Long-term outcomes of endovenous radiofrequency obliteration of saphenous reflux as a treatment for superficial venous insufficiency

BACKGROUND: Endovascular radiofrequency obliteration has been used as an alternative to conventional vein-stripping surgery for elimination of saphenous vein insufficiency. A clinical registry was established in 1998, and its mid-term results have been reported previously. This study is to demonstrate the long-term treatment outcomes and to determine the risk factors that affect treatment efficacy. METHODS: Data were collected in an ongoing multicenter, prospective registry. Patients were treated before October 2004. Clinical and duplex ultrasound follow-up was performed 1 week, 6 months, 1 year, and yearly thereafter to 5 years. Treatment efficacy and clinical improvement after the procedure were analyzed. Three types of anatomical failure were identified. Logistic regression analysis was performed to determine the existence of any significant risk factors associated with anatomical failure. Risk factors considered were age, gender, body mass index, vein diameter, and pullback speed. The impact of anatomical failure on clinical symptoms and varicose vein recurrence was also analyzed. RESULTS: There were 1,006 patients (1,222 limbs) treated, their mean age was 47.4 +/- 12.1 years, and 78.1% were female. Veins treated included 89.1% great saphenous vein above-knee segments, 1.2% great saphenous vein below-knee segments, 4.1% great saphenous vein groin-to-ankle, 4.3% small saphenous veins, and 1.3% accessory saphenous veins. Mean vein diameter was 7.5 mm, with a maximum of 24 mm. Vein occlusion rates were 87.1%, 88.2%, 83.5%, 84.9%, and 87.2%, and reflux-free rates were 88.2%, 88.2%, 88.0%, 86.6%, and 83.8% at each annual follow-up. Clinical symptom improvement was seen in 70% to 80% of limbs with anatomical failures and in 85% to 94% of limbs with anatomical success from 6 months to 5 years after the radiofrequency obliteration. Logistic regression analysis showed that catheter pullback speed (P < .0001) and body mass index (P < .0333) were risk factors for anatomical failure. Limbs that had type II and type III anatomical failures were found to be more prone to varicose vein recurrence. CONCLUSIONS: Endovascular radiofrequency obliteration of saphenous vein reflux exhibits enduring efficacy. Adequate pullback speed during the procedure should be emphasized to ensure the proper thermal dose delivery. A whole treatment strategy to address hemodynamically significant tributaries and perforators can further improve treatment outcomes. Body mass index is a risk factor for anatomical failure, indicating the impact of hemodynamic factors on disease progression and recurrence.     

Endovascular obliteration of saphenous reflux: a multicenter study

OBJECTIVE: The objective of this study was to assess the differences in clinical outcomes in patients treated with endovenous saphenous vein obliteration with technical outcome of either complete occlusion (CO), near complete occlusion (NCO), defined as < or =5-cm segment of flow in treated vein, or recanalization, defined as >5-cm segment of flow in treated vein. STUDY DESIGN: The study was designed as a prospective registry with follow-up at intervals through 24 months. The subjects were 286 patients from 30 clinical sites with saphenous vein reflux as measured with duplex scanning. A total of 319 limb treatments were performed. Intervention included endovenous catheter obliteration of insufficient saphenous veins with temperature controlled radiofrequency heat, without high ligation of the saphenofemoral junction. The main outcome measures were status of occlusion of treated vein segments, presence of varicose veins and reflux, clinical symptoms scores, physician evaluation of procedure success, and patient satisfaction. RESULTS: At 12 months, 83.6% of treated limbs were classified as CO, 5.6% were categorized as NCO, and 10.8% were recanalized. At 24 months, 85.2% of treated veins were CO, 3.5% were NCO, and 11.3% were recanalized. Varicose veins were present in 95% of limbs before treatment. The presence of varicose veins in limbs with CO was 10.5%, 7.3%, 5.7%, and 8.3% at 1 week, 6 months, 12 months, and 24 months, respectively. The presence of varicose veins in NCO limbs was similar at each interval. Overall, 91.4% of 232 limbs followed to 12 months and 90.1% of 142 limbs at 24 months were free of saphenous vein reflux, regardless of technical outcome. Paresthesia was reported in 3.9% of limbs at 1 year and in 5.6% at 2 years. The pretreatment mean symptom severity score was 2.0. Mean posttreatment symptom scores decreased to 0.07, 0.0, and 0.50 for CO, NCO, and recanalized limbs, respectively, at 6 months. At 12 months, the mean scores were 0.06, 0.0, and 0.32 for CO, NCO, and recanalized limbs, respectively; at 24 months, the scores were at 0.10, 0.40, and 0.63. Patient satisfaction was achieved in 195 of 212 patients (92%) at 1 year and in 121 of 128 (94.5%) at 2 years. CONCLUSION: Endovenous vein obliteration without high ligation dramatically reduces the presence of varicosities and reflux and, when performed with the prescribed pull-back methodology, is comparable with vein stripping at 1 and 2 years. Patient satisfaction with the procedure is high at 2 years, regardless of technical outcome. At 2 years, the closure procedure is a viable alternative to stripping.     

