Foam sclerotherapy for the treatment of superficial venous insufficiency

Foam sclerotherapy has been refined over the past decade to become a safe and effective treatment for varicose veins and venous insufficiency. Using duplex ultrasound guidance, it can be used to treat large and small varicosities, saphenous trunks, incompetent perforating veins, and venous stasis ulcerations. Serious complications are rare, and in experienced hands, efficacy rivals that of traditional surgical ligation and stripping. Disadvantages of the technique are the need in many cases for more than one treatment session, and lack of US Food and Drug Administration approval of all currently available sclerosants. Foam sclerotherapy offers advantages of low cost, quick patient recovery, and ease of use; as such, it is an important tool for modern vein treatment.     

Initial experience of subfascial endoscopic perforator vein surgery in patients with severe chronic venous insufficiency

Subfascial Endoscopic Perforator Surgery (SEPS) is a foolproof method of treatment of perforating veins reflux without direct surgical manipulation in the area of trophic disturbances. In this paper, we present initial case series, consisted of 5 patients with severe chronic venous insufficiency (CEAP classes C4-C6), SEPS being used in complex treatment. The criteria used for selection of the patients for SEPS was presence of incompetent perforating veins in the area of trophic disturbances, confirmed by duplex scanning of the venous system. Dual-port SEPS technique with using of space-maker was performed in combination with high ligation and below-knee stripping of long saphenous vein. No early postoperative complications related to SEPS were noted. Healing of all active venous ulcers among patients in class C6 and decrease of clinical severity score in all cases were achieved during follow-up period ranged from 2 to 13 months. Results of treatment in the presented case series confirm high effectiveness of SEPS in severe chronic venous insufficiency.     

内镜下深筋膜下交通支离断术治疗老年下肢慢性静脉性溃疡

目的 :探讨电视内镜下深筋膜下交通支静脉离断术治疗老年下肢慢性静脉性溃疡的可行性。方法 :大隐静脉曲张 6例 (10条肢体 ) ,同时存在浅静脉倒流、交通支静脉功能不全和静脉性溃疡 ,4条肢体深静脉功能不全。手术方法为高位结扎大隐静脉 ,分段抽剥 ,内镜下行深筋膜下交通支离断术 ,1例行股静脉戴戒术。结果 :术后肢体症状和浅静脉曲张消失 ,肢体溃疡或皮炎 3周内愈合。结论 :内镜下深筋膜下交通支结扎术具有微创、有效的特点 ,是治疗下肢静脉功能不全性溃疡的有效方法     

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.     

Subfascial endoscopic perforator vein surgery: who benefits?

The advent of minimally invasive endoscopic surgery has rekindled interest in perforator vein ligation. Subfascial endoscopic perforator vein surgery (SEPS) utilizes techniques to interrupt incompetent perforators under direct vision using an endoscopic videocamera and instrumentation placed through small ports remote from the active ulcer or area of diseased skin. The safety and early efficacy of SEPS has been established in several studies, and it yields lower wound complication rates than observed with open surgical techniques such as the Linton procedure. Available results confirm the superiority of SEPS over open perforator ligation, but do not address the its role in the surgical treatment of advanced chronic venous insufficiency (CVI) and venous ulceration. Ablation of superficial reflux by high ligation and stripping of the greater saphenous vein with avulsion of branch varicosities is concomitantly performed in the majority of patients undergoing SEPS. The clinical and hemodynamic improvements attributable to SEPS thus are difficult to ascertain. As with open perforator ligation, clinical and hemodynamic results are better in patients with primary valvular incompetence (PVI) than in those with the postthrombotic (PT) syndrome. Until prospective, randomized, multicenter clinical trials are carried out to answer lingering questions regarding the efficacy of SEPS, the procedure is recommended in patients with advanced CVI secondary to PVI of superficial and perforating veins, with or without deep venous incompetence. The performance of SEPS in patients with PT syndrome remains controversial.     

