Superficial vein surgery and SEPS for chronic venous insufficiency

Venous insufficiency in its severe forms leads to skin changes which, in turn may be treated by surgical therapy. Interventions are directed towards correction of the underlying abnormal venous physiology. This involves removal of varicose veins and ablation of incompetent axial veins and relevant perforating veins. In performing ablation of saphenous vein reflux, techniques include high ligation with stripping, radiofrequency ablation, endovenous laser therapy, and foam sclerotherapy. Incompetent perforator interruption can be accomplished surgically by subfascial endoscopic perforator surgery (SEPS) or controlled sclerotherapy using ultrasound. A variety of techniques have emerged to manage the varicose veins themselves. Surgical treatment of chronic venous insufficiency with high ligation in the groin and inversion stripping of the great saphenous vein to the knee combined with stab avulsion of varicose veins continues to be the standard in treatment of varicose veins. There are few comparisons of sclerotherapy of perforating veins with SEPS, but SEPS has become the most popular of surgical options.     

Aneurysmal dilatation of the great saphenous vein stump after endovenous laser ablation

Endoluminal ablation either by laser or radiofrequency energy of the great saphenous vein has become the standard therapy for varicose veins caused by great saphenous vein insufficiency. The rapid recovery time and low complication profile are both reasons practitioners and patients choose this treatment modality. Complications are rare and are usually minor. This report presents a patient who presented with aneurysmal dilatation of the saphenous vein remnant, with evidence of an arteriovenous fistula, 15 months after endovenous laser therapy. The abnormality was surgically resected and the fistula successfully ligated. This may be the first report of the formation and treatment of a venous aneurysm with arteriovenous fistula involving the great saphenous vein stump after endovenous laser therapy.     

Endovenous saphenous ablation corrects the hemodynamic abnormality in patients with CEAP clinical class 3-6 CVI due to superficial reflux

This investigation was designed to determine whether minimally invasive radiofrequency or laser ablation of the saphenous vein corrects the hemodynamic impact and clinical symptoms of chronic venous insufficiency (CVI) in CEAP clinical class 3-6 patients with superficial venous reflux. Patients with CEAP clinical class 3-6 CVI were evaluated with duplex ultrasound and air plethysmography (APG) to determine anatomic and hemodynamic venous abnormalities. Patients with an abnormal (>2 mL/second) venous filling index (VFI) and superficial venous reflux were included in this study. Saphenous ablation was performed utilizing radiofrequency (RF) or endovenous laser treatment (EVLT). Patients were reexamined within 3 months of ablation with duplex to determine anatomic success of the procedure, and with repeat APG to determine the degree of hemodynamic improvement. Venous clinical severity scores (VCSS) were determined before and after saphenous ablation. Eighty-nine limbs in 80 patients were treated with radiofrequency ablation (RFA) (n = 58), or EVLT (n = 31). The average age of patients was 55 years and 66% were women. There were no significant differences in preoperative characteristics between the groups treated with RFA or EVLT. Postoperatively, 86% of limbs demonstrated near total closure of the saphenous vein to within 5 cm of the saphenofemoral junction. Eight percent remained open for 5-10 cm from the junction, and 6% demonstrated minimal or no saphenous ablation. The VFI improved significantly after ablation in both the RF and EVLT groups. Postablation, 78% of the 89 limbs were normal, with a VFI <2 mL/second, and 17% were moderately abnormal, between 2 and 4 mL/second. VCSS scores (11.5 +/-4.5 preablation) decreased significantly after ablation to 4.4 +/-2.3. Minimally invasive saphenous ablation, using either RFA or EVLT, corrects or significantly improved the hemodynamic abnormality and clinical symptoms associated with superficial venous reflux in more than 90% of cases. These techniques are useful for treatment of patients with more severe clinical classes of superficial CVI.     

