Strip-track revascularization after stripping of the great saphenous vein

BACKGROUND: Varicose veins that recur after standard high tie and strip are often associated with venous reflux in the thigh, as shown by duplex ultrasonography. The aim of this study was to look for evidence of revascularization in the strip track after great saphenous vein (GSV) stripping. METHODS: A consecutive series of patients with duplex-proven great saphenous varicose veins underwent saphenofemoral ligation with intraoperative confirmation of successful stripping. Duplex ultrasonography was performed 1 week and 1 year after surgery. The presence and extent of haematoma was noted, as was any venous reflux within the strip track. RESULTS: At 1 year, four (6 per cent) of 70 patients had complete revascularization of the strip track and 12 (17 per cent) had partial revascularization, all with duplex-proven reflux. Partial revascularization was in the distal third of the track in six legs (9 per cent of the 70 patients), in the distal half in five (7 per cent) and was almost complete in one leg (1 per cent). All patients with revascularization had a significant strip-track haematoma at 1 week after surgery. CONCLUSION: Revascularization of the GSV strip track after stripping was found in 23 per cent of patients after 1 year; all of these had a postoperative haematoma in the track.     

Duplex Ultrasound Outcomes Following Ultrasound-Guided Foam Sclerotherapy of Symptomatic Primary Great Saphenous Varicose Veins

ObjectivesTo describe duplex ultrasound (DUS) outcomes 12 months following ultrasound-guided foam sclerotherapy (UGFS) of primary great saphenous varicose veins (GSVV).MethodsA consecutive series of UK National Health Service patients underwent serial DUS examinations following UGFS with 3% sodium tetradecyl sulphate for symptomatic primary GSVV.Results344 treated legs (CEAP C_2/3 237, C₄ 72, C₅ 14, C₆ 21) belonging to 278 patients (103 male) of median age 57 (range 21–89) years were enrolled between November 2004 and May 2007. The median volume of foam used was 10 (range 2–16) ml. Above-knee (AK) and below-knee (BK) GSV reflux was present in 333 (96.8%) and 308 (89.5%) legs respectively prior to treatment. AK and BK-GSV reflux was completely eradicated by a single session of UGFS in 323 (97.0%) and 294 (95.5%) legs respectively; and by two sessions of UGFS in 329 (98.8%) and 304 (98.7%) legs respectively. In those legs where GSV reflux had been eradicated, recanalisation occurred in 18/286 (6.3%) AK and 23/259 (8.9%) BK-GSV segments after 12 months follow-up.ConclusionsA single session of UGFS can eradicate reflux in the AK and BK-GSV in over 95% of patients with symptomatic primary GSVV. Recanalisation at 12 months is superior to that reported after surgery and similar to that observed following other minimally invasive techniques.     

Fate and clinical significance of saphenofemoral junction tributaries following endovenous laser ablation of great saphenous vein

BACKGROUND: Unlike surgery, endovenous laser ablation (EVLA) abolishes great saphenous vein (GSV) reflux but does not specifically interrupt the GSV tributaries at the groin. The fate and clinical significance of these tributaries were assessed in a prospective study. METHODS: Eight-one legs (70 patients) underwent colour flow duplex ultrasonography 12 months after GSV ablation for primary varicose veins. Saphenofemoral junction (SFJ) reflux, tributary patency, and recurrent or residual varicosities were recorded, and Aberdeen Varicose Vein Severity Scores (AVVSS) were compared with pretreatment values. RESULTS: The GSV had recanalized without evidence of reflux in two patients. None of the 81 legs showed SFJ reflux although one or more patent tributaries were visible in 48 (59 per cent); all were competent. In 32 legs (40 per cent) there was flush GSV occlusion with the SFJ and no tributaries were detectable. One leg showed evidence of neovascularization in the groin. AVVSS values were similar in groups with or without visible tributaries, both before and after EVLA: median (interquartile range) 13.9 (7.6-19.2) before EVLA and 2.9 (0.6-4.8) at follow-up in patients with visible tributaries, and 14.9 (9.2-20.2) and 3.1 (0.8-5.1) respectively in those without. Recurrent varicosities were present in one leg only, due to an incompetent mid-thigh perforating vein. CONCLUSION: Persistent non-refluxing GSV tributaries at the SFJ did not appear to have an adverse impact on clinical outcome 1 year after successful EVLA of the GSV.     