The utility of the Venous Clinical Severity Score in 682 limbs treated by radiofrequency saphenous vein ablation

OBJECTIVES: The goal of endovenous ablation is to reduce the symptoms associated with chronic venous insufficiency. This prospective study was designed to apply the venous clinical severity score to limbs before and after endovenous saphenous vein radiofrequency ablation and to identify risk factors associated with treatment failure. METHODS: Between September 2003 and March 2005, 499 patients underwent 682 saphenous vein radiofrequency ablation procedures. Preoperative venous clinical severity scores were documented. Follow-up clinical and duplex examinations were performed at 4 days, 4 weeks, and 4 months after saphenous vein radiofrequency ablation and at > or=6 months thereafter. Venous clinical severity scoring was repeated at follow-up visits, and patients were asked to evaluate their level of satisfaction with the procedure. RESULTS: The mean +/- standard deviation age of the patients was 53.5 +/- 13.3 years (range, 28 to 86 years), and 68% were women. Pretreatment CEAP clinical class C3/C4 comprised 80% of limbs (520/682). Preoperative, 4-day, 4-week, and 4-month venous clinical severity scores were, respectively, 8.8 +/- 3.7 in 648 limbs, 5.2 +/- 3.0 in 629, 4.1 +/- 2.4 in 530, and 3.3 +/- 1.6 in 479 limbs. Saphenous vein radiofrequency ablation significantly reduced pain related to lower extremity venous disease from 95.7% to 15.2% (P < .0001) and edema from 92.4% to 17.0% (P < .0001). Before treatment, venous stasis ulcers were present in 52 limbs and healed at a rate of 86%. Complications in 633 limbs at last follow-up included superficial thrombophlebitis in 12.0%, paresthesia in 0.3%, and nonocclusive thrombus extension in 0.2%. No skin thermal injury was observed. Fewer than 2% of patients reported dissatisfaction with their procedural outcome. Age (relative risk, 0.98; P = .06), female sex (relative risk, 0.19; P < .0001), and tumescent volume >250 mL (relative risk, 0.59; P = .06) were associated with higher rates of occlusion. The overall occlusion rate was 87.1%. CONCLUSIONS: As determined by the venous clinical severity score, treatment of saphenous vein reflux with endovenous radiofrequency ablation results in the clinical improvement of symptoms and aids in the healing of venous ulcers. Age, female sex, and tumescent volume are associated with high success rates of occlusion. We found the venous clinical severity score to be an excellent stand-alone tool for assessing outcomes after saphenous vein radiofrequency ablation.     

Treatment of primary varicose veins by endovenous obliteration with the VNUS closure system: results of a prospective multicentre study.

