Infrequent early recanalization of greater saphenous vein after endovenous laser treatment

OBJECTIVE: The frequency of recanalization of the greater saphenous vein (GSV) after endovenous laser treatment (ELT) is unclear. This study was undertaken to establish the incidence of early recanalization after ELT and to study the histopathologic features of reperfused and excised GSV. METHODS: One hundred nine GSV in 85 consecutive patients with clinical stage C(2-6) E(P,S) A(S,P,D) P(R) disease were treated with ELT. Twelve months of follow-up with duplex scanning at regular intervals was possible in 104 treated veins (95.4%) in 82 patients (96.5%). Recanalized vessels were removed surgically and examined at histopathology. RESULTS: ELT-induced occlusion proved permanent at duplex scanning over 12 months of follow-up in 94 of 104 GSV (90.4%) in 73 patients. In 4 patients, 5 GSV (4.8%) were recanalized completely after 1 week, after 3 months (n = 3), or after 12 months. Another 5 GSV (4.8%) in 5 patients exhibited incomplete proximal recanalization over the 12 months of follow-up. Finally, 9 recanalized vessels (8.6%) required further treatment with high ligation and stripping. Histopathologic analysis of recanalized GSV revealed a multiluminal pattern, as commonly noted in reperfusion after spontaneous thromboplebotic occlusion of the GSV. During follow-up, secondary incompetency of untreated lateral accessory saphenous veins was observed in two legs (1.9%). CONCLUSION: Early recanalization requiring retreatment is observed in less than 10% of GSV after ELT. The histopathologic pattern mimics recanalization after thrombophlebotic occlusion.     

Reduced recanalization rates of the great saphenous vein after endovenous laser treatment with increased energy dosing: definition of a threshold for the endovenous fluence equivalent

BACKGROUND: Recent reports indicated a correlation between the amount of energy released during endovenous laser treatment (ELT) of the great saphenous vein (GSV) and the success and durability of the procedure. Our objective was to analyze the influence of increased energy dosing on immediate occlusion and recanalization rates after ELT of the GSV. METHODS: GSVs were treated with either 15 or 30 W of laser power by using a 940-nm diode laser with continuous fiber pullback and tumescent local anesthesia. Patients were followed up prospectively with duplex ultrasonography at day 1 and at 1, 3, 6, and 12 months. RESULTS: A total of 114 GSVs were treated with 15 W, and 149 GSVs were treated with 30 W. The average endovenous fluence equivalents were 12.8 +/- 5.1 J/cm2 and 35.1 +/- 15.6 J/cm2, respectively. GSV occlusion rates according to the method of Kaplan and Meier for the 15- and 30-W groups were 95.6% and 100%, respectively, at day 1, 90.4% and 100% at 3 months, and 82.7% and 97.0% at 12 months after ELT (log-rank; P = .001). An endovenous fluence equivalent exceeding 20 J/cm2 was associated with durable GSV occlusion after 12 months' follow-up, thus suggesting a schedule for dosing of laser energy with respect to the vein diameter. CONCLUSIONS: Higher dosing of laser energy shows a 100% immediate success rate and a significantly reduced recanalization rate during 12 months' follow-up.     

Outcome of different endovenous laser wavelengths for great saphenous vein ablation