Closure of the Greater Saphenous Vein with Endoluminal Radiofrequency Thermal Heating of the Vein Wall in Combination with Ambulatory Phlebectomy: 50 Patients with More Than 6-Month Follow-up

BACKGROUND: Incompetence of the saphenofemoral junction (SFJ) with reflux into the greater saphenous vein (GSV) is one cause of chronic venous hypertension that may lead to the development of varicose and telangiectatic leg veins. OBJECTIVE: To evaluate with long-term follow-up a novel method for closing the incompetent GSV at its junction with the femoral vein through an endoluminal approach. METHODS: Fifty patient legs with reflux at the SFJ into the GSV were treated with radiofrequency (RF) heating of the vein wall through an endoluminal catheter. Patients were evaluated at 6, 9, 12, and 18-24 months to determine treatment efficacy as well as adverse sequelae. RESULTS: Nine patients could not return for evaluation after 3 months. The remaining 41 patient legs were evaluated. Sixty-eight percent of treated legs achieved complete closure of the SFJ and GSV. Twenty-two percent of legs had an open GSV without reflux. Three patients (four legs) (10%) had an open and refluxing GSV. Three of 41 legs had recurrent varicose veins. Only 1 of 41 legs had recurrent symptoms. Complete treatment took an average of 20 minutes. Adverse sequelae were minimal, with 28 legs showing purpura less than 2 weeks, 5 legs with erythema less than 1 week, and 8 legs with an indurated fibrous cord lasting for up to 6 months posttreatment. CONCLUSION: Endoluminal RF thermal heating of an incompetent GSV has been shown to be easily accomplished and efficacious throughout the 24-month-follow-up period.     

Randomized clinical trial of routine preoperative duplex imaging before varicose vein surgery

BACKGROUND: Duplex imaging is used increasingly for preoperative evaluation of varicose veins, but its value in terms of the long-term results of surgery is not clear. METHODS: Patients with primary varicose veins were randomized to operation with or without preoperative duplex imaging. Reoperation rates, clinical and duplex findings were compared at 2 months and 2 years after surgery. RESULTS: Two hundred and ninety-three patients (343 legs) had varicose vein surgery after duplex imaging (group 1; 166 legs) or no imaging (group 2; 177 legs). In 44 legs (26.5 per cent), duplex examination suggested a different surgical procedure than had been considered on clinical grounds; the procedure was changed accordingly for 29 legs. At 2 months, incompetence was detected at the saphenofemoral or saphenopopliteal junction (or both) in 14 legs (8.8 per cent) in group 1 and in 44 legs (26.5 per cent) in group 2 (P < 0.001). At 2 years, two legs (1.4 per cent) had undergone or were awaiting reoperation in group 1, and 14 legs (9.5 per cent) in group 2 (P = 0.002). In the remainder, major incompetence was found in 19 legs (15.0 per cent) in group 1 and in 53 (41.1 per cent) in group 2 (P < 0.001). CONCLUSION: Routine preoperative duplex examination led to an improvement in results 2 years after surgery for patients with primary varicose veins.     

Recovery after ultrasound‐guided foam sclerotherapy compared with conventional surgery for varicose veins

Background:

The advantages of minimally invasive alternatives such as ultrasound‐guided foam sclerotherapy (UGFS) over conventional surgery for the treatment of varicose veins include lower morbidity and faster recovery times. The aim was to compare morbidity, analgesia use, and time to return to driving and work following UGFS with those reported after conventional surgery for varicose veins.

Methods:

Patients who had UGFS or surgery for varicose veins were sent a questionnaire 4 weeks after treatment.