腔内射频闭合术联合TriVex刨吸术治疗下肢静脉功能不全

目的 评价腔内射频闭合术联合TriVex刨吸术治疗下肢静脉功能不全的疗效.方法 150例下肢静脉功能不全患者(150条患肢)随机分为A、B两组,每组75例.A组行大隐静脉射频闭合术联合曲张浅静脉TriVex刨吸术,B组行大隐静脉高位结扎抽剥术联合曲张浅静脉TriVex刨吸术.比较两组的手术时间、术后首次下床时间、术后48 h的疼痛视觉模拟评分(VAPS)值、术后住院天数、皮下血肿和皮下硬结的发生情况;比较患者对手术的自身评价、手术前后美国静脉联盟CEAP分级、临床严重程度计分(VCSS)、慢性静脉功能不全问卷(CIVIQ)生活质量评分的变化.结果 两组手术时间差异不显著,A组术后疼痛轻、下床时间早、住院天数少、皮下血肿发生率低,但皮下硬结发生率高于B组;术后4周对手术的评价A组优于B组;A、B手术前后CEAP分级、VCSS、CIVIQ评分变化差别有统计学意义(P<0.05),两组间VCSS分差、CIVIQ评分差异无统计学意义(P>0.05).结论 利用射频闭合术联合TriVex刨吸术治疗下肢静脉功能不全有效,且微创、并发症少、更具人性化;CEAP临床分级、VCSS临床计分和CIVIQ生活质量评分可用于评价其疗效.     

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.     

Endovenous radiofrequency ablation of superficial and perforator veins

Radiofrequency ablation of superficial and perforator veins for venous insufficiency has emerged as a leading alternative to traditional vein stripping operations. This percutaneous technique can be performed in less than an hour using local anesthetic or sedation. The VNUS Closure catheters (VNUS Medical Technologies, San Jose, California) work by resistive heating in the vein wall that is constantly monitored through a feedback loop to the VNUS Closure generator. Side effects are less than with other endovenous ablation techniques and patients resume normal activity immediately. The new ClosureFAST catheter is an important advancement that combines the speed of endovenous laser ablation with the expected fewer side effects of radiofrequency ablation.     

Endovascular radiofrequency ablation: a novel treatment of venous insufficiency in Klippel-Trenaunay patients

INTRODUCTION: Klippel-Trenaunay Syndrome (KTS) is an uncommon congenital disorder of uncertain etiology that comprises the clinical triad of varicose veins, port wine stain, and bony or soft-tissue hypertrophy. The literature suggests that the deep venous system is often under-developed. We propose that duplex venous ultrasound can effectively demonstrate patent deep venous systems in KTS patients with mild to moderate disease, and that endovascular radiofrequency ablation can be utilized in a safe and appropriate therapeutic manner. METHODS: A single center retrospective review of three patients with KTS treated with endovascular radiofrequency ablation of the KT veins and/or great saphenous veins was conducted. Preoperatively, patients underwent both venography and were studied with color flow duplex ultrasound system iU22 with a 7-5 MHz linear array probe (Philips Medical Systems, NA, Bothell, Wash). The anomalous KT veins, great saphenous and saphenous tributaries, and associated incompetent perforators were ablated with radiofrequency catheters (VNUS Medical Technologies, Inc, San Jose, Calif). All the radiofrequency ablations were complimented by ultrasound guided sclerotherapy of the varicose tributaries and when evident, incompetent perforator veins. RESULTS: The diagnostic series of duplex ultrasounds performed on our KTS patients has demonstrated contiguous deep venous systems in the effected extremity and effectively recognized the associated anomalous superficial venous systems. Our treatment resulted in successful occlusion of the incompetent veins in all three patients. DISCUSSION: The three patients, females aged 39, 19, and 16, presented with port wine stains and many years of leg-swelling and varicose veins that were recalcitrant to conservative treatment measures, including compression stockings and pulsed-dye laser therapy. Venography initially revealed poorly developed deep venous systems. However, venous ultrasound demonstrated patent and competent deep venous systems in all of the affected limbs. Radiofrequency ablations were performed to manage the sequella of venous insufficiency. At short-term follow-up, all patients demonstrated markedly decreased leg pain, edema, and varicose vein bulging. CONCLUSIONS: Three KTS patients were successfully treated with radiofrequency ablation of the incompetent great saphenous and/or anomalous superficial veins. Although the deep veins were poorly visualized on venography, they were clearly demonstrated with duplex ultrasound and functioned adequately once the incompetent superficial veins were ablated.     