内镜筋膜下交通静脉结扎治疗慢性下肢静脉性溃疡的临床体会

目的:探讨内镜筋膜下交通静脉结扎术(subfascial endoscopic perforator surgery,SEPS)治疗慢性下肢静脉性溃疡的临床效果。方法:回顾分析78例,86条下肢慢性静脉性溃疡患者行内镜深筋膜下交通静脉离断+大隐静脉高位结扎并抽剥术的临床资料。结果:患者术后均恢复良好,浅静脉曲张消失,溃疡愈合,未发生明显并发症,随访1~3年,无皮肤溃疡及浅静脉曲张复发。结论:大隐静脉高位结扎剥脱术+SEPS治疗下肢静脉性溃疡有效,患者创伤小、康复快,效果好。     

Radiofrequency ablation of the long saphenous vein without high ligation versus high ligation and stripping for primary varicose veins: pros and cons

Primary varicose vein disease is prevalent in our society, and although it is infrequently the cause of serious venous insufficiency, it often is associated with symptoms of local discomfort. These symptoms eventually may outweigh any cosmetic concerns of patients with this disease. Greater saphenous vein (GSV) reflux is the most important pathophysiologic component of primary venous insufficiency. To date, the surgical treatment of GSV reflux has evolved into 1 of 3 procedures: high ligation of the saphenofemoral junction, with or without perforator ligation; high ligation and stripping of the GSV; and high ligation with retrograde sclerotherapy of the GSV. High ligation and stripping of the GSV to below the knee enjoys the most durable success yet is associated with significant perioperative morbidity. A new treatment, radiofrequency ablation of the GSV without high ligation, recently has been described and promises a less invasive alternative to stripping with decreased morbidity and increased patient acceptance. The results of high ligation and stripping of the GSV will be compared with those with radiofrequency ablation of the GSV without high ligation.     

冷光源引导下泡沫硬化剂注射小腿曲张浅静脉在下肢静脉溃疡治疗中的应用探讨

目的探讨冷光源引导下泡沫硬化剂注射小腿曲张浅静脉联合腔镜深筋膜下交通支静脉离断术(SEPS)及大隐静脉高位结扎抽剥术治疗下肢交通静脉功能不全所致的静脉溃疡中的作用效果。 方法选取2012年6月至2013年5月就诊的42例(46条患肢)小腿交通静脉功能不全合并浅静脉曲张的静脉溃疡患者,行SEPS术及大隐静脉高位结扎抽剥术,并在SEPS术的冷光源引导下行小腿曲张静脉泡沫硬化剂注射术。 结果共注射263条曲张浅表静脉。随访期间所有患者静脉溃疡均愈合。9例患者的9条下肢(9/46,19.57%)在术后4周内出现局部疼痛,口服止疼药可缓解。22例患者的24条下肢(24/46,52.17%)共46条静脉(46/263,17.49%)在术后1 ~ 2周出现沿治疗曲张静脉行程的黄褐色色素沉着,于3 ~ 6个月内自行消失。3例患者3条下肢(3/46,6.52%)共11条静脉(11/263, 4.18%)在治疗后1周出现沿曲张静脉分布的红、热、痛和压痛,诊断为浅表性静脉炎,外用多磺酸黏多糖乳膏后缓解。经过注射的263条曲张静脉中,245条(245/263,93.16%)达到治疗成功标准,18条(18/263,6.84%)达到部分成功标准,无一条静脉未成功注射。 结论冷光源引导下的小腿曲张静脉泡沫硬化剂注射联合SEPS术及大隐静脉高位结扎抽剥术是良好的治疗交通静脉功能不全所致静脉溃疡的方法,其长期作用效果有待进一步观察。     

Foam sclerotherapy for the treatment of varicose veins

Treatment of venous insufficiency with liquid sclerotherapy is considered by some to be an unfulfilled promise. It was heralded in the first half of the last century to be a replacement for surgery, but as recurrences of varicose veins appeared in limbs treated with injection techniques, surgery reappeared and was dominant in the last half of the century. Just as saphenous stripping was proved to be superior to proximal ligation, both were replaced by use of electromagnetic energy, such as radiofrequency and laser venous ablation, as a means of taking the saphenous veins out of the circulation. Now reports of recurrent varices in 20 to 50% of operated cases are making some physicians look to alternatives in treating varicose veins. Foam sclerotherapy must be looked upon as an entirely new method of treatment. It is useful in all types of varices and is proven to be safe, simple, cheap, reliable, and repeatable.     

Role of precapillary arteriovenous shunting in the pathogenesis of varicose veins and its therapeutic implications

