射频消融治疗大隐静脉曲张的近期有效性及安全性

目的观察射频消融(RFA)治疗大隐静脉曲张的近期有效性及安全性。方法回顾性分析接受超声引导下RFA治疗的17例大隐静脉曲张患者(26条患肢)术前1周、术后即刻及术后1、3、6个月临床资料。结果 26条患肢中,术后即刻及术后1、3、6个月大隐静脉闭塞率均为100%(26/26)。术后3、6个月患肢活动能力较术前1周好转(P均0.05),术后6个月疼痛程度较术前1周缓解(P0.05)。术后1、3、6个月患肢临床-病因-解剖-病理生理(CEAP)临床分级及修订版静脉临床严重程度评分(rVCSS)与术前1周比较分级均降低(P均0.01)。术后6个月内7条患肢发生皮下条索僵硬静脉,1条隐股点不适,3条皮下出血。结论 RFA治疗大隐静脉曲张近期疗效好,且并发症少。     

Deep venous thrombosis after radiofrequency ablation of greater saphenous vein: a word of caution

PURPOSE: Radiofrequency ablation (RFA) of the greater saphenous vein (GSV; "closure") is a relatively new option for treatment of venous reflux. However, our initial enthusiasm for this minimally invasive technique has been tempered by our preliminary experience with its potentially lethal complication, deep venous thrombosis (DVT). METHODS: Seventy-three lower extremities were treated in 66 patients with GSV reflux, between April 2003 and February 2004. There were 48 (73%) female patients and 18 (27%) male patients, with ages ranging from 26 to 88 years (mean, 62 +/- 14 years). RFA was combined with stab avulsion of varicosities in 55 (75%) patients and subfascial ligation of perforator veins in 6 (8%) patients. An ATL HDI 5000 scanner with linear 7-4 MHz probe and the SonoCT feature was used for GSV mapping and procedure guidance in all procedures. GSV diameter determined the size of the RFA catheter used. Veins less than 8 mm in diameter were treated with a 6F catheter (n = 54); an 8F catheter was used for veins greater than 8 mm in diameter (n = 19). The GSV was cannulated at the knee level. The tip of the catheter was positioned within 1 cm of the origin of the inferior epigastric vein (first GSV tributary). All procedures were carried out according to manufacturer guidelines. RESULTS: All patients underwent venous duplex ultrasound scanning 2 to 30 days (mean, 10 +/- 6 days) after the procedure. The duplex scans documented occlusion of the GSV in 70 limbs (96%). In addition, DVT was found in 12 limbs (16%). Eleven patients (92%) had an extension of the occlusive clot filling the treated proximal GSV segment, with a floating tail beyond the patent inferior epigastric vein into the common femoral vein. Another patient developed acute occlusive clots in the calf muscle (gastrocnemius) veins. Eight patients were readmitted and received anticoagulation therapy. Four patients were treated with enoxaparin on an ambulatory basis. None of these patients had pulmonary embolism. Initially 3 patients with floating common femoral vein clots underwent inferior vena cava filter placement. Of the 19 limbs treated with the 8F RFA catheter, GSV clot extension developed in 5 (26%), compared with 7 of 54 (13%) limbs treated with the 6F RFA catheter (P =.3). No difference was found between the occurrence of DVT in patients who underwent the combined procedure (RFA and varicose vein excision) compared with patients who underwent GSV RFA alone (P =.7). No statistically significant differences were found in age or gender of patients with or without postoperative DVT (P = NS). CONCLUSION: Patients who underwent combined GSV RFA and varicose vein excision did not demonstrate a higher occurrence of postoperative DVT compared with patients who underwent RFA alone. Early postoperative duplex scans are essential, and should be mandatory in all patients undergoing RFA of the GSV.     

Popliteal vein thrombosis after radiofrequency ablation of greater saphenous vein for varicose vein

Percutaneous endovenous techniques, such as radiofrequency ablation (RFA), have become the preferred method for treatment for varicose veins associated with great saphenous vein (GSV) insufficiency. Reports have shown safety and efficacy of these techniques with relatively few complications. Deep venous thrombosis after RFA is rare and usually involves extension of thrombus from great saphenous vein to common femoral vein, hence the requirement for postoperative ultrasound. We report a case of symptomatic popliteal vein thrombosis after RFA of GSV requiring anti-coagulation.     