Saphenous ablation: what are the choices, laser or RF energy

Endovenous ablation has been reported to be safe and effective in eliminating the proximal portion of the great saphenous vein from the venous circulation, with faster recovery and better cosmetic results than surgical stripping. However, the definition of a successful outcome in the literature has not been uniform. As in a successful stripping procedure, complete elimination of at least the proximal portion of the great saphenous vein should also be the standard for these endovenous ablation procedures. Our experience with over 1,400 endovenous ablation procedures, of which 1,150 were radiofrequency and over 250 were laser procedures, has allowed evaluation and comparison of these two techniques. And while we have not seen as high success rates as in published reports (especially with laser ablation), we have still concluded that both radiofrequency and laser techniques to destroy the saphenous vein are safe and effective. Patient acceptance is overwhelmingly better than stripping. Physicians performing these techniques should embrace a commitment to addressing all sites of venous insufficiency in a patient, not just the proximal great saphenous vein. Without this level of commitment, one will be left with poor results and a dissatisfied patient.     

The state of the art of endothermal ablation

Complaints relating to reflux in the venous system can be addressed by conservative, surgical, or interventional treatment options. The aim of the treatment is to prevent complications and progression of venous disease and to improve patients' quality of life. Endovenous thermal ablation therapies have become the most frequently used type of therapy for saphenous varicose veins. The available endovenous thermal techniques are endovenous laser ablation, radiofrequency ablation, and endovenous steam ablation. In this review, the procedures, indications, and treatment parameters of the three endovenous thermal ablation treatments are discussed as well as their advantages and disadvantages.     

两种不同术式治疗下肢静脉功能不全的近期疗效对照研究

目的 评价腔内射频闭合术联合TriVex刨吸术治疗下肢静脉功能不全的疗效. 方法 150例下肢静脉功能不全患者(150条患肢)随机分为A、B两组,每组75例.A组行大隐静脉射频闭合术联合曲张浅静脉TriVex刨吸术,B组行大隐静脉高位结扎抽剥术联合曲张浅静脉TriVex刨吸术.比较两组手术情况、术后4周患者对手术的自身评价、手术前后CEAP(clinic,etiologic,anatomic and pathophysiological classification)分级和临床严重程度计分(venous clinical severity score,vcss)的变化.结果 A、B两组手术时间分别为(67±11)min和(69±9)min(P＞0.05),A组术后疼痛轻、下地时间早、住院天数少、皮下血肿发生率低,但皮下硬结发生率高于B组;对手术的评价A组为(11.21±2.00)分优于B组(10.52±2.08)分,差异有统计学意义(P＜0.05);两组手术前后CEAP分级和VCSS计分变化差异均有统计学意义(P＜0.01),A、B两组手术前后VCSS分差为(4.6±2.5)分和(4.3±2.7)分(P＞0.05).结论 利用射频闭合术联合TriVex刨吸术治疗下肢静脉功能不全有效,且微创、并发症少.CEAP临床分级和VCSS临床记分可用于其疗效评价.     

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.     

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.     

腔内激光治疗静脉曲张的探讨

摘要：目的: 探讨腔内激光(EVLT)联合手术个性化治疗静脉曲张的综合方法。方法:下肢慢性静脉功能不全（CVI）285例（295条患肢），根据临床表现和双功超声、静脉造影，基于CEAP分期，分为A，B，C 3组，采取3种手术方式进行治疗。A组用单纯腔内激光闭塞术;B组用腔内激光加点式结扎；C组用股浅静脉包窄术加腔内激光加点式结扎。结果:全组曲张浅静脉均消失，皮肤颜色变浅，肿胀改善，溃疡愈合或缩小。结论:EVLT技术治疗下肢浅静脉曲张是有效的微创手术治疗方法，只要根据CEAP分期，通过标准化的诊断，选择好适应证，采用EVLT联合其他手术治疗原发性下肢深静脉瓣膜功能不全是可行和有效的。     

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.     

静脉内射频消融术与激光消融术治疗大隐静脉曲张的比较

目的 比较静脉内射频消融术和激光消融术治疗大隐静脉曲张的安全性和有效性.方法 回顾性分析2018年4～12月接受静脉内射频和激光消融术治疗的80例大隐静脉曲张患者临床资料,其中射频组39例,激光组41例.比较两种方法的手术并发症发生率、术后疼痛视觉模拟评分(visual analogue scale,VAS)、静脉临床...     

