous surgery has evolved, a number of clinical trials have established the optimal methods of surgical treatment, and the clinical benefit of routine stripping. Long-term trials, however, have uncovered a high recurrence rate after varicose vein surgery that approaches 70% after 10 years. There is much debate about whether this is the result of the dilatation of existing tributaries in the groin or the growth of new veins as a result of angiogenesis that follows surgical treatment and healing (neovascularisation). The addition of barrier technology to current crossectomy has the potential to improve the results of surgery in the future. In the meanwhile, new techniques are evolving to obliterate the great saphenous vein, including endovenous laser, radiofrequency ablation and foam sclerotherapy. Randomised clinical trials are urgently required to compare these new treatments against standard surgery, and they will need to focus on whether the short-term gains in reduced convalescence and morbidity are balanced by durable long-term results.     

Stripping the long saphenous vein reduces the rate of reoperation for recurrent varicose veins: five-year results of a randomized trial

OBJECTIVE: The purpose of this study was to investigate the possible long-term clinical advantages of stripping the long saphenous vein during routine primary varicose vein surgery. METHODS: The study was designed as a 5-year, clinical and duplex scan follow-up examination of a group of patients who were randomized to stripping of the long saphenous vein during varicose vein surgery versus saphenofemoral ligation alone. The study was conducted in the vascular unit of a district general hospital. One hundred patients (133 legs) with uncomplicated primary long saphenous varicose veins originally were randomized. After invitation 5 years later, 78 patients (110 legs) underwent clinical review and duplex scan imaging. RESULTS: Sixty-five patients remained pleased with the results of their surgery (35 of 39 stripped vs 30 of 39 ligated; P = .13). Reoperation, either done or awaited, for recurrent long saphenous veins was necessary for three of 52 of the legs that underwent stripping versus 12 of 58 ligated legs. The relative risk was 0.28, with a 95% confidence interval of 0.13 to 0.59 (P = .02). Neovascularization at the saphenofemoral junction was responsible for 10 of 12 recurrent veins that underwent reoperation and also was the cause of recurrent saphenofemoral incompetence in 12 of 52 stripped veins versus 30 of 58 ligated legs. The relative risk was 0.45, with a 95% confidence interval of 0.26 to 0.78 (P = .002). CONCLUSION: Stripping reduced the risk of reoperation by two thirds after 5 years and should be routine for primary long saphenous varicose veins.     

Comparative Study of Duplex-Guided Foam Sclerotherapy and Duplex-Guided Liquid Sclerotherapy for the Treatment of Superficial Venous Insufficiency

PURPOSE: To compare the preliminary results of hemodynamic changes between duplex-guided foam sclerotherapy and duplex-guided liquid sclerotherapy. METHODS: Seventy Seven limbs in 77 patients with isolated greater saphenous vein incompetence were treated with duplex-guided sclerotherapy. Thirty Seven limbs were treated with duplex-guided foam sclerotherapy and the remaining 40 limbs were treated with duplex-guided liquid sclerotherapy. Pretreatment exam was performed using a color duplex scanner and air plethysmography. The sclerosing foam was produced by Tessari's method using 1% and 3% polidocanol. The varicose vein was injected with 2 mL of 1% polidocanol or 1% polidocanol foam, and then 1 mL of 3% polidocanol or 3% polidocanol foam was injected into the greater saphenous vein under duplex guidance. Venous obstruction and recanalization were screened by serial posttreatment duplex examination, and posttreatment air plethysmography analysis was performed 3, 6, 9, and 12 months after the sclerotherapy. RESULTS: Duplex scanning demonstrated complete occlusion in the greater saphenous vein for duplex-guided foam sclerotherapy in 25 limbs (67.6%), which was a significantly higher proportion than for the duplex-guided liquid sclerotherapy (7 limbs, 17.5%, p<0.0001). Recurrent varicose veins were found in 3 patient (8.1%) in the duplex-guided foam sclerotherapy group and 10 (25%) in the duplex-guided liquid sclerotherapy group at 1-year (p=0.048). In duplex-guided foam sclerotherapy, venous filling index values remained normal during the subsequent follow-up examinations, whereas in duplex-guided liquid sclerotherapy, venous filling index began to increase, and there was a significant difference at 6 months between duplex-guided foam sclerotherapy and the duplex-guided liquid sclerotherapy (p<0.0005). At 9 months, there was a significant difference in the residual venous fraction between the two groups, and the residual venous fraction value continued to improve in duplex-guided foam sclerotherapy (p=0.033). CONCLUSIONS: Duplex-guided foam sclerotherapy could have greater promise compared to duplex-guided liquid sclerotherapy in the treatment of superficial venous insufficiency.     