Ultrasound findings after radiofrequency ablation of the great saphenous vein: descriptive analysis

OBJECTIVE: As an emerging endovascular alternative to ligation and stripping of the incompetent greater saphenous vein (GSV), radiofrequency ablation was monitored with ultrasound scanning to evaluate anatomic results. Neovascularization and inflammation are potential consequences that lead to the appearance of small vessels. The natural history of the below-knee untreated GSV segment may be important in our understanding of ongoing chronic venous disease. An ultrasound follow-up study was conducted to determine the prevalence of small vessel networks, defined as veins and arteries less than 2 mm in diameter, adjacent to the saphenofemoral junction (SFJ); prevalence of small vessel networks adjacent to the treated GSV in the thigh; and fate of the below-knee untreated GSV distal to the ablated segment. METHODS: One hundred six extremities with radiofrequency ablation of the GSV for treatment of superficial venous insufficiency were followed up with high-resolution ultrasound imaging 4 to 25 months (median, 9 months) after the procedure. Ninety-three limbs had concomitant ligation and division of the SFJ and its tributaries, and 13 limbs underwent radiofrequency ablation without SFJ ligation. Ultrasound was used to evaluate patients for small vessel networks, and concomitant findings of small vessel networks and recanalization at the SFJ and adjacent to the treated GSV. The status of the below-knee segment of untreated GSV was evaluated for patency and reflux. Data analysis compared the findings in the ligation group with those in the no-ligation group, with the chi 2 test and Fisher exact test. RESULTS: We found small vessel networks in 65% (n = 69) of extremities: 15% (n = 16) at the SFJ only, 26% (n = 28) in the thigh only, and 24% (n = 25) at both the SFJ and thigh, resulting in a small vessel network prevalence of 39% (n = 41) at the SJF and 50% (n = 53) in the thigh. The prevalence of small vessel networks at the SFJ was significantly less after radiofrequency ablation with SFJ ligation (34%, 32 of 93) than after radiofrequency ablation without ligation (69%, 9 of 13; P = .035). Small vessel networks and GSV recanalization at the SFJ was more common in patients undergoing radiofrequency ablation without ligation (46%, 6 of 13) than after radiofrequency ablation with ligation (14%, 13 of 93; P = .014). The prevalence of small vessel networks in the thigh was not affected by SFJ ligation. The below-knee GSV was patent in 79% (84 of 106), and 58% (61 of 106) demonstrated reflux, a decrease from the pre-radiofrequency ablation rate of 71% (75 of 106), possibly because thrombosis extended distally beyond the ablated segment in 16% (17 of 106) of the legs. CONCLUSIONS: Small vessel networks were detected adjacent to or in connection with most of the radiofrequency ablation-treated GSVs. SFJ ligation was associated with fewer small vessel networks and proximal GSV recanalization. Most below-knee untreated GSV segments remained patent, and most exhibited reflux.     

Endoluminal radiofrequency ablation of the great saphenous vein versus stripping. A preliminary study

AIM: To compare the postoperative courses of patients subjected to closure procedure or stripping of the great saphenous vein (GSV). METHODS: We examined 2 groups of 15 patients with ostial and truncular saphenous insufficiency matched for CEAP clinical and anatomic classes. Group A patients underwent saphenous closure; short stripping was performed on those of Group B. In the Group A surgery was performed under spinal (12) or local (3) anesthesia; the procedure was preceded by crossotomy (5), crossectomy (1) or saphenous ligation (8); in 11 cases micro-phlebotomies were associated. In the Group B surgery was performed under general (5), spinal (7) or local (3) anesthesia; the procedure always was preceded by crossectomy (1); in 11 cases micro-phlebotomies were associated. RESULTS: Group A patients were discharged 6-18 hours after surgery. None presented ecchymosis, hyperemia or skin lesions. Five complained of mild aching thigh pain, which did not require pain medication. All resumed normal daily activities the day after surgery and returned to work after 4.9 days. Six months after surgery, none of the patients had evidence of saphenous vein re-channeling. Group B patients were discharged 12-18 hours after surgery. Nine had ecchymosis on the thigh. Five reported mild thigh pain requiring analgesics. Normal daily activities and work were resumed 2.7 and 9.3 days after surgery. CONCLUSIONS: This retrospective study seems to confirm that endoluminal radiofrequency ablation of the GSV provides good immediate results with no significant complications and can reduce postoperative pain and the length of convalescence with respect to those of stripping.     