OBJECTIVE: The objective of this randomized, prospective, blinded study was to determine the relative effects of two laser wavelengths in the treatment of great saphenous vein (GSV) insufficiency. METHODS: Fifty-one male and female patients scheduled for routine laser treatment of GSV insufficiency provided signed informed consent for the procedure. Patients were randomized to receive endovenous laser treatment with a wavelength of 810 or 980 nm. The same surgeon, blinded to the wavelength, performed all procedures. Nonoperating study staff, blinded to the laser wavelengths, evaluated patients before and after the procedure regarding physical signs and symptoms. Patients were monitored within 72 hours after the procedure (via duplex ultrasonography), at 1 week (by procedural site photos scored for bruising, as well as a pain score), at 3 weeks, and at 4 months for bruising, physical and emotional effects of the procedure (scored by patients on a five-point visual analogue scale), and symptoms (scored by the physician), along with adverse events. Patients were followed up for a year to determine the long-term efficacy of the procedure. RESULTS: The 51 patients (38 women and 13 men; mean age, 52.4 +/- 11.7 years) completed treatment and follow-up examination (30 legs for each wavelength). At 72 hours after the procedure, no significant differences were noted between patient outcomes, physical conditions, and symptoms and or possible adverse events. At 1 week after the procedure, bruising scores were significantly different (P < .005): patients in the 980-nm group showed less bruising of the procedure site than the patients in the 810-nm group. Only three physical or symptom parameters presented with significant differences (P < .05) over time-less itching was noted by 810 nm-treated patients at 3 weeks after the procedure, lower levels of pain intensity were seen in the 980 nm-treated patients at the 4-month follow-up visit, and lower varicose vein ratings were seen for the 980 nm-treated patients at the 4-month follow-up visit. Thirteen legs were phlebitic at 7 days after the procedure (10 in the 810-nm group and 3 in the 980-nm group). Two treatment failures occurred (one patient in each treatment group); both patients exhibited flow in the treated venous segment at the 4-month follow-up visit. Two other patients (one in each group) had treatment failure at the 1-year follow-up, demonstrating venous insufficiency in the treated segment. CONCLUSIONS: Both laser wavelengths were effective in treating GSV insufficiency, with no major complications and a paucity of adverse outcomes.     

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.     

Deep venous thrombosis and superficial venous reflux

OBJECTIVE: Although superficial venous reflux is an important determinant of post-thrombotic skin changes, the origin of this reflux is unknown. The purpose of this study was to evaluate the frequency and etiologic mechanisms of superficial venous reflux after acute deep venous thrombosis (DVT). METHODS: Patients with a documented acute lower extremity DVT were asked to return for serial venous duplex ultrasound examinations at 1 day, 1 week, 1 month, every 3 months for the first year, and every year thereafter. Reflux in the greater saphenous vein (GSV) and lesser saphenous vein (LSV) was assessed by standing distal pneumatic cuff deflation. RESULTS: Sixty-six patients with a DVT in 69 lower extremities were followed up for a mean of 48 (SD +/- 32) months. Initial thrombosis of the GSV was noted in 15 limbs (21.7%). At 8 years, the cumulative incidence of GSV reflux was 77.1% (SE +/- 0.11) in DVT limbs with GSV involvement, 28.9% (+/- 0.09%) in DVT limbs without GSV thrombosis, and 14.8% (+/- 0.05) in uninvolved contralateral limbs (P <.0001). For LSV reflux, the cumulative incidence in DVT limbs was 23.1% (+/- 0.06%) in comparison with 10% (+/- 0.06%) in uninvolved limbs (P =.06). In comparison with uninvolved contralateral limbs, the relative risk of GSV reflux for DVT limbs with and without GSV thrombosis was 8.7 (P <.001) and 1.4 (P =.5), respectively. The relative risk of LSV reflux in thrombosed extremities compared with uninvolved extremities was 3.2 (P =.07). Despite these observations, the fraction of observed GSV reflux that could be attributable to superficial thrombosis was only 49%. CONCLUSIONS: Superficial venous thrombosis frequently accompanies DVT and is associated with development of superficial reflux in most limbs. However, a substantial proportion of observed reflux is not directly associated with thrombosis and develops at a rate equivalent to that in uninvolved limbs.     