Reflux patterns in the ovarian and hypogastric veins in patients with varicose veins and signs of pelvic venous incompetence

Patients with varicose veins who also had clinical and/or duplex ultrasound findings suspicious of pelvic venous incompetence (PVI) underwent selective retrograde catheter phlebography of the pelvic veins. One hundred and one patients (all female, mean age 49.3 years) underwent selective phlebography of the pelvic veins. In 68 cases (67.3%) a varicose vein recurrence after previous stripping of the greater saphenous vein was present, and about half the patients (n=45, 44.6%) were multipara ( > or =2 episodes of childbirth). The presence and extent of any reflux was documented and the ovarian and pelvic veins affected by the reflux were recorded. Retrograde selective phlebography demonstrated a PVI in 75 patients (74.2%). The left ovarian vein and the right hypogastric vein were most frequently affected by reflux (n = 41, 54.6% each). The left hypogastric vein was incompetent in 35 patients (46.6%) and the right ovarian vein in 3 cases (4%). In about half the patients with pelvic venous incompetence, reflux was demonstrated in more than one of the main pelvic veins (n=38, 50.6%). Fifty-one (68%) of the 75 patients with pelvic venous incompetence had varicose vein recurrence after previous stripping of the greater saphenous vein. Extension of the reflux into varicose veins of the groin or lower leg was demonstrated in 44 patients (58.6%). Thirty-nine patients (52%) received treatment for their pelvic venous incompetence (coil embolisation, sclerotherapy or videoscopic ovarian vein ligation). Pelvic venous reflux was present in 75% of our study population. Combined reflux in more than one pelvic vein was common and in about 60% of cases the pelvic reflux was shown to feed varicose veins of the legs. Therefore, typical clinical and/or duplex findings should lead to a strong suspicion of pelvic venous incompetence and reduce the need for selective retrograde catheter phlebography in this selected group of patients.     

Causes of varicose vein recurrence: late results of a randomized controlled trial of stripping the long saphenous vein

BACKGROUND: The purpose of this study was to investigate the long-term outcomes following stripping of the long saphenous vein during primary varicose vein surgery and to identify factors which may predict recurrence and the need for reoperation. METHODS: The original study was designed as a randomized trial of 100 patients (133 legs) who underwent saphenofemoral ligation with or without long saphenous vein stripping. After invitation 11 years later, 51 patients (74 legs) underwent clinical review and duplex imaging and completed an Aberdeen Varicose Vein Symptom Severity Score (AVVSSS). The hospital notes of the original cohort of patients were used to compile cumulative data and assess predictive factors. RESULTS: A cumulative total of 83 legs had developed clinically recurrent varicose veins by 11 years (62%). There was no statistically significant difference between the ligation-only and the stripping groups. Reoperation was required for 20 of 69 legs that underwent ligation alone compared with 7 of 64 legs that had additional long saphenous vein stripping (relative risk [RR], 2.65; 95% confidence interval, 1.20 to 5.84; P = .012). By life table analysis, freedom from reoperation at 11 years was 70% after ligation, compared with 86% after stripping ( P = .01). The presence of neovascularization (RR, 2.88; P = .15) , an incompetent superficial vessel in the thigh (RR, 3.24; P = .03) or an incompetent saphenofemoral junction on duplex imaging at 2 years postoperatively (RR, 4.89; P = .0001) increased the risk of a patient's developing clinically recurrent veins. Patients with visible recurrent varicose veins had a significantly worse AVVSSS ( P = .001). CONCLUSION: Stripping the long saphenous vein is recommended as part of routine varicose vein surgery as it reduced the risk of reoperation by 60% after 11 years, although it did not reduce the rate of visible recurrent veins.     

Superficial vein surgery and SEPS for chronic venous insufficiency

Venous insufficiency in its severe forms leads to skin changes which, in turn may be treated by surgical therapy. Interventions are directed towards correction of the underlying abnormal venous physiology. This involves removal of varicose veins and ablation of incompetent axial veins and relevant perforating veins. In performing ablation of saphenous vein reflux, techniques include high ligation with stripping, radiofrequency ablation, endovenous laser therapy, and foam sclerotherapy. Incompetent perforator interruption can be accomplished surgically by subfascial endoscopic perforator surgery (SEPS) or controlled sclerotherapy using ultrasound. A variety of techniques have emerged to manage the varicose veins themselves. Surgical treatment of chronic venous insufficiency with high ligation in the groin and inversion stripping of the great saphenous vein to the knee combined with stab avulsion of varicose veins continues to be the standard in treatment of varicose veins. There are few comparisons of sclerotherapy of perforating veins with SEPS, but SEPS has become the most popular of surgical options.     