Chronic venous insufficiency due to great saphenous vein incompetence treated with radiofrequency ablation: an effective and safe procedure in the elderly

Chronic venous insufficiency (CVI) with the resultant clinical sequelae significantly reduces quality of life. Most elderly patients with CVI are treated nonoperatively owing to concerns of increased operative risk and therefore suffer more advanced disease. Radiofrequency ablation (RFA) has emerged as a minimally invasive procedure to treat patients with superficial venous insufficiency (SVI) due to great saphenous vein (GSV) incompetence. The purpose of this study was to review our experience using RFA of the GSV to treat CVI due to superficial disease in elderly patients compared to younger patients in terms of procedure-related morbidity and severity of disease at time of treatment. RFA treatment of the GSV was performed in 490 extremities of 421 patients with SVI between March 2001 and December 2002. Indications, medical history, and outcome (operative complications and hospital stay) were compared between 2 groups: Group I:41 extremities of 35 patients, 70 years if age or older (mean 75 +/-4); and Group II:449 limbs of 386 patients younger than 70 years (mean 47 +/-11). The incidence of skin pigmentation and healed/nonhealed ulcers (CEAP 4-6) was significantly higher in the elderly than in the younger group (41% vs 16%, p <0.05). Hypertension, diabetes, and previous myocardial infarction were 2.8, 5.4, and 6.7 times more prevalent in the elderly (p <0.05), respectively. There were no major postoperative complications in either group; 97% of all patients were discharged on the day of operation and there was no difference between the 2 groups in overnight hospital stay. There is a treatment bias against operative management in elderly patients with SVI, as evidenced by their more advanced disease at the time of definitive treatment than their younger cohort. However, operative morbidity is no different compared to the younger subset. RFA is a safe and effective procedure for older patients; therefore, the threshold for operative management of older patients should be lowered.     

保留主干的激光闭合术治疗下肢静脉功能不全

目的 探讨保留上段主干的腔内激光闭合术(EVLA)在慢性静脉功能不全(CVI)治疗中的应用.方法 将术前经Doppler超声和光电容积描记法证实隐股瓣膜无反流且大隐静脉根部直径小于或等于8 mm的63例(71条肢体)CVI患者分成两组:保留组(35例,38条肢体)和非保留组(28例,33条肢体),分别实施保留和不保留大隐静脉上段主干的EVLA术,对两组的临床疗效、复发率和并发症发生率进行比较.结果 保留组的手术耗时少于非保留组[(17.5±4.3)min vs(22.7±5.6)min,P＜0.01)];保留组隐神经损伤比例低于非保留组(2/38 vs 4/33,P＜0.05);两组的Aberdeen评分改善值和住院天数基本相当,且组织灼伤、皮下硬结、瘀斑等并发症发生率在两组间比较,差异无统计学意义(P＞0.05),两组均未出现肺栓塞等严重并发症.结论 保留大隐静脉上段主干的EVLA是治疗下肢静脉功能不全安全有效的微创手术方法.     

静脉剥脱导管大隐静脉主干剥脱术与腔内微波消融术治疗大隐静脉曲张的临床疗效

目的 探讨静脉剥脱导管大隐静脉主干剥脱术与腔内微波消融术治疗大隐静脉曲张患者的疗效及安全性.方法 选取河北医科大学第一医院2021年1—6月收治的80例大隐静脉曲张患者,根据治疗方法不同分将患者分为观察组与对照组,每组40例,对照组患者实施静脉剥脱导管大隐静脉主干剥脱术,观察组患者实施微波大隐静脉主干消融闭合术.观察两...     

Neovascularization after great saphenous vein ablation.