Results:

A total of 332 (84·9 per cent) of 391 patients who had UGFS and 53 (56 per cent) of 94 who had surgery returned a questionnaire. The groups were similar in terms of age, sex, and the proportion who had treatment of bilateral or recurrent veins. Patients who had surgery were more likely to have significant bruising (44 versus 7·2 per cent; P < 0·001) and pain (17 versus 5·5 per cent; P = 0·001). After UGFS, 43·2 per cent of patients returned to work within 24 h compared with none who had surgery (P < 0·001). Patients who had UGFS were more likely to return to driving within 4 days (P = 0·014).

Conclusion:

UGFS was associated with less pain and analgesia requirement, time off work and quicker return to driving. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Comparative Study of Outcome of Duplex Ultrasound-Guided,Catheter-Directed Foam Sclerotherapy and Radio-frequency Ablation in the Management of Great Saphenous Varicose Veins

Chronic venous insufficiency of lower limbs is a common problem in adults. We compared the two modalities, namely duplex ultrasound-guided, catheter-directed foam sclerotherapy (UGFS) and radio-frequency ablation (RFA), in the management of great saphenous varicose veins using clinical assessment (Venous Clinical Severity Score, Venous Disability Score) and duplex imaging. Patients presenting with great saphenous vein (GSV) varicosity due to incompetent saphenofemoral junction (SFJ) were selected and randomly assigned in each arm, i.e., duplex UGFS group and RFA group. Patients were assessed on days 7, 30, and 90 both clinically and sonologically. Clinical assessment was based on the Venous Clinical Severity Score (VCSS) and Venous Disability Score (VDS). Obliteration of the treated GSV segment was noted in all the limbs of the RFA group (31/31) on duplex sonography on days 7, 30, and 90, while in the UGFS group, out of 30 limbs, obliteration was successful in 28 (28/30) and 2 had treatment failure. However, outcome of both the groups were statistically comparable (P value?>?0.05). After the procedure, improvement in the VCSS was noted in both the study arms in every follow-up and both the modalities were found to be equally effective. Improvement in the Venous Disability Score was there on every follow-up, but maximum improvement was seen on the second visit, i.e., post-treatment day 30. Improvement was statistically significant and equal in both arms after the initial 1 week. Foam sclerotherapy, especially catheter-directed, is as effective as radio-frequency ablation in achieving anatomical obliteration and yielding relief in clinical signs and symptoms in patients with GSV varicosity with SFJ incompetence.     

改良内翻抽剥法预防大隐静脉剥脱术中隐神经损伤

目的:探讨改良内翻抽剥法在大隐静脉抽剥过程中隐神经损伤预防中的作用。方法:采用改良内翻抽剥法治疗大隐静脉属支曲张250例(350条肢体),技术要点包括:①选用超长(300 cm)小口径(2.6 mm)抽剥器确保内翻抽剥;②尽可能在切口以远低位切断踝部大隐静脉,保证有足够长度的静脉残端与抽剥器固定;③先剥脱曲张属支再抽剥主干以减少抽剥过程中属支对主干的牵扯。结果:本组全部完成大隐静脉自踝至腹股沟全程内翻抽剥。并发症包括腹股沟血肿1例,术后1周时出现隐神经损伤症状1例。结论:手术技巧改良提高了大隐静脉内翻抽剥技术成功率,可较好地预防隐神经损伤发生。     

Causes of re-recurrence after polytetrafluoroethylene patch saphenoplasty for recurrent varicose veins