The conventional pathogenesis of varicose veins and their subsequent development is essentially based on primary valvular insufficiency of the main saphenous trunk and incompetence of the perforating veins. In contrast, the concept of the pathogenesis of varicose veins presented in this review is based on the presence of arteriovenous (AV) shunting that occurs primarily in the venous tributaries and rarely in the main trunks of the saphenous system. Identification of arteriovenous communications (AVCs) with varicose veins has been documented by visual observation during surgery and especially by use of high-powered microscopes or magnifying lenses. The AVCs have been found consistently to originate subfascially and to terminate in tributaries extrafascially, thus bypassing the capillary network. By means of serial arteriography it was shown that in more than 80% of varicose veins there is premature venous opacification. By means of Doppler ultrasonography, it was demonstrated that AV shunting was present in 80% of the cases. A correlative study of these parameters has shown that the initial significant pathology in varicose veins is mostly confined to the tributaries, although at an advanced stage the main trunk may also be subsequently affected to a lesser degree. In terms of management, these data strongly imply that sclerotherapy or surgical treatment (ligation or excision) should be confined to the tributaries and that high saphenofemoral ligation and stripping should be avoided except in cases where evidence shows valvular involvement and incompetency of the latter. As a result, this study strongly suggests that one could most often spare the main trunk of the saphenous vein for eventual use as a vascular graft.     

筋膜下内镜交通支离断术治疗下肢静脉性溃疡的体会

目的:探讨深筋膜下内镜交通支静脉离断术(subfascial endoscopic perforator surgery,SEPS)治疗下肢静脉性溃疡的可行性及应用价值。方法:回顾分析2008年12月至2011年4月为7例(8条肢体)下肢静脉性溃疡伴下肢静脉交通支瓣膜功能不全患者行大隐静脉剥脱术及SEPS的临床资料。结果:7例(8条肢体)手术均获成功,曲张静脉团块消失,下肢静脉血淤滞得到解决,色素沉着减轻,溃疡愈合。术后随访1～3年,无一例复发。结论:SEPS适于治疗下肢静脉交通支瓣膜功能不全的下肢静脉性溃疡患者,手术创伤小、安全、简单、易行,疗效确切,应用价值较高。     

下肢静脉曲张治疗方法进展及要点

下肢静脉曲张是血管外科最为常见的疾病，经典的传统术式为大（小）隐静脉高位结扎剥脱术。但近年来该治疗领域涌现了不少新技术新方法，腔内热闭合就是其中之一，近年来该技术逐渐成为了治疗下肢静脉曲张的主流朮式，大有取代经典传统手术的趋势。随着下肢静脉曲张治疗理念的更新，后热闭合时代也即将来临，常温闭合技术展现出了广阔的应用前景。下肢静脉曲张的治疗方法选择日趋多样化、个体化和微创化。     

Update of endovenous treatment modalities for insufficient saphenous veins—A review of literature

Lower-limb venous insufficiency resulting from saphenous vein incompetence is a common disorder, increasing with age. For decades, surgical stripping of the great saphenous vein has been the gold standard in varicose vein treatment. The desire to optimize outcomes of treatment and reduce surgical trauma has led to the development of endovenous techniques. Today, several endovenous techniques are available to ablate the saphenous vein segments with abnormal vein valve function. In this review, we discuss the techniques, mechanisms of action, outcomes, and complications of all endovenous treatment modalities for the treatment of symptomatic lower-limb varicose veins.     

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。     

腘静脉肌袢成形术治疗下肢深静脉瓣膜功能不全

目的研究下肢腘静脉肌袢成形术治疗下肢深静脉瓣膜功能不全的临床疗效. 方法 1997年1月～2001年6月,选择经过彩色多谱勒、静脉造影确诊为原发性下肢深静脉瓣膜功能不全的27例(27条)下肢,病程2～32年,平均17.4年.均有浅静脉曲张;其中小腿沉重感25例;肿胀22例;足靴区色素沉着25例;单侧慢性溃疡19例;2例曾行单纯大隐静脉结扎剥脱术.静脉压静息直立时平均为(11.00±0.73) kPa, 活动后平均为(9.14±0.68) kPa.均行腘静脉肌袢成形术,同时行大隐静脉高位结扎抽剥术,有12例行腔镜下交通支结扎. 结果术后27条患肢静脉压活动后平均下降为(5.94±0.82) kPa.与术前活动后平均值比较,差异有统计学意义(P<0.01).近期疗效良好,小腿沉重感及肿胀完全或基本消失,溃疡创面在2周内愈合.术后22条患肢获2～6年随访,21条患肢疗效优良,无复发;1例随访3年时因肌袢粘连导致小腿深静脉血栓形成. 结论严格掌握适应证,规范手术操作,腘静脉肌袢成形术治疗下肢深静脉瓣膜功能不全,可获得满意效果.     