BACKGROUND: Radio frequency obliteration of the saphenous veins has been introduced as a less invasive alternative to traditional surgery for varicose veins. OBJECTIVE: To report the efficacy of obliteration and clinical outcomes following endovenous obliteration of the saphenous vein with limited follow-up to 3 years. MATERIALS AND METHODS: Radiofrequency obliteration (Closure system, VNUS Medical Technologies, San Jose, CA) was performed in 330 limbs of 294 patients in a prospective worldwide multicentre study with 31 participating sites. Follow-up duplex ultrasound and clinical examinations were performed at annual intervals. The main outcome measures were the completeness of occlusion of the treated vein segment, presence of reflux and presence of signs and symptoms of venous disease. RESULTS: Before treatment 3.9% of limbs were categorised as CEAP clinical class zero or one. This improved to 82.9% at 1 year, 83.1% at 2 years and 86.8% at 3 years following treatment. Varicose vein free rates were 1 year: 90.1%, 2 years: 87.2%, 3 years: 88.2%. Duplex ultrasound demonstrated a reflux-free rate of about 88% over 3 years. Total occlusion (TO) of veins was 1 year: 81%, 2 years: 80.4% and 3 years: 75%. Partial occlusion (PO, <5 cm open segment) was 1 year: 6.3%, 2 years: 7.4% and 3 years: 17.6%. Incomplete occlusion (IO, >5 cm open segment) was 1 year: 12.7%, 2 years: 12.2% and 3 years: 7.4%. Partial occlusion did not result in any differences in the symptom severity score, the number of symptom free limbs, or the varicose vein absence rates at any follow-up time point when compared to the total occlusion group. The varicose vein absence rates were significantly lower in the IO group comparing to the TO and PO groups. CONCLUSIONS: Radiofrequency saphenous vein obliteration improves the symptoms of varicose veins. The reflux-free rates in the treated veins remain constant over a 3 year follow-up period. There is no difference in clinical outcomes between the TO and the PO limbs, suggesting clinical effectiveness of the PO category. Greater than a 5 cm open segment in treated veins poses a risk of recurrence.     

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。     

Prospective randomized study of endovenous radiofrequency obliteration (closure procedure) versus ligation and stripping in a selected patient population (EVOLVeS Study)

PURPOSE: This study was designed as a prospective multicenter randomized comparison of procedure-related complications, patient recuperation, and quality-of-life outcomes between patients undergoing vein stripping with high ligation and patients undergoing great saphenous vein (GSV) obliteration with temperature-controlled radiofrequency ablation without adjunctive high ligation (Closure procedure). METHODS: Eighty-five patients (86 limbs) from five sites (France, 2; Austria, 1; United States, 2) were randomly allocated to undergo radiofrequency obliteration (RFO) or stripping and high ligation (S&L). Final analysis included data for 44 limbs in the RFO group and 36 limbs in the S&L group. Follow-up examinations were performed at 72 hours, 1 week, 3 weeks, and 4 months. All patients completed the CIVIQ2 quality-of-life (QOL) questionnaire and underwent clinical and ultrasound examinations at each follow-up visit. RESULTS: Immediate success on the day of treatment was reported for 95% (42 of 44) of limbs in the RFO group and 100% (36 of 36) of limbs in the S&L group. In seven RFO limbs (16.3%) a scan obtained 72 hours after the procedure showed flow in the proximal GSV. Five of these segments had reflux in the open segment. At 1 week two of these closed, and an additional segment closed at 3 weeks. In no cases did flow reappear after complete occlusion of the GSV. Time to return to normal activities was significantly less in the RFO group (mean, 1.15 days; 95% confidence interval [CI], 0.05-2.34) compared with the S&L group (mean, 3.89 days; CI, 2.67-5.12; P =.02). In the RFO group, 80.5% of patients returned to routine activities of daily living within 1 day, compared with 46.9% of patients in the S&L group (P <.01). Patients in the RFO group were able to return to work in 4.7 days (CI, 1.16-8.17), compared with 12.4 days (CI, 8.66-16.23) for the S&L group (P <.05). Analysis of the QOL surveys showed statistically significant differences in favor of the RFO group for global score and pain score during follow-up. The magnitude of the difference, however, progressively decreased between 1 week and 4 months. CONCLUSIONS: In the absence of significant complications, such as deep vein thrombosis and pulmonary embolism, severe neuritic sequelae, and skin burns, there are significant early advantages to endovascular obliteration of the GSV compared with conventional vein stripping.     

