腔内激光治疗大隐静脉曲张并发症的防治

对近2年来采用激光治疗的下肢静脉曲张192例的临床资料进行回顾性分析。结果示术后共发生并发症92例次，其中皮下淤血48例；大隐静脉主干及小腿局部条索状硬结、红肿及严重疼痛7例；皮肤感觉异常，隐神经损伤35例；溃疡合并感染1例；下肢深静脉血栓形成1例。提示激光治疗创伤较小、安全，但有一定并发症发生率，应认真对待和处理。     

下肢静脉曲张腔内激光治疗术与抽剥术的疗效比较

目的回顾性分析下肢浅静脉曲张腔内激光治疗术（endovenous laser treatment,EVLT）与同期开展传统曲张静脉剥脱法的手术疗效。方法40例（46条肢体）下肢静脉曲张患者,在硬膜外或腰麻下,采用EVLT术;同期选择手术前条件相似的46条肢体,采用传统大隐静脉剥脱术。结果EVLT手术患者术后住院时间为2～5d,平均3．64d。传统剥脱术后平均8．12d;EVLT术较传统剥脱术的切口数少,创口小。结论EVLT术与传统剥脱术相比,术式简单又减小手术创伤。     

保留主干的激光闭合术治疗下肢静脉功能不全

目的 探讨保留上段主干的腔内激光闭合术(EVLA)在慢性静脉功能不全(CVI)治疗中的应用.方法 将术前经Doppler超声和光电容积描记法证实隐股瓣膜无反流且大隐静脉根部直径小于或等于8 mm的63例(71条肢体)CVI患者分成两组:保留组(35例,38条肢体)和非保留组(28例,33条肢体),分别实施保留和不保留大隐静脉上段主干的EVLA术,对两组的临床疗效、复发率和并发症发生率进行比较.结果 保留组的手术耗时少于非保留组[(17.5±4.3)min vs(22.7±5.6)min,P＜0.01)];保留组隐神经损伤比例低于非保留组(2/38 vs 4/33,P＜0.05);两组的Aberdeen评分改善值和住院天数基本相当,且组织灼伤、皮下硬结、瘀斑等并发症发生率在两组间比较,差异无统计学意义(P＞0.05),两组均未出现肺栓塞等严重并发症.结论 保留大隐静脉上段主干的EVLA是治疗下肢静脉功能不全安全有效的微创手术方法.     

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.     

Diffuse phlegmonous phlebitis after endovenous laser treatment of the greater saphenous vein

Endovenous laser treatment (EVLT) has become a valuable and safe option in the treatment of varicose veins. Although long-term results are lacking, most patients seem to benefit in the short-term from EVLT. Reported postoperative complications are limited, consisting usually of pain, ecchymosis, induration, phlebitis, or spot skin burn injuries. The most feared complication is an extension of the saphenous thrombus into the femoral vein, with possible pulmonary embolism. Here we report a septic thrombophlebitis after EVLT resulting in a phlegmonous infection of the whole leg that was treated by surgical drainage. Aggressive local therapy and antibiotic treatment resulted in complete resolution of symptoms and eventual satisfactory healing.     

Endovenous treatment of the greater saphenous vein with a 940-nm diode laser: thrombotic occlusion after endoluminal thermal damage by laser-generated steam bubbles