Treatment of primary varicose veins has changed with the introduction of new techniques

New technologies have produced a revolution in primary varicose vein treatments. Duplex ultrasound is now used for preoperative diagnosis, postoperative surveillance, and during many procedures. Ultrasound has also altered our understanding of the pathophysiology of chronic venous disease. Laser and radiofrequency saphenous ablations are common. Classic techniques, such as sclerotherapy, high ligation, stripping, and phlebectomy, have been improved. Magnetic resonance venography, computed tomographic venography, and intravascular ultrasound have improved diagnostic capabilities. New strategies like ambulatory selective varices ablation under local anesthesia (ASVAL) and conservative hemodynamic treatment for chronic venous insufficiency (CHIVA) raise important questions about how to manage these patients.     

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.     

Randomized clinical trial of the effect of adding subfascial endoscopic perforator surgery to standard great saphenous vein stripping

BACKGROUND: This randomized trial was undertaken to investigate the fate of incompetent perforating veins (IPVs) following saphenofemoral ligation and stripping of the great saphenous vein (GSV), with or without subfascial endoscopic perforator surgery (SEPS). METHODS: Patients with venous reflux (greater than 0.5 s) of the GSV and additional IPVs were allocated randomly to standard surgery (saphenofemoral ligation, stripping and phlebectomies alone) or with the addition of SEPS. Patients with ulceration, recurrent veins, deep venous reflux/thrombosis or saphenopopliteal reflux were excluded. Duplex ultrasonography was carried out before operation, and at 1 week, 6 weeks, 6 months and 1 year after surgery. Quality of life questionnaires were completed and visual analogue scale scores collected at the same time points. RESULTS: Thirty-eight patients were allocated to SEPS and 34 to the no SEPS group. Two patients in the no SEPS group were excluded (one withdrew and the other had the wrong treatment). There were no differences between the two groups with respect to pain, mobility or quality of life scores during follow-up. A significantly higher proportion of patients in the no SEPS group had IPVs on duplex imaging at 1 year (25 of 32 versus 12 of 38; P < 0.001). CONCLUSION: IPVs do not remain closed following standard varicose vein surgery. The addition of SEPS was not associated with significant morbidity but did reduce the number of IPVs. Up to 1 year this had no effect on recurrence rates or quality of life, but late results remain to be seen. Registration number: ISRCTN18288048 (http://www.controlled-trials.com).     

激光闭合在小腿交通支静脉功能不全治疗中的临床应用

目的评价经皮穿刺激光腔内闭合小腿交通支静脉治疗下肢大隐静脉曲张合并交通支静脉功能不全的临床疗效。方法全组36例(42条肢体)下肢大隐静脉曲张伴交通支静脉功能不全患者均行大隐静脉全程加下肢浅表曲张静脉穿刺激光烧灼闭合,同时在超声引导下经皮穿刺激光腔内闭合有病变交通支静脉。结果全组42条肢体术前检查有82支病变交通支静脉,术后随访1～18个月内彩超检查证实82支交通支静脉闭合。C6级的10条小腿溃疡肢体,于术后2～8周全部愈合。结论经皮穿刺激光腔内闭合小腿交通支静脉,是治疗下肢大隐静脉曲张合并交通支静脉病变可行的微创治疗方法,安全、有效、创伤小,对于合并有小腿溃疡的患者尤为适宜。     

Endovenous radiofrequency ablation for the treatment of varicose veins

Chronic venous insufficiency (CVI) is the most common vascular disease and represents a significant health care problem in the United States. Reflux of the great saphenous vein is the most common cause of this condition, whose symptoms include varicose veins, leg swelling, skin discoloration, and ulceration. The traditional treatment of this condition is saphenofemoral ligation with stripping of the saphenous vein followed by varicose vein removal, if necessary. Recent advances in minimally invasive endovenous therapy have led to the development of catheter-based radiofrequency ablation (RFA) of the saphenous vein, which has gained an increasing acceptance in clinical practice. Endovenous RFA was introduced into clinical practice in Europe in 1998 and in the United States in 1999. Since then, over 250,000 procedures have been performed worldwide. Procedure safety and efficacy are well understood, with over 60 publications on the subject in the peer review literature, including four randomized trials comparing this technology with traditional vein stripping surgery. With the advent of tumescent anesthesia, the majority of RFA procedures are now performed in an office setting. This article examines the current technology using RFA in saphenous vein ablation with the Closure catheter system. Procedural techniques and clinical outcome using RFA in saphenous vein ablation are discussed. Clinical data comparing RFA versus saphenous vein stripping are also examined. Lastly, the clinical utility of a new RFA catheter, ClosureFAST, is discussed. ClosureFAST is a new generation of RFA catheter and has exhibited significant improvement in the ease of use and the procedure speed over the previous generation catheters while maintaining the favorable patient recovery profile seen with the RFA technology.