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。     

Real-time color duplex scanning after sclerotherapy of the greater saphenous vein

A color real-time duplex scanner was used to scan the greater saphenous vein in 89 limbs of 55 patients to study the efficacy of prior greater saphenous vein sclerotherapy. The greater saphenous vein was insonated from the saphenofemoral junction to the knee to evaluate both reflux to a standardized 30 mm Hg Valsalva maneuver and evidence of greater saphenous vein obliteration by sclerotherapy. These data were correlated with the number of sclerosing injections used (mean, 1.8; range, 1 to 6), time from the last injection (mean, 27.5 mo.; range, 3 to 55 mo), and concentration of injectant used (0.5% to 3% sodium tetradecyl sulfate). Fifty-one of 89 injected limbs (57%) demonstrated reflux through the saphenofemoral junction, and reflux down the more distal greater saphenous vein was found in 67 of 89 injected limbs (75%). Greater saphenous vein obliteration was noted in only 18 of 89 injected limbs (20%); two were totally obliterated, and 16 were partially obliterated. The greater saphenous vein was obliterated in 6% below a refluxing saphenofemoral junction and in 40% below a nonrefluxing junction. A greater saphenous vein obliteration rate of 9% was found with a refluxing greater saphenous vein, and 50% in a nonrefluxing greater saphenous vein. Femoral vein reflux was identified in 11 of the 110 limbs (10%) and in every case was associated with both saphenofemoral junction and greater saphenous vein reflux. We noted a trend toward more successful results with more concentrated injectate (3% sodium tetradecyl sulfate). Fifty percent of patients reported improvement in symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)     

Endovascular Radiofrequency Obliteration Using 90°C for Treatment of Great Saphenous Vein

The recommended treatment temperature for endovascular radiofrequency obliteration (RFO) of the great saphenous vein (GSV) is 85°C. Faster catheter pullback rates are possible when the operating catheter tip temperature is increased. We studied the safety and effectiveness of RFO of the GSV using a temperature of 90°C, tumescent infiltration, and catheter pullback rates double the current standard. Sixty-eight patients (85 limbs) with ultrasound-documented saphenofemoral valve reflux underwent Closure procedure. Treatment temperature was increased to 90°C, and pullback times were increased to 5-6 cm/min. Outcome measures were occlusion of treated vein segments at 3 days and 6 months postoperatively and clinical evaluation of complications at 3 days and 6 months postoperatively. At 3 days, 96% (80/83) of GSVs were occluded and at 6 months 90% (66/73) were occluded. At 3 days and 6 months, no limbs had evidence of deep venous thrombosis or skin burns. Pullback times were shortened from 15-18 min to 8 min. Closure procedure of the GSV using 90°C and faster catheter pullback rates occluded a refluxing GSV with similar 3-day and 6-month occlusion rates as 85°C. Presented at the annual meeting of the Society for Clinical Vascular Surgery, Rancho Mirage, CA, March 10-13, 2004.     

Controlled Radiofrequency Endovenous Occlusion Using a Unique Radiofrequency Catheter Under Duplex Guidance to Eliminate Saphenous Varicose Vein Reflux: A 2-Year Follow-Up

BACKGROUND: Saphenous vein reflux is often the underlying anatomic cause of varicose veins. It is necessary to eliminate this reflux originating at the saphenofemoral junction (SFJ) to treat the resultant varicose veins. OBJECTIVE: To report 2-year follow-up results after closing the incompetent greater saphenous vein starting from its junction (SFJ) with the femoral vein using radiofrequency (RF) endoluminal ablation. METHODS: One hundred and forty incompetent greater saphenous veins from 120 patients with an incompetent SFJ and large painful varicosities were treated. Patients were evaluated clinically and with duplex ultrasound at 1 week, 6 weeks, 6 months, 12 months, and 24 months to determine treatment efficacy as well as adverse sequelae. RESULTS: Vein occlusion, defined as the absence of any duplex ultrasound-determined flow, was successfully achieved in 137 of 140 (98%) scanned veins at 1-week follow-up. At the 12-month follow-up, none of the treated patients developed recanalization that was not seen at 6 weeks, with a successful outcome in 90%. At the 24 month follow-up, 19 of 21 patients had complete disappearance of the treated saphenous vein, for a success rate of 90%. Side effects were minimal, and no skin burns or thromboses were observed. CONCLUSION: RF endovenous occlusion allows patients to obtain treatment with the positive attributes of surgery, that is, a single treatment and low rate of recurrent reflux, but without the morbidity, need for general anesthesia, or extensive convalescence associated with vein stripping and ligation surgery. Patient satisfaction was routinely achieved, with 98% of patients indicating a willingness to recommend the RF endovascular procedure to a friend or family member.     