Patterns of venous insufficiency after an acute deep vein thrombosis

BACKGROUND: The purpose of this study was to investigate patterns of venous insufficiency during a 12-month period after an acute deep vein thrombosis. STUDY DESIGN: Seventy limbs in 67 patients with an acute deep vein thrombosis (DVT) involving 147 anatomic segments were evaluated with duplex scanning at 1 month, 3 months, 6 months, and 1 year. Venous segments were examined whether they were occluded, partially recanalized, or totally recanalized, and the development of venous reflux was evaluated. RESULTS: The segments investigated were the common femoral vein (38 segments), femoral vein (33 segments), popliteal vein (36 segments), and calf veins (40 segments). There were 35 limbs with isolated DVT and the remaining 35 had multisegment DVT. At 1 year, thrombi had fully resolved in 76% of the segments, 20% remained partially recanalized, and 5% were occluded. The venous occlusion was most predominant in the femoral vein (21%) at 1 year. On the contrary, rapid recanalization was obtained in calf veins than in proximal veins at each examination (p < 0.01). Deep vein insufficiency was detected as early as 1 month after development of DVT, and the reflux was most predominant in popliteal veins (56%), followed by femoral veins (18%). No reflux was found in calf veins. Multisegment DVTs had a significantly higher incidence of deep vein insufficiency than single segment DVTs at 1 year. Development of superficial venous insufficiency was found in 5 limbs (7%) and perforating vein insufficiency in 5 (7%). CONCLUSIONS: Lower extremity venous segments showed different proportions of occlusion, partial recanalization, and total recanalization. Calf veins showed more rapid recanalization than proximal veins. Venous reflux was noted as early as 1 month. The limbs involving multisegment DVTs on initial examination had a higher incidence of deep vein insufficiency and could require much longer followup studies.     

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.     

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.     

Nonocclusion and Early Reopening of the Great Saphenous Vein After Endovenous Laser Treatment Is Fluence Dependent

Background. Parameters influencing failure and recanalization rates of endovenous laser treatment (ELT) of the great saphenous vein (GSV) are still to be determined.
Objective. To evaluate treatment-related parameters of ELT with respect to early failure of occlusion or recanalization of GSVs.
Methods. A series of 77 consecutive patients received ELT of 106 GSVs with continuous pullback of the laser fiber. Duplex examination was performed at 1 day, 4 weeks, and 3 months after the procedure. Clinical patient and vessel characteristics as well as technical parameters of the ELT procedure were evaluated via multiple logistic regression analysis.
Results. A median vein length of 60 cm (range of 18 to 90) was treated with a median pullback velocity of 0.6 cm/sec (range of 0.4 to 1.3), resulting in a median energy delivery of 23.4 J/cm (range of 11.8 to 35.5) and a median laser fluence of 11.8 J/cm² (range of 2.8 to 37.3). At day 1 after ELT, 6 GSVs (6%) were not occluded. At 1 and 3 months after ELT, 9 GSVs (9%) and 11 GSVs (10%), respectively, were found open by color duplex examination. Risk factors for nonocclusion 3 months after ELT, by univariate analysis, were laser fluence, laser energy per centimeter of vein length, diameter of the vein before treatment, and distance of the thrombus to the sapheno-femoral junction at day 1 after treatment. Finally, multiple regression analysis selected laser fluence (p=0.004, odds ratio=0.40 J/cm²) as the relevant risk factor for ELT failure or recanalization.
Conclusion. ELT failure seems to be related to the administration of low laser fluences.     