BACKGROUND: The aim of this study was to determine whether a polytetrafluoroethylene (PTFE) patch sutured over the religated saphenofemoral junction could reduce the rate of recurrence after operation for recurrent varicose veins. METHODS: Fifty patients who had surgery for recurrent long saphenous incompetence (81 legs had a small PTFE patch sutured over the religated saphenofemoral junction. There were no major complications following surgery. Three patients had a wound infection or delayed healing. All patients were invited for clinical examination and duplex imaging at a median of 19 (range 6-39) months after operation. RESULTS: Some 38 of 43 patients (70 legs) remained satisfied with the results of surgery; 16 (23 per cent) of 70 legs had visible veins on inspection and eight of these (11 per cent) involved symptomatic recurrence. Duplex imaging showed that recurrence was due to saphenofemoral junction incompetence in ten legs; two appeared to have a major groin connection but the other eight appeared to have neovascularization. Other causes were thigh perforator reflux (three legs) and cross-groin collaterals (three). Eleven of the 16 legs with recurrence had varicography but in two the procedure was a technical failure. Two legs had evidence of a significant connection (more than 3 mm) and two a minor connection (less than 3 mm) to the femoral vein at the level of the PTFE patch, but in the remainder recurrence was due to upper thigh perforating veins. There was good concordance between duplex imaging and varicography. CONCLUSION: PTFE patch saphenoplasty appears to be safe. Although these are early results, the technique seems potentially as effective as other barrier methods that have been investigated; in ten legs (12 per cent) recurrence was attributed to failure at the level of the PTFE patch.     

Prospective randomised comparative study of visual foam sclerotherapy alone or in combination with ultrasound-guided foam sclerotherapy for treatment of superficial venous insufficiency: preliminary report

ObjectiveThe aim of the study is to compare ultrasound-guided foam sclerotherapy (UGFS: injection of foam sclerosant under ultrasound guidance) of the great saphenous vein (GSV) combined with visual foam sclerotherapy (VFS: injection of foam sclerosant under visual control) for varicose tributary veins and VFS alone in the treatment of GSV reflux.Design and methodsA total of 133 limbs in 97 patients with GSV reflux were randomised to receive either VFS alone or VFS combined with UGFS. In both groups, 1% polidocanol foam was used. Assessments included duplex ultrasonography, evaluation of Venous Clinical Severity Scores (VCSS) and CEAP (clinical, etiologic, anatomic, and pathophysiologic) scores. Ultrasonographic inspection of the foam in the GSV was carried out during 5 min before compression was applied. The primary ‘end’ point of the study was obliteration of the GSV at 6 months.ResultsA total of 51 limbs in 48 patients were treated with UGFS + VFS and the remaining 52 limbs in 49 patients were treated with VFS alone. There were no significant inter-group differences in patient age, male: female ratio, height, weight, body mass index, CEAP clinical scores or VCSS. The GSV diameter was 6.0 ± 1.7 mm (median ± interquartile range) in the UGFS + VFS group and 5.7 ± 1.6 mm in the VFS group (p = 0.419). The mean injected volume of foam for varicose tributary veins was 4 ± 2 ml in the UGFS + VFS group and 6 ± 2 ml in the VFS group, a significantly higher amount of foam being used in the latter (p < 0.001). However, the mean total amount of foam was greater in limbs treated with UFGS + VFS than in those treated with VFS alone (p = 0.017). Ultrasonographic inspection revealed complete vasospasm of the GSV in 37 (72.5%) limbs in the UGFS + VFS group and 29 (55.8%) in the VFS group during sclerotherapy (p = 0.097). At 6-month follow-up, complete occlusion was found in 23 limbs (45.1%) treated with UGFS + VFS and in 22 limbs (42.3%) treated with VFS. The difference between the two groups was not significant (p = 0.775). Reflux was absent in 30 limbs (58.8%) treated with UGFS + VFS and in 37 (71.2%) treated with VFS (p = 0.190). There was no inter-group difference in post-treatment VCSS (p = 0.223).ConclusionsThese results show that UGFS + VFS and VFS are equally effective for the treatment of GSV reflux, despite the lower volume of foam used for VFS alone.     

Results and significance of colour duplex assessment of the deep venous system in recurrent varicose veins.