OBJECTIVE: To determine the prevalence, distribution, and flow characteristics of intraluminal neovascularization in patients undergoing great saphenous vein (GSV) endovenous laser (EVLT) or radiofrequency ablation (RFA). METHODS: Duplex ultrasound (DU) was performed in patients undergoing EVLT or RFA before, during, and after their procedures. Follow-up included assessment for deep venous thrombosis and obliteration. When new vessels were identified, the source, extent, direction, and location of flow were noted. Flow channel diameters were measured and the resistivity index (RI) was used to characterize the flow patterns. RESULTS: A total of 102 venous ablations were performed of which 46 were RFA, and 56 EVLT. Arterio-venous fistulae (AVF) were found in five patients that were not identified by DU prior to intervention. Involved segments had variable length and multiple channels (mean diameter 2.2mm). No patient had local or systemic symptoms related to the AVF. The mean RI was 0.42, consistent with an AVF. The perivenous arteries feeding the AVF had enhanced flow but a significantly higher RI (0.63, p<0.001). CONCLUSION: Multiple small vessels were found directly adjacent to the involved vein segments forming small AVF within the obliterated vein. The prevalence of AVF in the ablated GSV was 5%. This process may be responsible for recanalization or recurrence after endovenous ablation procedures.     

日间手术模式下腔内射频消融术与静脉剥脱导管主干剥脱术治疗大隐静脉曲张疗效比较

目的 比较日间手术模式下大隐静脉腔内射频消融术与静脉剥脱导管主干剥脱治疗大隐静脉曲张的安全性及有效性.方法 收集2020年2月至2021年1月大连市金州区第一人民医院收治的84例行日间手术的大隐静脉曲张患者的临床资料,根据手术方式的不同将患者分为射频组(n=44,采用大隐静脉主干射频消融术+小腿浅表静脉泡沫硬化+部分小...     

The great saphenous vein for central venous access and haemodialysis

Background. Utilising an open surgical technique the Great Saphenousvein in the proximal thigh can be used for the insertion ofcentral venous catheters for haemodialysis. This approach issafe and efficacious, and may be performed under local or generalanaesthesia. This technique is of particular importance in patientsrequiring vascular access for haemodialysis in whom the uppercentral veins are stenosed and the femoral vessels are not amenableto percutaneous cannulation. Methods. The Great saphenous vein is exposed via a surgicalincision in the thigh. The central venous catheter is then insertedand advanced until in the desired position, as confirmed onfluoroscopy. Results. Seven Great saphenous catheters were placed over aperiod of six months. All catheters insertions were technicalsuccesses with completion of at least one dialysis session.Primary patency rates were 57%, 49%, 23% at 30, 60 and 90 daysrespectively. Conclusion. The great saphenous vein offers an additional sitefor the insertion of central venous catheters. These data demonstrateequivalence in patency between this novel technique and percutaneousfemoral vein cannulation.     

Clinical and hemodynamical findings in legs with previous surgery of the great saphenous vein: role of the small saphenous vein

AIM: To assess the role of small saphenous vein (SSV) reflux in patients with a long history of varicose disease and previous stripping of the great saphenous vein (GSV). METHODS: Consecutive patients with a history of GSV stripping 5-19 years earlier were enrolled in this prospective clinical study. A total of 101 legs of 75 consecutive patients fulfilled the study criteria: previous stripping of GSV from ankle to groin at least 5 years earlier, no history of thromboembolism and no previous surgery of deep veins or SSV. All patients were studied clinically using standardized classifications: clinical class, clinical disability score (CDS) and venous clinical scoring system (VCSS). Colour flow duplex imaging (CFDI) was used to assess reflux in deep and superficial veins. Details of prior surgery were evaluated. RESULTS: Overall, SSV reflux was noted in 28 (28%) of the legs, recurrent GSV (rGSV) in the thigh in 41 (41%), reflux in tributaries alone in 28 (28%) and a combination of SSV and rGSV reflux in 4 (3%). Segmental deep reflux was measured in 23 (23%) of the legs; the prevalence of deep reflux was significantly higher in complicated than in uncomplicated legs (12% versus 47%; P<0.05). Deep reflux was more frequently associated with SSV reflux than with rGSV reflux (50% versus 22%; P<0.05). The prevalence of SSV with or without deep reflux increased from 17% to 50% (P<0.05) when uncomplicated (C2-3) and complicated (C4-6) legs were compared. A similar increase was not seen in the legs with rGSV (39% versus 44%; P>0.05). SSV reflux without deep reflux was observed in 25% of the legs with complicated (C4-6) disease, whereas the prevalence of SSV reflux was low (9%) in uncomplicated (C2-3) legs. VCSS was higher in the legs with SSV reflux than in those with rGSV reflux. CDS scores tended to be higher in the SSV reflux group than in the legs with rGSV reflux or tributary reflux alone. After exclusion of deep reflux, the results remained at the same level. CONCLUSION: Small saphenous vein (SSV) reflux is common in legs with recurrent varicose veins and previous stripping of the GSV. SSV reflux alone is frequent in complicated legs, and SSV reflux is typically associated with segmental deep reflux. Clinical and hemodynamical findings stress the role of SSV reflux in this selected venous population.     