Endovenous 980-nm laser treatment of saphenous veins in a series of 500 patients

BACKGROUND: In recent years, endovenous laser treatment (ELT) has been proposed to treat incompetent great saphenous veins (GSV). This study reports the long-term outcome of ELT in a series of 500 patients. METHODS: Incompetent GSV segments in 500 patients (436 women, 64 men) with a mean age of 52.6 years (range, 19 to 83 years) were treated with intraluminal ELT using a 980-nm diode laser (Pharaon, Osyris, France). The GSV diameter was measured by Duplex examination in an upright position in different GSV segments (1.5 cm below the saphenofemoral junction, crural segment, condylar segment, and sural segment). These measurements were used to determine the optimal linear endovenous energy density (LEED) for each segment. During treatment, patients were maintained in the Trendelenburg position. Patients were evaluated clinically and by duplex scanning at 1 and 8 days, 1 and 6 months, and at 1, 2, 3, and 4 years to assess treatment efficacy and adverse reactions. RESULTS: A total of 511 GSVs were treated. The mean diameter was 7.5 mm (range, 2.4 to 15.0). The LEED was tuned as a function of the initial GSV diameter measured in the orthostatic position, from 50 J/cm (3 mm) up to 120 J/cm (15 mm). At the 1-week follow-up, 9.3% of the patients reported moderate pain. In the immediate postoperative period, the closure rate was 98.0% and remained constant during the 4-year follow-up to reach 97.1%. After 1 year, a complete disappearance of the GSV or minimal residual fibrous cord was noted. Major complications have not been detected; in particular, no deep venous thrombosis. Ecchymoses were seen in 60%, transitory paresthesia was observed in 7%. There was no dyschromia, superficial burns, thrombophlebitis, or palpable indurations. Complementary phlebectomy was done in 98% of patients. Failures occurred only in large veins (saphenofemoral junction diameter >1.1 cm or for GSV truncular diameter >0.8 cm) CONCLUSION: ELT of the incompetent GSV with a 980-nm diode laser appears to be an extremely safe technique, particularly when the energy applied is calculated as a function of the GSV diameter. It is associated with only minor effects. Currently, ELT has become the method of choice for treating superficial veins and has almost replaced the treatment of traditional ligation and stripping.     

Stabilization of the proximal ulnar stump in the Sauvé-Kapandji procedure by using the extensor carpi ulnaris tendon: long-term follow-up studies

PURPOSE: The Sauvé-Kapandji procedure is considered a useful treatment option for distal radioulnar disorders. Postoperative instability of the proximal ulnar stump and radioulnar convergence, however, may be symptomatic. We modified the Sauvé-Kapandji procedure by stabilizing the proximal ulnar stump with a half-slip of the extensor carpi ulnaris tendon. We previously reported on 13 patients with this procedure at an average follow-up period of 35 months; the patients had satisfactory clinical results and improved stability of the proximal ulnar stump as shown by x-ray examination. In this article we address the question of whether those clinical and radiographic results noted at an average follow-up period of 35 months after surgery were maintained at later follow-up examinations. METHODS: We re-examined 12 of the 13 original patients and compared their initial follow-up results with their current results after an average follow-up period of 95 months. RESULTS: The results of this series after 95 months of follow-up evaluation were similar to the results at 35 months. CONCLUSIONS: The results presented in this article suggest that the clinical radiographic results at the 35-month follow-up examination were maintained in the long-term 95-month follow-up evaluation despite the finding that the hole in the proximal ulnar stump had broken in 3 wrists at follow-up examination. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

Long-term Treatment of Deep Venous Thrombosis with a Low Molecular Weight Heparin (Tinzaparin): A Prospective Randomized Trial

OBJECTIVES: Evaluation of the effectiveness and safety of the low molecular weight heparin (LMWH) tinzaparin versus unfractionated heparin (UFH) followed by acenocoumarol in proximal deep venous thrombosis (DVT). DESIGN: Prospective, randomized clinical trial. MATERIAL AND METHODS: Consecutive patients (n=108) with acute leg DVT, confirmed by duplex, were randomized to either tinzaparin alone or UFH and acenocoumarol for 6 months. Patients were evaluated ultrasonographically at entry, 1, 3, 6 and 12 months. Thrombus regression, reflux distribution and the incidence of complications were studied. A cost-analysis, comparing the two treatments, was performed. RESULTS: The overall incidence of major events (mortality, DVT recurrence, pulmonary embolism, major bleeding, heparin-induced thrombocytopenia) was significantly different (p=0.035) in favor of tinzaparin (7 versus 17 events). The ultrasonographic clot volume score (an index of recanalization) decreased significantly in both treatment groups. However, tinzaparin produced significantly more extended overall recanalization from 3 months onwards (p<0.02). Thrombus regression was equivalent or in favor of tinzaparin in the different DVT subgroups and venous segments, but the statistical significance varied. Reflux showed non-significant differences overall or in subgroups. A cost-analysis resulted in favor of LMWH. CONCLUSIONS: A fixed daily dose of tinzaparin for 6 months was at least as effective and safe as UFH and acenocoumarol. Regarding major events and recanalization, there was a significant benefit in favor of tinzaparin. Long-term DVT treatment with tinzaparin could represent an alternative to conventional treatment.     