PURPOSE: Despite a rapid spread of the technique, very little is known about the laser-tissue interaction in endovenous laser treatment (EVLT). We evaluated EVLT of the incompetent greater saphenous vein (GSV) for efficacy, treatment-related adverse effects, and putative mechanisms of action. METHODS: Twenty-six patients with 31 limbs of clinical stages C(2-6), E(P), A(S,P), P(R) with incompetent GSV proven by means of duplex scanning were selected for EVLT in an outpatient setting. A 600-microm fiber was entered into the GSV via an 18-gauge needle below the knee and proceeded to the saphenofemoral junction (SFJ). After infiltration of tumescent local anesthesia, multiple laser pulses of 15 J energy and a wavelength of 940 nm were administered along the vein in a standardized fashion. D-dimers were determined in peripheral blood samples 30 minutes after completion of EVLT in 16 patients and on postoperative day 1 in 20 patients. One GSV that was surgically removed after EVLT was examined by means of histopathology. Additionally, an experimental in vitro set-up was constructed as a means of investigating the mechanism of laser action within a blood-filled tube. RESULTS: A median of 80 laser pulses (range, 22-116 laser pulses) were applied along the treated veins. On days 1, 7, and 28, all limbs except one (97%) showed a thrombotically occluded GSV. In one patient, the vessel showed incomplete occlusion. The distance of the proximal end of the thrombus to the SFJ was a median 1.1 cm (range, 0.2-5.9 cm) in the remaining patients. Adverse effects in all 26 patients were ecchymoses and palpable induration along the thrombotically occluded GSV that lasted for 2 to 3 weeks. In two limbs (6%), thrombophlebitis of a varicose tributary required oral treatment with diclofenac. D-dimers in peripheral blood were tested with normal results in 14 of 16 patients 30 minutes after completion of the procedure and elevated results in 7 of 20 patients at day 1 after EVLT. However, an increase of D-dimers from day 0 to day 1 was observed in 15 of the 16 patients undergoing tests 30 minutes after EVLT and on day 1. The 940-nm laser was demonstrated by means of in vitro experiments and the histopathological examination of one explanted GSV to act by means of indirect heat damage of the inner vein wall. CONCLUSION: EVLT of the GSV with a 940-nm diode laser is effective in inducing thrombotic vessel occlusion and is associated with only minor adverse effects. Laser-induced indirect local heat injury of the inner vein wall by steam bubbles originating from boiling blood is proposed as the pathophysiological mechanism of action of EVLT.     

Evaluation of endovenous radiofrequency ablation and laser therapy with endoluminal optical coherence tomography in an ex vivo model

BACKGROUND: This study evaluated the ability of endovascular optical coherence tomography (eOCT) to detect qualitative tissue alteration and quantitative changes of vein wall thickness and vein lumen diameter comparing endovenous radiofrequency ablation (RFA) and endovenous laser therapy (ELT) in an established ex vivo model. METHODS: Endoluminal eOCT was performed by means of a new prototype rotating system (System M1, LightLab Imaging Inc, Boston, Mass) with automatic pullback of 1 mm/s. In the course of an eOCT examination of a 50-mm vein segment, 264 electronic cross section images with a spatial resolution of 15 to 20 mum are acquired. The eOCT scans were performed before and after treatment of each of 13 treated vein segments and of six control vein segments. Thirteen subcutaneous cow foot veins were reperfused in situ, and the defined 50-mm vein segments in the study were treated with RFA (n = 2) and ELT (n = 11). RFA followed the clinical VNUS-Closure protocol (VNUS Medical Technologies, San Jose, Calif) using a 6F 60-mm Closure-Plus catheter. ELT was performed using light of lambda = 980 nm with a laser power of 3 (n = 2), 5 (n = 2), and 7 W (n = 4) with a paced pullback protocol with laser irradiation for 1.5 seconds every 3 mm, resulting in linear endovenous energy densities (LEED) of 15, 25, and 35 J/cm. Using 11 W (n = 3) with a continuous pullback protocol at 3 mm/s resulted in a LEED of 36.5 J/cm. Ten histologic cross sections of each treated and control vein segment were correlated with the corresponding eOCT cross sections to evaluate qualitative representation of vein wall layers and tissue alterations such as ablation and vein wall perforation. In addition, 26 eOCT cross sections of every treated vein segment before and after treatment and every control vein segment were analyzed to calculate quantitative changes in media thickness and vein lumen diameter. RESULTS: In all specimens, qualitative analysis with eOCT demonstrated a clear match with histologic cross sections. A symmetrical, complete, circular disintegration of intima and media structures, without any transmural tissue defects, was shown after RFA. Pronounced semicircular tissue ablations (3 to 14 per 50 mm) and complete vessel wall perforations (0 to 16 per 50 mm) were detected after ELT. The quantitative analysis demonstrated a significant (P < .0001) increase in intima-media thickness after RFA (37.8% to 66.7%) and ELT (11.1% to 45.7%). A significant (P < .0001) reduction of vessel lumen diameter (36.3% to 42.2%) was found after RFA. Owing to the limited number of treated vein segments and inhomogeneous baseline vein lumen diameters, no linear correlation between laser energy level and effects on tissue such as ablation/perforation, media thickening, or vein lumen diameter could be identified. CONCLUSIONS: In our ex vivo cow foot model, eOCT is able to reproduce normal vein wall structures and endovenous acute thermal alterations, such as tissue ablation and vessel wall perforations. Endovenous eOCT images can also be analyzed quantitatively to measure media thickness or vein lumen diameter. Endovascular OCT could become a valuable alternative tool for morphologic investigation of tissue alterations after endovenous thermal procedures.     