超声引导下血管腔内射频消融联合局部点式剥脱治疗下肢静脉曲张

目的 观察超声引导下血管腔内射频消融联合点式剥脱治疗下肢静脉曲张的效果。方法 回顾性分析接受腔内射频消融联合点式剥脱治疗下肢静脉曲张的373例患者共397条下肢静脉(单侧349例、双侧24例),包括大隐静脉384条、小隐静脉13条,观察治疗中及治疗后不良反应;记录治疗后随访复查静脉彩色多普勒超声所见,评估静脉闭合率。结果 对373例397条静脉均顺利完成治疗,技术成功率100%(397/397)。治疗中不良反应主要包括穿刺及肿胀麻醉过程中轻度疼痛;治疗后6例切口明显渗血、3例局部血肿、2例切口局部感染,经相应治疗后均好转;治疗后1个月1例发生肺栓塞,予抗凝治疗后缓解。治疗后1、6、12个月,经治下肢曲张静脉闭合率分别为99.24%(394/397)、100%(307/307)及100%(217/217);治疗后随访2~5年,期间6例下肢局部新发曲张静脉,予以剥脱处理,1例溃疡愈合后再次复发,予局部换药。结论 血管腔内射频消融联合点式剥脱治疗下肢静脉曲张安全、有效。     

Defining the role of extended saphenofemoral junction ligation: a prospective comparative study

OBJECTIVE: This study explores the added effect of extended saphenofemoral junction (SFJ) ligation when the greater saphenous vein (GSV) has been eliminated from participating in thigh reflux by means of endovenous obliteration. GSV obliteration, unlike surgical stripping, can be done with or without SFJ ligation to isolate and study SFJ ligation's specific contribution to treatment results. METHODS: Sixty limbs treated with SFJ ligation and 120 limbs treated without high ligation were selected from an ongoing, multicenter, endovenous obliteration trial on the basis of their having primary varicose veins, GSV reflux, and early treatment dates. RESULTS: Five (8%) high-ligation limbs and seven (6%) limbs without high ligation with patent veins at 6 weeks or less were excluded as unsuccessful obliterations. Treatment significantly reduced symptoms and CEAP clinical class in both groups (P =.0001). Recurrent reflux developed in one (2%) of 49 high-ligation limbs and eight (8%) of 97 limbs without high ligation by 6 months (P =.273). New instances of reflux did not appear thereafter in 57 limbs followed to 12 months. Recurrent varicose veins occurred in three high-ligation limbs and four limbs without high ligation by 6 months and in one additional high-ligation limb and two additional limbs without high ligation by 12 months. Actuarial recurrence curves were not statistically different with or without SFJ ligation (P >.156), predicting greater than 90% freedom from recurrent reflux and varicosities at 1 year for both groups. CONCLUSION: These early results suggest that extended SFJ ligation may add little to effective GSV obliteration, but our findings are not sufficiently robust to warrant abandonment of SFJ ligation as currently practiced in the management of primary varicose veins associated with GSV vein reflux.     

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.     