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.     

Endovenous laser ablation of saphenous vein is an effective treatment modality for lower extremity varicose veins

We present our first experiences with the use of a new minimally invasive treatment of lower extremity varicose veins. We studied the occlusion rates of the great saphenous vein (GSV) with laser ablation, its failure rates, and its complications. Sixty-six limbs in 62 consecutive patients were treated and followed-up for 1 year. All of the patients had incompetent GSV proven by means of duplex scanning. The GSV segment from 2 cm distal to the sapheno-femoral junction to just above the knee was ablated by using laser energy. In addition, all patients had stab avulsions of the varicose veins of the leg with Crochet hooks. All patients were followed postoperatively on the 3rd day, 1 month, 3 months, and 1 year after surgery. All patients were treated as day-case surgeries. Among 62 patients studied, 46 patients were women (74%) and 16 were men (26%). The median age of the patients was 53 years (range 28-69 years). Median operation time was 65 min (range 40-140 min). Successful treatment (total obliteration of the GSV on duplex) was accomplished in 64 of 66 limbs (97%). In two cases, recanalization of the lower one-third of the treated segment of the GSV was noted after 3 months. There were no instances of neuropathy or skin burn. Endovenous laser ablation of varicose veins is effective in inducing thrombotic vessel occlusion and is associated with only minor adverse effects. The procedure seems to be a promising alternative for surgical stripping of the GSV.     

Randomized prospective study comparing preoperative epidural and intraoperative perineural analgesia for the prevention of postoperative stump and phantom limb pain following major amputation

BACKGROUND AND OBJECTIVES: Acute stump pain and phantom limb pain after amputation is a significant problem among amputees with a reported incidence of phantom limb pain in the first year following amputation as high as 70%. Epidural analgesia before limb amputation is commonly used to reduce postamputation acute stump pain in the immediate postoperative period and phantom pain in the first year. We investigated whether immediate postamputation stump pain and phantom pain in the first year is reduced by preoperative epidural block with bupivacaine and diamorphine compared with intraoperative placement of a perineural catheter infusing bupivacaine. METHODS: In a randomized prospective trial, 30 patients scheduled for lower limb amputation were randomly assigned epidural bupivacaine at the standard rate used in our hospital (0.166%, 2 to 8 mL/h) and diamorphine (0.2 to 0.8 mg/h) for 24 hours before and during operation (14 patients; epidural group) and 3 days postoperatively, or an intraoperatively placed perineural catheter (16 patients; perineural group) for intra and postoperative administration of bupivacaine (0.25%, 10 mL/h). All patients had general anesthesia for the amputation and were asked about stump and phantom pain in the first 3 days and then at 6 and 12 months by an independent examiner. Study endpoints were rate of stump and phantom pain, intensity of stump and phantom pain, and consumption of opioids. The groups were well matched in baseline characteristics. RESULTS: Stump pain scores in the first 3 days were significantly higher in the perineural group compared with the epidural group (P <.01). After 3 days, 4 (29%) patients in the epidural group and 7 (44%) in the perineural group had phantom pain (P =.32). Numbers of patients with phantom pain for epidural versus perineural group were: 5 (63%) versus 7 (88%) (P =.25) at 6 months; 3 (38%) versus 4 (50%) (P =.61) at 12 months. Stump pain and phantom sensation were similar in both groups at 6 and 12 months. CONCLUSIONS: Using our regimen, perioperative epidural block started 24 hours before the amputation is not superior to infusion of local anaesthetic via a perineural catheter in preventing phantom pain, but gives better relief of stump pain in the immediate postoperative period.     

Recanalization of arterial occlusions with a lensed fiber and a holmium:YAG laser.