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.     

Early clinical outcomes after subfascial endoscopic perforator surgery (SEPS) and saphenous vein surgery in chronic venous insufficiency

BACKGROUND: Subfascial endoscopic perforator surgery (SEPS) has recently become popular as a minimally invasive way to treat chronic venous insufficiency (CVI) of the lower extremities. We report the early clinical outcomes of SEPS and saphenous vein surgery in a prospective series of Chinese patients who presented with severe CVI. METHODS: All patients referred to our hospital for the management of severe CVI (class IV disease or above) after January 1998 underwent SEPS using an ultrasonic scalpel in conjunction with saphenous vein surgery. All patients were followed up prospectively to assess ulcer healing, ulcer recurrence, and symptoms after SEPS. Clinical outcome was evaluated by the scoring system suggested by the Consensus Committee of the American Venous Forum on Chronic Venous Disease. RESULTS: Over a 24-month period, we performed 36 SEPS on 31 patients. Nineteen lower extremities (53%) had active or healing ulcers. Sapheno-femoral ligation was also performed in 33 limbs (92%). Four limbs (11%) developed superficial wound infection, and two (6%) had saphenous nerve dysesthesia. The mean clinical score and disability score decreased from 8.42 to 3.42 and 1.45 to 0.31 respectively, after a median follow-up of 14 months (range, 6-22) (p < 0.005). Eleven ulcers (58%) healed within 6 weeks after surgery. At 1-year follow-up, ulcer recurrence was found in two legs (11%). Conclusion: SEPS is safe and feasible. Early clinical results have shown a promising outcome in patients with severe chronic venous insufficiency.     

Validation of an in vitro model of human saphenous vein hyperplasia.

OBJECTIVE: The purpose of this study was the validation of the physiologic appropriateness of in vitro organ culture of human saphenous vein as a model with the demonstration of the occurrence of the processes of cell proliferation, remodeling, and hyperplasia. METHODS: Saphenous vein from 28 patients was cross-sectioned into seven 2-mm segments and maintained in organ culture for 2 days or 2 weeks. Three organ culture media were used: a chemically well-defined medium (RPMI-1640) and the same medium supplemented with the undefined protein-containing supplements fetal bovine serum (FBS) or pooled adult human plasma (type AB). The outcome measures at 2 days and 2 weeks were compared with measurements of segments from the same vein at the time of harvest. Excess saphenous vein harvested for arterial bypass grafting was obtained after approval of the study protocol by the Institutional Review Board. Cell proliferation was measured with immunostaining for proliferating cell nuclear antigen. Remodeling and intimal hyperplasia were measured with micromorphometric comparisons of vein segment cross-sectional area before and after organ culture. RESULTS: There was no evidence of cell death or tissue degeneration on histologic examination of the cultured vein segments. Cell proliferation, expressed as proliferation index (PI; positive proliferating cell nuclear antigen nuclei/total nuclei), significantly increased as compared with freshly harvested vein after 2 days of culture in undefined, protein-supplemented media (mean PI, 42.4 +/- 7.4%; P <.001). A significant increase in cell proliferation did not occur in the defined, unsupplemented medium until 2 weeks (mean PI, 16.2 +/- 7.1%; P <.001). The cross-sectional area of the vein wall increased during culture in all media. A statistically significant increase in the cross-sectional area of the vein wall occurred during culture with plasma (P <.001) and FBS supplementation (P =.002). The increase in the cross-sectional area of the vein in defined media was almost statistically significant (P =.089). A significant increase was seen in the cross-sectional area of the media (P =.006) and adventitia (P =.030) of veins cultured with plasma supplementation and in the cross-sectional area of the adventitia (P =.034) of veins cultured with FBS supplementation. CONCLUSION: These results show that human saphenous vein in culture is viable, shows cell proliferation, and exhibits remodeling of the layers of the vein wall. This is the first report to document hyperplasia in human vascular tissue cultured in a defined medium.     

