大隐静脉曲张腔内激光治疗术后并发症原因分析及预防

目的探讨腔内激光治疗（endovenous laser treatment,EVLT）大隐静脉曲张术后并发症发生原因及防治。方法回顾我院2003年8月～2007年2月采用大隐静脉高位结扎联合EVLT治疗342例（530条肢体）大隐静脉曲张,分析术后186条肢体出现的并发症。结果随访6个月,23条肢体皮下淤血、血肿,65条肢体静脉炎反应,20条肢体皮肤烧伤,经治疗全部治愈。77条肢体隐神经损伤（皮肤感觉异常）,经治疗57条治愈,余20条好转。1例深静脉血栓形成并发肺栓塞,经治疗好转。结论EVLT术中联合大隐静脉高位结扎,根据部位适当调整激光功率,轻柔操作,术后早期活动及预防性抗凝等措施,可预防或减少并发症的发生。     

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.     

Energy Delivery During 810 nm Endovenous Laser Ablation of Varicose Veins and Post-procedural Morbidity

AimThe durability of occlusion post endovenous laser therapy (EVLT) for varicose veins is linked to the magnitude of energy delivered to the vein and consequently increasing amounts of energy are employed. The aim of this study is to establish whether increasing the energy results in greater periprocedural morbidity or complications.MethodsLinear and logistic regression models were built to study the effect of energy delivery on outcome. The models controlled for age, gender, BMI, pre-operative quality of life and vein dimension. The outcomes were pain and analgesia requirement in week 1, change in disease specific quality of life (Aberdeen varicose vein questionnaire (AVVQ), change in generic quality of life (Short Form-36 (SF-36) and Euroqol (EQ5D)at week 1 and 6 and complication rates. The sample size calculation established that 115 patients would be required to detect any significant relationship.Results232 patients were included. The mean (range) age was 50 (18–83) years. 63% were women. The mean (range) energy delivery was 89.8 (44.5–158.4) J/cm. There was no significant effect on any outcome related to increasing energy delivery.ConclusionUp to 160J/cm, increasing energy delivery has no significant effect upon the morbidity or complications of EVLT for superficial venous insufficiency.     

Retrospective Comparison of Clinical Outcomes between Endovenous Laser and Saphenous Vein-sparing Surgery for Treatment of Varicose Veins

Background  

The purpose of the present study was to compare management of varicose veins by endovenous laser ablation (EVL) and a vein-sparing procedure (CHIVA: Conservatrice et Hémodynamique de l’Insuffisance Veineuse en Ambulatoire) for management of varicose veins.     

改良微创剥脱联合电凝术治疗下肢大隐静脉曲张

目的探讨改良微创剥脱联合电凝术治疗下肢大隐静脉曲张的疗效。方法2005年1月-2010年1月,对891例（957条）下肢大隐静脉曲张行改良微创剥脱联合电凝术：保留旋髂浅静脉、腹壁浅静脉、阴部外静脉,剥脱大隐静脉主干,再联合电凝法处理曲张的浅静脉。术后2周、1个月、3个月和每年来院复查,应用彩超检查是否有深静脉血栓或再发新的曲张静脉,随访症状改善情况,是否有神经损伤及溃疡愈合情况。结果单侧肢体手术时间25-40min,平均32min。住院时间3-5d,平均4．3d。下肢溃疡69例术后溃疡愈合时间平均6．1周（2-11周）。术后无下肢深静脉血栓发生,无皮肤灼伤发生,内踝处伤口周围皮肤麻木52例,术后自行恢复。796例随访1-5年,随访率89．3％（796／891）,复发24例,复发率3．0％（24／796）,再次手术或电凝闭锁。对复发危险因素进行单因素和多因素分析logistic回归分析显示：体重指数（BMI）〉33．4、曲张静脉直径〉8．7mm是静脉曲张复发的独立危险因素。结论改良微创剥脱联合电凝术治疗下肢大隐静脉曲张是一种安全、有效的方法。     