Laser recanalization of totally occluded swine iliac arteries was performed to assess the safety and efficacy of a lensed fiber laser angioplasty system with a holmium:YAG (2.1 microns) laser. Silica lenses of 1.0 mm, 1.3 mm, and 1.5 mm in diameter attached to the distal end of a 300-microns diameter silica fiber delivered fluences of 79.5 J/cm2, 31.4 J/cm2, and 25.5 J/cm2, respectively. The pulse duration of the laser was 250 microseconds and the repetition rate was 4 Hz. The mean length of the total occlusions was 5.3 +/- 2.0 cm (range 0.5 cm to 8.0 cm). Successful recanalization was obtained in 16/16 lesions without angiographic vessel perforation. Angiographically significant residual stenoses (greater than 50%) remained in every case following successful laser recanalization. Histologically there was minimal evidence of thermal or acoustic tissue injury; however, in 4 of 16 arteries there was evidence of deep arterial dissection following laser recanalization. We conclude that this lensed fiber coupled with a holmium:YAG laser is a safe and effective method for crossing total occlusions in the relatively straight iliac arteries of this animal model.     

Low molecular weight heparin versus oral anticoagulants in the long-term treatment of deep venous thrombosis

PURPOSE: The purpose of this study was to evaluate whether low molecular weight heparin (LMWH) could be equal or more effective than conventional oral anticoagulants (OAs) in the long-term treatment of deep venous thrombosis (DVT). METHODS: One hundred fifty-eight patients with symptomatic DVT of the lower limbs confirmed by means of duplex ultrasound scan were randomized to receive 3 to 6 months' treatment with nadroparine calcium or acenocoumarol. Quantitative and qualitative duplex scan scoring systems were used to study the evolution of thrombosis in both groups at 1, 3, 6, and 12 months. RESULTS: During the 12-month surveillance period, two (2.5%) of the 81 patients who received LMWH and seven (9%) of the 77 patients who received OAs had recurrence of venous thrombosis (not significant). In the LMWH group no cases of major bleeding were found, and four cases (5.2%) occurred in the OA group (not significant). The mortality rate was nine (11.1%) in the LMWH group and 7.8% in the OA group (not significant). The quantitative mean duplex scan score decreased in both groups during the follow-up and had statistical significance after long-term LMWH treatment on iliofemoral DVT (1, 3, 6, and 12 months), femoropopliteal DVT (1-3 months), and infrapopliteal DVT (first month). Duplex scan evaluation showed that the rate of venous recanalization significantly increased in the common femoral vein at 6 and at 12 months and during each point of follow-up in the superficial and popliteal veins in the LMWH group. Reflux was significantly less frequent in communicating veins after LMWH treatment (17.9% vs 32.2% in the OA group). The reflux rates in the superficial (22.4% in the LMWH group, 30.6% in OA group) and deep (13.4% vs 17.7%) venous system showed no significant differences between groups. CONCLUSIONS: The unmonitored subcutaneous administration of nadroparine in fixed daily doses was more effective than oral acenocoumarol with laboratory control adjustment in achieving recanalization of leg thrombi. With nadroparine, there was less late valvular communicating vein insufficiency, and it was at least as efficacious and safe as oral anticoagulants after long-term administration. These results suggest that LMWHs may therefore represent a real therapeutic advance in the long-term management of DVT.     

Incompetent Great Saphenous Veins Treated with Endovenous 1,320-nm Laser: Results for 71 Legs and Morphologic Evolvement Study