Endovenous Ablation of Saphenofemoral Insufficiency: Analysis of 100 Patients Using RF Closure Fast Technique

Chronic venous insufficiency is a common problem leading to varicose veins of lower limbs which was traditionally being treated with ligation and stripping. Endovenous ablation is an attractive alternative minimally invasive technique to treat such patients. We analysed the results of 100 consecutive patients treated with Radiofrequency based endovenous ablation using Closure Fast Catheter. Retrospective analysis of 100 consecutive patients with chronic venous insufficiency treated at our institution was done. All patients were classified pre and post procedure based on clinical, etiologic, anatomic and pathophyslogical classification, Venous clinical severity and Venous disablitity scores alongwith color doppler examination with follow up done at 2 weeks, 3 months and one year for any disease recurrence or residual symptoms. 97 of the 100 patients treated at 3 months and at 1 year showed good reduction of venous clinical severity and Venous disability scores to 0. Doppler showed complete closure of saphenofemoral junction and long saphenous vein at 2 weeks with no recanalisation at one year. No thrombus formation was observed. Minor complications like ecchymosis was seen in 9 patients and thrombophlebitis in 4 patients. Endovenous ablation using radiofrequency with Closure Fast technique showed improved short and long term results in patients with venous insufficiency with 100% closure seen on doppler studies along with lesser complications and no thrombus formation due shortened procedure time and improved catheter design.     

Varicose veins and their management

Varicose veins are a common condition, affecting up to a quarter of the UK population. They have been shown to negatively impact on patients' quality of life and are an important cause of morbidity. The management of varicose veins may be conservative (including lifestyle changes and compression hosiery) or surgical. Operative treatment aims to disconnect the superficial and deep venous systems at the sites of venous incompetence; traditionally saphenofemoral and saphenopopliteal junction ligation with or without stripping were the mainstay of treatment. In the last decade surgical treatment has been moving towards minimally invasive endovascular techniques, including thermal ablation (by means of radiofrequency, laser technology, steam), cryoablation and mechanochemical ablation. These are less invasive than open surgery and may be done under local anaesthesia.     

Endovenous laser treatment for primary varicose veins

Venous insufficiency of the lower extremities is a highly prevalent condition. Successful treatment of superficial venous insufficiency will most often necessitate treatment of the saphenofemoral junction incompetence with correction of saphenous vein reflux. In the majority of patients it concerns a reflux of the greater saphenous vein. The standard procedure consists of ligation and stripping of the greater saphenous vein combined with with additional phlebec-tomies or ligation of insufficient perforant veins if necessary. Although the standard procedure is widely known and accepted, the postoperative morbidity and postoperative limitations of activity are high. In this context minimally invasive percutaneous endovenous techniques were developed to improve the patients comfort and faster resumption of work. Among these, endovenous laser ablation of the greater saphenous vein is a relatively new procedure. Percutaneous introduction of a laser fiber into the incompetent vein and ablation with pulsed laser energy is far less invasive than stripping.     

Endovenous laser treatment for primary varicose veins

Venous insufficiency of the lower extremities is a highly prevalent condition. Successful treatment of superficial venous insufficiency will most often necessitate treatment of the saphenofemoral junction incompetence with correction of saphenous vein reflux. In the majority of patients it concerns a reflux of the greater saphenous vein. The standard procedure consists of ligation and stripping of the greater saphenous vein combined with with additional phlebectomies or ligation of insufficient perforant veins if necessary. Although the standard procedure is widely known and accepted, the postoperative morbidity and postoperative limitations of activity are high. In this context minimally invasive percutaneous endovenous techniques were developed to improve the patients comfort and faster resumption of work. Among these, endovenous laser ablation of the greater saphenous vein is a relatively new procedure. Percutaneous introduction of a laser fiber into the incompetent vein and ablation with pulsed laser energy is far less invasive than stripping.     

Radiofrequency ablation of primary and metastatic liver tumors: a critical review of the literature

BACKGROUND: Surgical resection is the treatment of choice for hepatic tumors; however, for various reasons, the vast majority of patients are not operative candidates. As a result, several local ablative therapies have emerged as alternatives to resection or as adjuncts in total oncologic care. Presently, the most widely employed liver-directed treatment is radiofrequency thermal ablation. METHODS: To define the current status of radiofrequency ablation (RFA), the authors reviewed available safety and efficacy data from select studies on RFA. A MEDLINE search was performed using the keywords "tumor type" + "radiofrequency ablation" + "survival." Only those studies containing long-term survival data on greater than 50 patients were included in this analysis. CONCLUSIONS: Although RFA has been readily adopted into treatment paradigms, more rigorous trials are needed to solidify its place in the armamentarium of therapeutic strategies for hepatic malignancy.