Hemodynamic Changes in Stripping Operation or Saphenofemoral Ligation of the Greater Saphenous Vein for Primary Varicose Veins

The aim of this study was to assess early hemodynamic improvement after a stripping operation or saphenofemoral ligation by means of air plethysmography. This prospective study assessed 109 limbs of 71 patients treated between May 2000 and December 2001 for primary varicose veins due to greater saphenous insufficiency. Eighty-nine limbs were treated by stripping surgery (stripping group), and 20 limbs were treated with saphenofemoral ligation (saphenofemoral ligation group). To evaluate venous hemodynamic changes, air plethysmography was performed before surgery and 7-14 days after surgery. A significant decrease and normalization of the venous filling index and residual volume function was observed in the two groups. A decrease in venous volume was observed in the ligation group, but the change was not statistically significant. In contrast, a significant decrease in venous volume was observed in the stripping group. The ejection fraction was not improved in either of the groups. From these results we conclude that hydrostatic forces can be controlled by means of a stripping operation as well as by saphenofemoral ligation in the early postoperative period.     

Comparison of Endovenous Radiofrequency Versus 810 nm Diode Laser Occlusion of Large Veins in an Animal Model

BACKGROUND: Endovenous occlusion using radiofrequency (RF) energy has been shown to be effective for the elimination of sapheno-femoral reflux and subsequent elimination of varicose veins. Recently, endovenous laser occlusion has been introduced with initial clinical reports indicating effective treatment for varicose veins. However, in our practice we note increased peri-operative hematoma and tenderness with the laser. Little is known regarding the mechanism of action of this new laser vein therapy. OBJECTIVE: To better understand the mechanism of action of endovenous laser vs. the endovenous RF procedure in the jugular vein of the goat model. METHODS: A bilateral comparison was performed using 810 nm diode laser transmitted by a bare-tipped optical fiber vs. the RF delivery by engineered electrodes with a temperature feedback loop using a thermocouple (Closure procedure) in three goat jugular veins. Immediate and one-week results were studied radiographically and histologically. Temperature measurements during laser treatment were performed by using an array of up to five thermocouples, spaced 2 mm apart, placed adjacent to a laser fiber tip during goat jugular vein treatment. RESULTS: Immediate findings showed that 100% of the laser-treated veins showed perforations by histologic examination and immediate contrast fluoroscopy. The RF-treated side showed immediate constriction with maintenance of contrast material within the vein lumen and no perforations. The difference in acute vein shrinkage was also dramatic as laser treatments resulted in vein shrinkage of 26%, while RF-treated veins showed a 77% acute reduction in diameter. At one week, extravasated blood that leaked into the surrounding tissue of laser treated veins acutely, continued to occupy space and impinge on surrounding structures including nerves. For the laser treatment, the highest average temperature was 729 degrees C (peak temperature 1334 degrees C) observed flush with the laser fiber tip, while the temperature feedback mechanism of the RF method maintains temperatures at the electrodes of 85 degrees C. CONCLUSION: Vein perforations, extremely high intravascular temperatures, failure to cause significant collagen shrinkage, and intact endothelium in an animal model justify a closer look at the human clinical application of the 810 nm endovenous laser technique. Extravasated blood impinging on adjacent structures may theoretically lead to increased peri-operative hematoma and tenderness. Further study and clinical investigation is warranted.     

腔内钬激光治疗下肢静脉曲张患者的护理

对96例(99条肢体)下肢静脉曲张患者行腔内钬激光治疗术,结果67条(67.7%)大隐静脉在术中即刻闭合,术后1周内99条(100%)全部闭合,均无创口感染;2例患者有轻度皮肤灼伤,1例隐神经损伤,3例大腿瘀斑,均经治疗后痊愈,3～4 d出院.提示术前心理护理,术后患肢的观察及并发症处理是护理成功的关键.     