BACKGROUND: Endovenous lasers with various wavelengths have been utilized with good outcomes in treating leg varicose veins. The natural history and evolution of treated veins after endovenous procedures, however, have seldom been addressed. OBJECTIVE: This study determines the efficacy vein ablation and serial venous morphologic evolution of incompetent great saphenous veins (GSVs) after endovenous 1,320-nm laser treatment. METHODS: Fifty patients with symptomatic varicose veins secondary to GSV insufficiency treated with 1,320-nm endovenous laser ablation were enrolled. The treated varicose veins in each limb were mapped and sized before laser treatment. Vein wall diameters were measured with duplex ultrasound at follow-up visits. RESULTS: Seventy-one limbs in 50 patients were enrolled. During the mean 13.1-month follow-up, closure of GSVs was observed in 94% of limbs (67/71). Vein diameters at 3 cm below saphenofemoral junction level were reduced to 81% at 2 days, 75% at 1 month, 48% at 3 months, and 39% at 5 months. Average mean duration for treated GSVs to narrow as fibrotic cords (internal diameter,<2.5 mm) was 5.8 months. CONCLUSION: The endovenous 1,320-nm laser ablation procedures have excellent efficacy in treating incompetent GSVs. This excellent shrinkage behavior may be the basis for nice long-term results of patients treated with 1,320-nm Cooltouch endovenous laser.     

Adjunctive Proximal Vein Ligation with Endovenous Obliteration of Great Saphenous Vein Reflux: Does It Have Clinical Value?

The risk of clot extension to the deep venous system or pulmonary embolism following endovenous great saphenous vein (GSV) obliteration is possibly related to the size of the proximal GSV. Some practitioners therefore exclude endovenous GSV obliteration for veins greater than an arbitrary size, starting as little as 15 mm. Others provide adjunctive proximal GSV ligation either routinely, or in selected patients with large veins. The clinical value of adjunctive proximal GSV ligation is unknown. A survey of either the American Venous Forum or the American College of Phlebology, selected for their pedagogic or long-time experience with endovenous GSV obliteration. Respondent characteristics included obliteration technique (laser, radiofrequency [RF], or foam sclerotherapy), academic status, surgical training, indication for and frequency of adjunctive proximal GSV ligation, and society membership. The incidence of pulmonary embolus (PE) and deep vein thrombus (DVT) was also tallied. Twenty-one thousand nine hundred sixty-five endovenous GSV obliteration cases were reported, 10,290 with a laser (46.8%), 6,275 (28.6%) with RF, and 5,400 (24.6%) with foam. Only two PEs were reported. Of the 34 patients with DVT, at least 11 had only asymptomatic ultrasound evidence of thrombus extension into the femoral vein, and at least five had only calf vein thrombosis. Comparing ligators (7) with non-ligators (15), the only characteristic significantly correlating with adjunctive proximal GSV ligation was whether the respondent had complete general or vascular surgical training; non-surgeons never ligated the saphenous vein (p < .001). There was no difference between outcomes of ligators and non-ligators. Endovenous obliteration of the GSV poses little risk of PE or DVT, no matter what size the proximal GSV. Although these adverse events may be reduced with adjunctive proximal GSV ligation, the results of this study suggest that adjunctive proximal GSV ligation is superfluous in most patients.     

Durability of reflux-elimination by a minimal invasive CHIVA procedure on patients with varicose veins. A 3-year prospective case study.

OBJECTIVES: to assess the outcome of a conservative and haemodynamic method for insufficient veins on an ambulatory basis (French acronym, "CHIVA") with preservation of the greater saphenous vein (GSV) for treatment of primary varicose veins. METHODS: duplex incompetence of the sapheno-femoral junction (SFJ) and the GSV trunk, with the re-entry perforating point located on a GSV tributary was demonstrated in 58 patients with varices (58 limbs). The re-entry point was defined as the perforator, whose compression of the superficial vein above its opening eliminates reflux in the GSV. Duplex scanning was performed preoperatively and at 7 days, and patients were followed prospectively at 1, 3, 6, 12, 24, and 36 months after CHIVA. Operation consisted in flush ligation and division from the GSV of the tributary containing the re-entry perforating vein (no additional high ligation is included). If reflux returned, SFJ interruption was performed in a second surgical procedure. RESULTS: the GSV diameter showed an average reduction from 6.6 to 3.9 mm 36 months after surgery. Reflux in the GSV system was demonstrated in all but five (8%) patients. Of the 53 patients with recurrent reflux, 46 underwent SFJ interruption. CONCLUSIONS: elimination of reflux in the GSV after the interruption of insufficient collaterals is only temporary.