逆行静脉腔内射频闭合并点状抽剥治疗下肢静脉曲张

目的探讨逆行静脉腔内射频闭合并点状抽剥法治疗下肢静脉曲张的效果。方法本组在2005年3月-2007年5月对25例原发性大隐静脉曲张患者,共38条患肢的曲张大隐静脉采用数控射频静脉闭合系统逆行闭合大隐静脉主干并同时用点状抽剥法治疗小腿散在曲张浅静脉。结果随访1～24个月,所有患者大隐静脉主干均闭合良好,无复发,近期疗效满意。结论逆行静脉腔内射频闭合并点状抽剥法治疗下肢静脉曲张具有术式简便、创伤少、疗效可靠、康复快、住院时间短等优点。     

Indications and technique for sclerotherapy of varicose veins

Sclerotherapy is in general a very safe method for the treatment of teleangiectasias and reticular varicose veins done by an experienced therapist. The complication-rate is very low, with the use of Polidocanol the rate of skin-necrosis ranges between 0.001 and 0.2%, the incidence of superficial thrombophlebitis is 0.08%, the incidence of an allergic reaction is reported with 0.2%. The sclerotherapy of large perforating veins and the long or short saphenous veins is controversially discussed. The results of prospective randomized studies show better results with operative treatment in comparison to sclerotherapy. The recurrence-rate of sclerotherapy of the long saphenous vein varies between 22 and 37% after 3 years, between 40 and 70% after 5 years and 94% after 10 years. Before starting the sclerotherapy the extension of the varicose vein disease should be diagnosed correctly. The diagnosis can be obtained with duplex-ultrasound, that gives either functional and morphologic information about the deep and superficial venous system.     

Long saphenous vein saving surgery for varicose veins. A long-term follow-up

The autologous saphenous vein is widely recognised as the graft material of choice in infra-inguinal arterial reconstructions. This study was undertaken to evaluate the long-term results of long saphenous vein saving surgery compared with standard stripping. Forty-two patients with varicose veins were randomly allocated to treatment, either with standard stripping of the long saphenous vein or high ligation. In both groups, local varicosities were avulsed and insufficient perforators ligated, on the basis of physical examination and phlebography. Follow-up was performed 52 +/- 5 months postoperatively. The recurrence rate was 12 and 11% in the stripping and the high ligation group respectively. At follow-up, the venous return time was increased significantly in both groups (P greater than 0.001). Vein mapping by means of high-resolution, real-time ultrasound at follow-up showed that 78% of the preserved saphenous veins were suitable for use as arterial conduits. These results suggest that removal of the long saphenous vein per se is of no therapeutic value if insufficient perforators have been ligated. It is possible to perform elective vein surgery for varicose veins with good results and preserve the long saphenous vein, which in turn can be used for future arterial reconstruction in most cases.     

High ligation of the greater saphenous vein for treatment of lower extremity varicosities: The fate of the vein and therapeutic results

This study was carried out to determine the subsequent fate of the greater saphenous vein and the efficacy of its high ligation along with surgical excision or sclerotherapy of varicosities. From 1988 to 1990, 22 patients underwent high ligation and sclerotherapy, 22 underwent high ligation and varicose vein excision, and four underwent high ligation alone. There were 36 women and 12 men patients. The average patient age was 48. Sixty limbs were scanned by duplex ultrasound pre- and postoperatively to determine the status of the greater saphenous vein. Average follow-up time was 10 months. Patients and surgeons rated the results of therapy for ablation of varicosities and alleviation of symptoms. Surgical complications were evaluated. At postoperative scan, 47 greater saphenous veins (78%) were found to be completely patent, nine (15%) were thrombosed for a short segment (less than 10 cm) and four (7%) were more significantly thrombosed. Those limbs in which high ligation and sclerotherapy were performed had the highest complete patency rate (96%). Patient and surgeon satisfaction was good to excellent in every case. The only complications were three symptomatic greater saphenous vein thromboses. Although follow-up is relatively brief, complete patency of the ligated greater saphenous vein was found in most cases. High ligation allows preservation of a patent greater saphenous vein, which can be used as an arterial conduit at a later date and gives therapeutic results comparable to stripping without the additional morbidity.Presented at the 16th Annual Meeting of the Peripheral Vascular Surgery Society, June 2, 1991, Boston, Massachusetts.     