Great saphenous vein stripping with preservation of sapheno-femoral confluence: hemodynamic and clinical results

BACKGROUND: Radiofrequency and laser vein treatment, which entail preservation of the saphenous confluence, have called into question the dogma of ligation of all tributaries at the sapheno-femoral confluence (SFC), so called "crossectomy". Nevertheless, crossectomy is still done when saphenous vein stripping is chosen for varicose vein treatment. The purpose of this study was to evaluate results after stripping procedures in which the SFC was preserved. METHODS: This was a retrospective cohort study for which limbs treated for varicose veins by surgical stripping of the great saphenous vein and preservation of the SFC were studied. All limbs had a preoperative duplex examination and showed SFC and truncal incompetence of the great saphenous vein. Periodic postoperative standing duplex ultrasound and clinical examinations were carried out, and results were recorded and analyzed retrospectively. RESULTS: A total of 195 lower limbs were operated on in 151 patients (128 women and 25 men) aged from 22 to 88 years (mean age 56.8). The preoperative diameter of the SFC ranged from 4.7 to 17 mm (mean 9.5 mm). The preoperative CEAP class distribution was C1 1.5%, C2 82.1%, C3 6.7%, and C4-C6 9.7%. Preoperative symptoms were present in 61.8% of cases. Postoperative thrombosis of the SFC was observed in one case with an extension to the deep femoral vein and pulmonary embolization at 1 month. Recovery was complete. At a mean of 24.4 months postoperatively (median 27.3 months, range 8 to 34.8), persistent SFC reflux was observed in only two cases (1.8%) and a SFC neovascularization in one case (0.9%). Recurrence of varicose veins appeared in seven cases (6.3%) but in conjunction with SFC reflux in only one case. Post treatment 83.9% of limbs were converted to CEAP clinical class 0 to 1 and significant symptom improvement was observed in 91.3% of cases with an aesthetic benefit in 95.5%. CONCLUSION: Preservation of the SFC during saphenous stripping gave good results with regard to hemodynamics and neovascularization on the SFC, varicose vein recurrence, improvement of symptoms, and aesthetic appearance for legs with a median follow-up of 27.3 months.     

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.     

In situ distal saphenous vein bypass using the intraluminal valve-disruption technique

In the last few years there has been a resurgence of interest in in situ saphenous vein bypass for lower extremity revascularization because of improved patency rates. We performed 28 in situ bypass operations in 26 patients with threatened limbs using the intraluminal Hall valve disrupter. Seventy-five percent of these bypasses were to tibial vessels and had a 93% early patency rate. Three late failures were salvaged before thrombosis of the bypass, resulting in a cumulative patency rate of 93% with a mean follow-up of 17 months. In situ saphenous vein bypass has become our procedure of choice for distal reconstruction in severely ischemic limbs because of improved long-term patency compared with reversed-saphenous vein bypass.     

Reconstruction of the superior vena cava: Benefits of postoperative surveillance and secondary endovascular interventions

Purpose: Superior vena cava (SVC) reconstructions are rarely performed; therefore the need for surveillance and the results of secondary interventions are unknown. Methods: During a 14-year period 19 patients (11 male, 8 female; mean age 41.9 years, range 8 to 69 years) underwent SVC reconstruction for symptomatic nonmalignant disease. Causes included mediastinal fibrosis (n = 12), indwelling foreign bodies (n = 4), idiopathic thrombosis (n = 2), and antithrombin III deficiency (n = 1). Spiral saphenous vein graft (n = 14), polytetrafluoroethylene (n = 4), or human allograft (n = 1) was implanted. Results: No early death or pulmonary embolism occurred. Four early graft stenoses or thromboses (spiral saphenous vein graft, n = 2, polytetrafluoroethylene, n = 2) required thrombectomy, with success in three. During a mean follow-up of 49.5 months (range, 4.7 to 137 months), 95 imaging studies were performed (average, five per patient; range, one to 10 studies). Venography detected mild or moderate graft stenosis in seven patients; two progressed to severe stenosis. Two additional grafts developed early into severe stenosis. Four of 19 grafts occluded during follow-up (two polytetrafluoroethylene, two spiral saphenous vein graft). Computed tomography failed to identify stenosis in two grafts, magnetic resonance imaging failed to confirm one stenosis and one graft occlusion, and duplex scanning was inconclusive on graft patency in 10 patients. Angioplasty was performed in all four patients with severe stenosis, with simultaneous placement of Wallstents in two. One of the Wallstents occluded at 9 months. Repeat percutaneous transluminal angioplasty was necessary in two patients, with placement of Palmaz stents in one. Only one graft occlusion and one severe graft stenosis occurred beyond 1 year. The primary, primary-assisted, and secondary patency rates were 61%, 78%, and 83% at 1 year and 53%, 70%, and 74% at 5 years, respectively. Conclusions: Long-term secondary patency rates justify SVC grafting for benign disease. Postoperative surveillance with contrast venography is indicated in the first year to detect graft problems. Endovascular techniques may salvage and improve the patency of SVC grafts. (J Vasc Surg 1998;27:287-301.)     