Factors influencing the effectiveness of endovenous laser ablation (EVLA) in the treatment of great saphenous vein reflux.

OBJECTIVE: Endovenous laser ablation (EVLA) is an alternative to surgery for treating sapheno-femoral and great saphenous vein (GSV) reflux. This study assesses factors that might influence its effectiveness. DESIGN: Prospective, observational study. METHOD: EVLA was used to treat the great saphenous vein in 644 limbs as part of the management of varicose veins. Body mass index (BMI), maximum GSV diameter, length of vein treated, total laser energy (TLE) and energy density (ED: Joules/cm) delivered were recorded prospectively. Data from limbs with ultrasound confirmed GSV occlusion at 3-months were compared with those where the GSV was partially occluded or patent. Complications were recorded prospectively. RESULTS: GSV occlusion was achieved in 599/644 (93%) limbs (group A). In 45 limbs (group B) the vein was partially occluded (n=19) or patent (n=26). Neither BMI [group A: 25.2 (23.0-28.5); group B: 25.1 (24.3-26.2)], nor GSV diameter [A: 7.2mm (5.6-9.2); B: 6.9 mm (5.5-7.7)] influenced success. TLE and ED were greater p<0.01) in group A (median [inter-quartile range]: 1877J (997-2350), 48 (37-59)J/cm) compared to group B (1191J (1032-1406), 37 (30-46)J/cm). Although TLE reflects the greater length of GSV ablated in Group A (33 cm v 29 cm, p=0.06) this does not influence ED. GSV occlusion always occurred when ED>/=60 J/cm with no increase in complications. CONCLUSIONS: ED (J/cm) of laser delivery is the main determinant of successful GSV ablation following EVLA.     

Chronic venous insufficiency due to great saphenous vein incompetence treated with radiofrequency ablation: an effective and safe procedure in the elderly

Chronic venous insufficiency (CVI) with the resultant clinical sequelae significantly reduces quality of life. Most elderly patients with CVI are treated nonoperatively owing to concerns of increased operative risk and therefore suffer more advanced disease. Radiofrequency ablation (RFA) has emerged as a minimally invasive procedure to treat patients with superficial venous insufficiency (SVI) due to great saphenous vein (GSV) incompetence. The purpose of this study was to review our experience using RFA of the GSV to treat CVI due to superficial disease in elderly patients compared to younger patients in terms of procedure-related morbidity and severity of disease at time of treatment. RFA treatment of the GSV was performed in 490 extremities of 421 patients with SVI between March 2001 and December 2002. Indications, medical history, and outcome (operative complications and hospital stay) were compared between 2 groups: Group I:41 extremities of 35 patients, 70 years if age or older (mean 75 +/-4); and Group II:449 limbs of 386 patients younger than 70 years (mean 47 +/-11). The incidence of skin pigmentation and healed/nonhealed ulcers (CEAP 4-6) was significantly higher in the elderly than in the younger group (41% vs 16%, p <0.05). Hypertension, diabetes, and previous myocardial infarction were 2.8, 5.4, and 6.7 times more prevalent in the elderly (p <0.05), respectively. There were no major postoperative complications in either group; 97% of all patients were discharged on the day of operation and there was no difference between the 2 groups in overnight hospital stay. There is a treatment bias against operative management in elderly patients with SVI, as evidenced by their more advanced disease at the time of definitive treatment than their younger cohort. However, operative morbidity is no different compared to the younger subset. RFA is a safe and effective procedure for older patients; therefore, the threshold for operative management of older patients should be lowered.     