Ultrasound-guided foam sclerotherapy combined with sapheno-femoral ligation compared to surgical treatment of varicose veins: early results of a randomised controlled trial.

AIM: This study is a prospective randomised controlled trial comparing sapheno-femoral ligation, great saphenous stripping and multiple avulsions with sapheno-femoral ligation and ultrasound guided foam sclerotherapy to the saphenous vein. Primary end points were patient recovery period and quality of life and secondary end points frequency of complications on the two arms of the trial and the cost of the treatment. MATERIAL AND METHOD: Sixty patients with primary varicose veins due to GSV incompetence and suitable for day case surgery were randomly allocated to undergo ultrasound-guided sclerotherapy with sapheno-femoral ligation under local anaesthesia (n=30) or sapheno-femoral ligation, stripping and multiple avulsions under general anaesthesia (n=30). The study protocol included history, physical examination, assignment of CEAP class and assessment venous clinical severity score (VCSS), completion of the aberdeen vein questionnaire (AVQ) and colour duplex ultrasound. RESULTS: All treatments were completed as intended. Median time to return to normal activities was significantly reduced in the foam sclerotherapy group (2 days) compared to the surgical group (8 days) (p<0.001, Mann-Whitney). AVQ score was also significantly reduced at 3 months by 46% in the sclerotherapy group, and by 40% in the conventional surgery group (p<0.001, Wilcoxon). The time taken to complete treatment was shorter in the foam sclerotherapy plus SFJ ligation group: 45 vs. 85 min (p<0.001, Mann-Whitney). The overall cost of the procedure in the sclerotherapy group ( 672.97 pounds) was significantly less compared to conventional surgery ( 1120.64 pounds). At 3 weeks, there was no statistical difference in the complication rate between the two groups. At 3 months, median CEAP class dropped from four pre-operatively to one following treatment in both groups and the median VCSS score dropped from five to one in group one and from seven to three in group two (p<0.001, Wilcoxon test). In group one four patients (13%) had a recanalised vein which needed further sessions of foam sclerotherapy, resulting in a short-term closure rate of 87%. CONCLUSION: Ultrasound guided sclerotherapy combined with sapheno-femoral ligation was less expensive, involved a shorter treatment time and resulted in more rapid recovery compared to sapheno-femoral ligation, saphenous stripping and phlebectomies.     

Resecting the great saphenous stump with endothelial inversion decreases neither neovascularization nor thigh varicosity recurrence

BACKGROUND: Neovascularization at the saphenofemoral junction is one of the principal causes of recurrent varicose veins after great saphenous vein surgery. Because angiogenic stimulation from the exposed endothelium of the great saphenous vein stump is considered an important trigger for this process, we hypothesized that complete resection of the stump with endothelial inversion might lessen grade 2 groin neovascularization and thereby decrease recurrence of thigh varicosities. METHODS: Two groups of consecutive patients with primary varicose veins of the great saphenous vein were studied. Group A was a historical control group of 70 limbs (48 patients) in which conventional flush ligation was performed at the level of the saphenofemoral junction. Group B was a prospectively studied clinical trial cohort of 65 limbs (45 patients), wherein the great saphenous vein stump was completely resected using a side-biting clamp to isolate the saphenofemoral junction, and the resulting common femoral vein venotomy was closed with a running inverting suture. Early postoperative follow-up was performed at 6 weeks. Clinical examinations and duplex ultrasound scans were performed after 2 years of follow-up. Grade 2 groin neovascularization was defined by the presence of >3 mm tortuous new refluxing veins, typically communicating with recurrent varicosities in the thigh. RESULTS: After 2 years, recurrent varicose veins were present in the thighs of 13 of 65 limbs (20%) in group A and in 22 of 61 limbs (36%) of group B (P = .049). Grade 2 neovascularization was present at the saphenofemoral junction in six of 65 limbs (9%) of group A and in 12 of 61 limbs (20%) of group B (P = .127). CONCLUSION: Complete resection of the great saphenous vein stump and inversion suturing of the common femoral vein venotomy, instead of simple flush ligation at the level of the saphenofemoral junction, do not appear to decrease grade 2 neovascularization and related thigh varicosity recurrence after great saphenous vein stripping for primary varicose veins.     