小隐静脉原位旁路术治疗下肢动脉缺血症

为探讨下肢动脉缺血症旁路重主新的移植材料,笔者于１９９２年５月至１９９７年５月,应用小隐静脉原位旁路术治疗下肢动脉闭塞严重缺血症１８例２４条肢体并监测随访１－５年。结果：１８例近期缺血症状均显著改善,临床有效率达８８．８％,远期疗效优良率达８３．３％,经寿命青法统计分析,移植物１,３,５年通畅率分别为９５．８％,７９．６％和７０．０％,认为以小隐静脉移植材料重建因肢体循环具有不受长度限制,我需预破     

Endovenous laser treatment of the small [corrected] saphenous vein: efficacy and complications

OBJECTIVE: The study was conducted to assess the efficacy and rate of complications of endovenous laser treatment (EVLT) of the short saphenous vein (SSV). METHODS: During a 17-month period, 210 (187 patients) with SSV incompetence documented by duplex ultrasound studies were treated with EVLT using a 980-nm diode laser. Duplex ultrasound examinations were performed on the day of the procedure, within the first week, and 2 to 11 months after the procedure (mean follow-up, 4 months). Clinical examinations were performed at 2 weeks and 6 weeks. Patients were assessed for deep venous thrombosis (DVT), nerve injury, and resolution of symptoms. RESULTS: All procedures were technically successful, and in the 126 patients (60%) who completed final follow-up scanning, 96% of SSVs remained closed. Three patients (1.6%) had numbness at the lateral malleolus at the 6-week follow-up. DVT, defined as a tail of thrombus protruding into the popliteal vein, was not detected in any limbs at the initial duplex study, but was noted in 12 limbs (5.7%) at the 1-week follow-up examination. Nine patients were treated with 3 days to 3 months of fractionated heparin and Coumadin (Bristol-Myers Squibb, Princeton, NJ), and there were no DVT extensions or pulmonary emboli. The anatomic configuration of the saphenopopliteal junction was the only factor predictive of DVT. CONCLUSIONS: Intermediate-term results of EVLT of the SSV demonstrate that the technique is effective at eliminating SSV reflux and affording symptomatic relief. The incidence of nerve injury is low, but the incidence of DVT is higher than reported for the great saphenous vein. Anatomic features of the SSV may predict patient risk for DVT.     

Radiofrequency Endovenous Obliteration versus Stripping of the Long Saphenous Vein in the Management of Primary Varicose Veins: 3-Year Outcome of a Randomized Study

We evaluated the 3-year outcome of a series of patients with primary varicose veins who were randomized to radiofrequency endovenous obliteration vs. stripping of the long saphenous vein (LSV). Twenty-eight patients were included in the study: 15 were randomized to the radiofrequency endovenous obliteration procedure and 13 to LSV stripping. At 3-year follow-up, five patients (33.3%) of the endovenous group had recurrent or residual varices and in three of them a reflux in the thigh veins was detected. None of the primarily occluded LSV segments was recanalized. In the stripping group, three patients (23.1%, p = 0.68) showed varicosities at clinical and duplex examinations. In one patient, a patent duplicate LSV trunk was detected. In the remaining two patients, no reflux in the thigh region was detected. According to the present results, radiofrequency endovenous obliteration of the LSV is associated with somewhat poorer short-term results compared with the stripping operation.