Endovenous laser therapy and radiofrequency ablation of the great saphenous vein: analysis of early efficacy and complications

BACKGROUND: Endovenous laser therapy (EVLT) and radiofrequency ablation (RFA) are new, minimally invasive percutaneous endovenous techniques for ablation of the incompetent great saphenous vein (GSV). We have performed both procedures at the Mayo Clinic during two different consecutive periods. At the time of this report, no single-institution report has compared RFA with EVLT in the management of saphenous reflux. To evaluate early results, we reviewed saphenous closure rates and complications of both procedures. METHODS: Between June 1, 2001, and June 25, 2004, endovenous GSV ablation was performed on 130 limbs in 92 patients. RFA was the procedure of choice in 53 limbs over the first 24-month period of the study. This technique was subsequently replaced by EVLT, which was performed on the successive 77 limbs. The institutional review board approved the retrospective chart review of patients who underwent saphenous ablation. According to the CEAP classification, 124 limbs were C2-C4, and six were C5-C6. Concomitant procedures included avulsion phlebectomy in 126 limbs, subfascial endoscopic perforator surgery in 10, and small saphenous vein ablation in 4 (EVLT in 1, ligation in 1, stripping in 2). Routine postoperative duplex scanning was initiated at our institution only after recent publications reported thrombotic complications following RFA. This was obtained in 65 limbs (50%) (54/77 [70%] of the EVLT group and 11/53 [20.8%] of the RFA group) between 1 and 23 days (median, 7 days). RESULTS: Occlusion of the GSV was confirmed in 93.9% of limbs studied (94.4% in the EVLT [51/54] and 90.9% in the RFA group [10/11]). The distance between the GSV thrombus and the common femoral vein (CFV) ranged from -20 mm (protrusion in the CFV) to +50 mm (median, 9.5 mm) and was similar between the two groups (median, 9.5 mm vs 10 mm). Thrombus protruded into the lumen of the CFV in three limbs (2.3%) after EVLT. All three patients were treated with anticoagulation. One received a temporary inferior vena cava filter because of a floating thrombus in the CFV. Duplex follow-up scans of these three patients performed at 12, 14, and 95 days, respectively, showed that the thrombus previously identified at duplex scan was no longer protruding into the CFV. No cases of pulmonary embolism occurred. The distance between GSV thrombus and the saphenofemoral junction after EVLT was shorter in older patients (P = .006, r(2) = 0.13). The overall complication rate was 15.4% (20.8% in the EVLT and 7.6% in the RFA group, P =.049) and included superficial thrombophlebitis in 4, excessive pain in 6 (3 in the RFA group), hematoma in 1, edema in 3 (1 in the RFA group), and cellulitis in 2. Except for two of the three patients with thrombus extension into the CFV, none of these adverse effects required hospitalization. CONCLUSION: GSV occlusion was achieved in >90% of cases after both EVLT and RFA at 1 month. We observed three cases of thrombus protrusion into the CFV after EVLT and recommend early duplex scanning in all patients after endovenous saphenous ablations. DVT prophylaxis may be considered in patients >50 years old. Long-term follow-up and comparison with standard GSV stripping are required to confirm the durability of these endovenous procedures.