Efficacy and safety of great saphenous vein sclerotherapy using standardised polidocanol foam (ESAF): a randomised controlled multicentre clinical trial.

AIM: To assess the safety and efficacy of sclerotherapy of the great saphenous vein (GSV) comparing standardised polidocanol foam to liquid polidocanol in a randomised controlled trial (RCT). METHODS: A multicentre randomised controlled clinical trial was carried out in which saphenous trunks were treated by sclerotherapy. 106 patients with primary varicose veins due to an incompetent GSV were treated with either standardised 3% polidocanol foam or 3% liquid polidocanol. The primary efficacy criterion was elimination of reflux (<0.5 sec) measured 3 cm below the sapheno-femoral junction (SFJ) by duplex ultrasonography 3 months after the last injection. RESULTS: A significantly greater number of patients were successfully treated by foam sclerotherapy resulting in 69% elimination of reflux compared to 27% patients treated with liquid sclerosant. The secondary endpoints of vein occlusion, reflux time, refilling time and patient satisfaction also improved significantly more in the foam group. The mean number of treatment sessions was 1.3 in the foam group compared to 1.6 in the liquid group. Differences between study centres occurred with a mean of 96% reflux elimination in 6 centres versus 39% in 4 other centres. Centres with a high response rate injected a higher mean volume (4.3 vs. 3.6 ml) in the first session in a vein with a smaller diameter (7.5 mm vs. 8.4 mm). No difference in adverse drug reactions was observed between treatment groups. CONCLUSIONS: Standardised 3% polidocanol foam is more efficient and equally safe compared to 3% liquid polidocanol for treatment of GSV. In comparison to other studies a relatively small volume was injected into relatively large veins.     

Patterns of venous insufficiency in patients with varicose veins

The nature and distribution of venous disease surrounding the development of varicose veins and its treatment is controversial. Using duplex ultrasonography, we evaluated 54 lower extremities in 32 patients with varicose veins who were symptomatic and had obvious varicose veins by clinical examination. Twenty-eight percent had greater saphenous trunk incompetence, 2% had lesser saphenous trunk incompetence, and 96% had branch disease. Deep valvular incompetence was seen in 41%, saphenofemoral junction incompetence in 46%, and incompetence of one or more perforators in 46% of the extremities. Thirty-three percent demonstrated no evidence of associated saphenofemoral junction, deep vein, or perforating vein incompetence, while 20% had concurrent saphenofemoral junction, deep vein, and perforating vein incompetence. These data support the heterogeneity of venous disease seen in patients with varicose veins and suggest that surgical therapy be directed to a patient's specific pattern of incompetence rather than routine saphenofemoral junction ligation or stripping of the greater saphenous trunk.     

保留大隐静脉膝上主干行静脉曲张手术可行性分析

目的探讨在大隐静脉曲张手术中保留膝上主干的可行性。 方法选取2013年8月至2014年10月于本院进行治疗的60例大隐静脉曲张患者,随机分为试验组和对照组,各30例。对试验组临床不同分期的大隐静脉曲张患者行保留膝上主干的剥脱术,对照组行传统大隐静脉高位结扎+剥脱术方式。随访观察两组试验对象的预后情况。 结果试验组在疼痛评分、手术时间、出血量、住院时间、血肿例数等指标上显著优于对照组（t=3.268、4.325、5.670、5.931、χ²=3.547,P<0.01）,而深静脉血栓、静脉炎、复发率、血管内皮细胞生长因子（VEGF）、白细胞介素1（IL-1）水平两组对比差异无统计学意义。保留后的大隐静脉主干除腔内血流速度较术前减慢外（t=10.87,P<0.01）,其管径、通畅度、隐股瓣膜功能、并发血栓等对比差异无统计学意义。 结论相对于传统手术方式,保留大隐静脉膝上主干手术并未增加术后并发症发生率,由于其保留了大隐静脉主干,为大隐静脉曲张手术方式的多样性提供理论依据,为保留自身血管材料防治血管疾病,行血管库储备可行性提供了数据支持。     