Crossectomy in the treatment of great saphenous vein insufficiency: a developing technique

Crossectomy is an old and simple surgical technique for great saphenous vein insufficiency. At present the results in the international literature are not encouraging, possibly owing to a lack of standardized indications. The authors describe their experience. Crossectomy with phlebectomy of collaterals or perforating veins was performed (cross < 8 mm) in 132 patients. The mean follow-up was 21 months in 71 patients: subjective results (patient's opinion) were satisfactory to good in 81% for symptoms and in 77% for cosmetic results (disappearance of varicose veins). Objective results (surgeon's opinion) were less satisfactory: recurrent varicose veins were observed in 17 patients (23%: teleangectasias or truncal varices) and a residual saphenous reflux at color-coded doppler ultrasonography was still present in 43 patients. Postoperative saphenous reflux did not correlate closely with symptoms, suggesting that crossectomy may improve venous pump function even if reflux is not totally abolished. Crossectomy requires further investigation for evaluation of long term results; more accurate indications and preoperative screening may further improve the success rate of this simple technique.     

Effects of laser irradiation at different wavelengths (660, 810, 980, and 1,064 nm) on mucositis in an animal model of wound healing

The aim of the present study was to compare the effectiveness of four different laser wavelengths (660, 810, 980, and 1,064 nm) used for low-level laser therapy (LLLT) on the healing of mucositis in an animal model of wound healing by investigating the expression of platelet-derived growth factor (PDGF), transforming growth factor beta (TGF-β), and blood-derived fibroblast growth factor (bFGF). Thirty-five male Wistar albino rats with a weight of 250–300 g body mass and 5 months old were used in the study. All animals were intraperitoneally injected with 100 mg/kg of 5-fluorouracil (5-FU) on the first day and 65 mg/kg of 5-FU on the third day. The tip of an 18-gauge needle was used in order to develop a superficial scratching on the left cheek pouch mucosa by dragging twice in a linear movement on third and fifth days. After ulcerative mucositis were clinically detected on the animals' left cheek pouch mucosa, the laser therapy was started. Four different laser wavelengths (660 nm, HELBO, Bredent; 810 nm, Fotona XD, Fotona; 980 nm, ARC Fox; and 1,064 nm, Fidelis Plus 3, Fotona) used for LLLT at ED 8 J/cm² daily from the first to the fourth days. Oval excisional biopsy was taken from the site of the wound, and the expression of PDGF, TGF-β, and bFGF was evaluated. The obtained data were analyzed by one2-way ANOVA, and then Tukey HSD tests were used for pairwise comparisons among groups (α?=?0.05). The one-way ANOVA test indicated that expression values of the growth factors, PDGF and bFGF, were significantly affected by irradiation of different wavelengths of lasers (p?TGF-β was not affected by irradiation of different wavelengths of lasers (p?>?0.05). The highest PDGF expression was detected in neodymium-doped yttrium aluminum garnet (Nd:YAG) laser group (p?p?>?0.05). The highest bFGF expression was detected in 980-nm diode and Nd:YAG laser groups (p?p?>?0.05). These findings suggest that low-level Nd:YAG and 980-nm diode laser therapy accelerate the wound healing process by changing the expression of PDGF and bFGF genes responsible for the stimulation of the cell proliferation and fibroblast growth.     

Investigation and significance of short saphenous vein incompetence.

In this study, 186 limbs with varicose veins or venous skin changes were examined using duplex ultrasonography. Limbs were classified on the basis of short saphenous or popliteal venous incompetence and the number of limbs with venous ulceration (active or healed) recorded. Short saphenous incompetence did not produce a significant increase in the incidence of ulceration, whereas popliteal reflux produced an increase in the risk of ulceration which was statistically significant when compared with limbs without reflux in these two veins (chi 2 = 4.55, P = 0.003). There was no significant difference in the proportion of limbs with concomitant long saphenous reflux between these two groups. Short saphenous reflux is not important in the pathogenesis of venous ulceration. Popliteal reflux is an important factor in the pathogenesis of venous ulceration. More attention should be paid to the surgical correction of popliteal reflux when present in limbs with venous ulceration that fail to heal by conservative measures.