腔内钬激光治疗下肢静脉曲张患者的护理

对96例（99条肢体）下肢静脉曲张患者行腔内钬激光治疗术。结果 67条（67．7％）大隐静脉在术中即刻闭合，术后1周内99条（100%）全部闭合，均无创口感染；2例患者有轻度皮肤灼伤，1例隐神经损伤，3例是腿瘀斑，均经治疗后痊愈．3-4d出院。提示术前心理护理．术后患肢的观察及并发症处理是护理成功的关键。     

激光联合大隐静脉高位结扎术治疗下肢静脉曲张46例临床分析

目的评价激光联合大隐静脉高位结扎术治疗下肢静脉曲张的近期疗效。方法对46例(55条肢体)下肢静脉曲张的曲张浅静脉施行腔内激光联合大隐静脉高位结扎术治疗。结果每条肢体手术时间30~65min,平均48min;手术切口1~5个,平均2.8个;术后住院时间为3~5d,平均3.6d。11条(20%)肢体出现皮下淤血,6条(11%)肢体出现皮肤灼伤。42例(50条肢体)随访2~19个月,平均13.5月,无复发。结论激光联合大隐静脉高位结扎术是治疗下肢静脉曲张的理想术式。     

早期小切口大隐静脉高位结扎剥脱术治疗伴急性血栓性浅静脉炎的大隐静脉曲张

目的探讨早期小切口大隐静脉高位结扎剥脱术治疗伴急性血栓性浅静脉炎的大隐静脉曲张的疗效。方法回顾性分析我院2008年10月～2011年5月32例大隐静脉曲张并发急性血栓性浅静脉炎的临床资料。发病2周内行小切口大隐静脉高位结扎剥脱术。结果全部患者术后局部红肿疼痛于3天内消退,切口全部甲级愈合,住院时间10～16d,平均12．6d。全部患者随访5～32个月,平均13．6月,其中11例〉12个月,未见复发。结论早期小切口大隐静脉高位结扎剥脱术治疗伴急性血栓性浅静脉炎的大隐静脉曲张是安全的,术后疗效满意。     

Endovenous Treatment of the Great Saphenous Vein Using a 1,320 nm Nd:YAG Laser Causes Fewer Side Effects than Using a 940 nm Diode Laser

BACKGROUND: Limited data are available about treatment-related side effects with respect to laser wavelength in endovenous laser treatment (ELT) of the great saphenous vein (GSV). OBJECTIVE: To compare the results and side effects of a 940 nm diode and a 1,320 nm neodymium:yttium-aluminum-garnet (Nd:YAG) laser. METHODS: Three patient cohorts (A, B, and C) received ELT of the GSV using a 940 nm diode laser at 15 W (group A) or 30 W (group B) or using a 1,320 nm laser at 8 W (group C). In all cases, energy was administered continuously with constant pullback of the laser fiber under perivenous tumescent local anesthesia. RESULTS: The GSVs of group A (n = 113), group B (n = 136), and group C (n = 33) received ELT. An average linear endovenous energy density of 24, 63, and 62 J/cm and an average endovenous fluence equivalent of 12, 30, and 33 J/cm2 were administered to the vein. Occlusion rates were 95% (group A), 100% (group B), and 100% (group C) at day 1 after ELT and 90.3% (group A), 100% (group B), and 97% (group C) at 3 months after ELT. With the 1,320 nm laser ELT (group C), treatment-related pain (50%) and the need for analgesics (36%) were significantly reduced (p < .005) in comparison with treatment-related pain (81%) and the need for analgesics (67%) after the 30 W 940 nm laser ELT (group B). Ecchymosis was also significantly reduced (p < .05) in group C (1,320 nm) compared with group B (30 W, 940 nm). CONCLUSION: ELT of the GSV using a 1,320 nm Nd:YAG laser causes fewer side effects compared with 940 nm diode laser ELT.     

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.