高位结扎并点式微创剥脱术治疗原发性下肢静脉曲张

目的探讨高位结扎并点式微创剥脱术治疗原发性下肢静脉曲张的临床效果。方法 2006年10月～2009年6月,对原发性大、小隐静脉曲张236例,术前应用彩色多普勒超声进行CEAP分类诊断,定位标记病变曲张浅静脉及贯通静脉走行,在静脉麻醉联合局部浸润麻醉下行高位结扎剥脱术,局部做1～3mm小切口,用静脉钩取出局部曲张血管或结扎功能不全的贯通静脉。结果 236例术后切口均正常愈合,曲张静脉全部消失,186例下肢浮肿术后1个月消退,40例术后3个月内皮肤色素沉着消退,10例下肢皮肤溃疡于2个半月全部愈合。无深静脉血栓及肺动脉栓塞等严重并发症,209例随访0.5～3年,平均12个月,无复发。结论术前彩色多普勒标记定位大、小隐静脉高位结扎并点式微创剥脱术治疗效果良好,具有损伤小、恢复快、治疗彻底、术后皮肤美观等优点。     

Comparison of Clinical Outcome of Stripping and CHIVA for Treatment of Varicose Veins in the Lower Extremities

The purpose of this nonrandomized case-review study was to compare the outcome of stripping and CHIVA for treatment of varicose veins in the lower extremities in our department. Outcome was evaluated by independent physicians. A total of 85 patients underwent saphenous vein stripping in association with phlebectomy and 90 patients underwent CHIVA cure. The duration of follow-up was 3 years. Study criteria were (1) presence of varicose veins as a cause of failure (1.1% in the CHIVA group vs. 15.3% in the stripping group), (2) appearance of telangiectasia (8.9% in the CHIVA group vs. 65.9% in the stripping group), (3) patient dissatisfaction rate (3.3% in the CHIVA group vs. 16.5% in the stripping group), (4) postoperative symptoms as a cause of failure (1.1% in the CHIVA group vs. 21.2% in the stripping group), and (5) saphenous nerve injury (1 patient in the CHIVA group vs. 16 in the stripping group). Differences between all five criteria were significantly in favor of the CHIVA group as compared to saphenous vein stripping with phlebectomy. Clinical results at 3 years are better for patients treated with CHIVA than stripping with regard to presence of varicose veins, clinical symptoms, presence of telangiectasia, cosmetic satisfaction, and neurologic complications. Data in our series of CHIVA treatments are comparable to those reported in the literature and better than those described in three series of stripping procedures with 3-year follow-up. A prospective randomized study is now underway to confirm these findings.     

Where does venous reflux start?

Purpose: This study was designed to identify the origin of lower limb primary venous reflux in asymptomatic young individuals and to compare patterns of reflux with age-matched subjects with prominent or clinically apparent varicose veins.Methods: Forty age- and sex-matched subjects with no symptoms (age, 15 to 35 years; 80 limbs; group A), 20 subjects (age, 19 to 32 years; 40 limbs) with prominent but nonvaricose veins (n = 26 limbs; group B), and 50 patients (age, 17 to 34 years; 100 limbs) with varicose veins (n = 64; group C) were examined with color flow duplex imaging. All proximal veins (above popliteal skin crease), superficial, perforator, and deep, in the lower limb were examined in the standing position, and all the distal veins in the sitting position. Patients who had a documented episode of superficial or deep vein thrombosis, previous venous surgery, or injection sclerotherapy were excluded from the study.Results: The prevalence of reflux in group A was 14% (11 of 80), in group B 77% (31 of 40), and in group C 87% (87 of 100). In more than 80% of limbs in the three groups, reflux was confined to the superficial veins alone. Deep venous reflux or combined patterns of reflux were uncommon even in group C. Reflux was detected in all segments of the saphenous veins and their tributaries. In the 125 limbs that had superficial venous incompetence, the below-knee segment of the greater saphenous vein was the most common site of reflux (85, 68%), followed by the above-knee segment of greater saphenous vein (69, 55%) and the saphenofemoral junction (41, 32%). Nonsaphenous reflux was rare (3, 2.4%). Reflux in the lesser saphenous vein (21, 17%) was seen in all groups, whereas involvement of both greater and lesser saphenous veins (8, 6.4%) was seen in group C alone. The incidence of multisegmental reflux was significantly higher in group C (61 of 64, 95%) than in group A (two of 11, 18%) or group B (14 of 26, 54%). The prevalence of distal reflux was comparable in all groups.Conclusions: Primary venous reflux can occur in any superficial or deep vein of the lower limbs. The below-knee veins are often involved in asymptomatic individuals and in those who have prominent or varicose veins. These data suggest that reflux appears to be a local or multifocal process in addition to or separate from a retrograde process. (J Vasc Surg 1997;26:736-42.)