OBJECTIVES: To establish the status of the deep veins in patients presenting with recurrent varicose veins and the effect on treatment decisions. DESIGN: Retrospective clinical series. MATERIALS AND METHODS: Duplex examination of 570 consecutive patients (843 limbs) presenting with recurrent varicose veins (CEAP C2-4). RESULTS: Approximately one third of these patients (34.8%:294 limbs) had no deep venous abnormality; 173 limbs with superficial vein abnormalities only had great and/or small saphenous junction incompetence, the remaining 121 legs had abnormal perforating or communicating veins. Deep venous abnormalities were found in 549 limbs with evidence of persisting deep venous obstruction in only 20. Deep venous incompetence was found in 529 limbs (62.7% of all legs). However three segment incompetence (common femoral, femoral and popliteal veins) was found in only 181 legs (21.4%), two segment incompetence in 137 (16.2%) and one segment incompetence in 211 (25%). CONCLUSIONS: Deep vein incompetence is common in patients with recurrent varicose veins. Deep venous obstruction is an infrequent finding but total deep venous reflux (three segment incompetence) affects just under one quarter of all limbs with recurrent varicose veins. Ablation or surgery of varicose veins in this group may be less effective. Patients should be advised of the implications of this finding.     

Neovascularization: an "innocent bystander" in recurrent varicose veins

OBJECTIVE: Varicose vein recurrence after surgery occurs in up to 60% of patients. A variety of technical factors have been implicated, but biological factors such as neovascularization have more recently been proposed. The objective of this study was to characterize the relative contribution of technical and biological factors to recurrence in a large prospective series of recurrent varicose veins. METHODS: Duplex and operative findings were recorded prospectively in a consecutive series of 500 limbs undergoing surgery for recurrent varicose veins between 1995 and 2005 in a university teaching hospital. Only limbs with previous saphenofemoral junction surgery were included. All limbs had preoperative duplex mapping by an accredited vascular technician who assessed the status of the great saphenous vein (GSV) in the thigh and groin, sought sonographic evidence of neovascularization, and reported on the presence of reflux in the short saphenous vein and perforator sites (typical and atypical). All operations were performed with an attending vascular surgeon as the lead operator. RESULTS: Primary GSV surgery was incomplete in 83.2% of limbs. A completely intact GSV system was present in 17.4% of limbs. An incompetent thigh saphenous vein was present in 44.2% of limbs, 37.6% had GSV stump incompetence with one or more intact tributaries, and 16% had both a residual thigh GSV and an incompetent stump with intact tributaries. Non-GSV sites of reflux were identified in 25% of limbs. Neovascularization was identified on duplex scanning in 41 (8.2%) limbs. However, in 27 of these, surgical exploration revealed a residual GSV stump with 1 or more significant tributaries. Each of the remaining 14 (2.8%) limbs had a residual incompetent thigh GSV. CONCLUSIONS: Despite reports to the contrary, neovascularization occurs in a relatively small proportion of patients with recurrent varicose veins. All recurrent varicose veins associated with duplex-diagnosed neovascularization are also associated with persistent reflux in the GSV stump tributaries, thigh GSV, or both. Recurrence after primary varicose vein surgery is associated with inadequate primary surgery or progression of disease, and neovascularization alone is not a cause of recurrent varicose veins.     

Blocking the Saphenofemoral Junction During Ultrasound-Guided Foam Sclerotherapy – Assessment of a Presumed Safety-measure Procedure

ObjectivesUltrasound-guided foam sclerotherapy (UGFS) is a technique in which a mixture of sclerosing drug and gas is used to treat varicose veins. Several authors have demonstrated transient systemic effects after UGFS. These effects are not well understood but probably originate from a systemic distribution of the sclerosing foam. Therefore, safety measures have been developed to prevent foam from flowing into the deep venous system. The aim of the study is to evaluate whether blockage of the saphenofemoral (SF) junction by either manual compression or surgical ligation prevents microbubbles from leaking into the deep venous circulation.MethodsTo detect the distribution of microbubbles, radioactive pertechnetate (^99mTcO₄^?) was added to the foam solution. Initially, in vitro trials were performed in the laboratory to investigate the effect of ^99mTc on foam stability. The time taken for foam to liquefy was measured for foam alone and for the mixture with ^99mTc. In subsequent research, eight varicose great saphenous veins (GSVs) were treated by UGFS. In three patients, this treatment was preceded by surgical ligation of the SF junction. In three patients, the groin was manually compressed during UGFS. In two patients, UGFS was performed without compression of the groin.ResultsIn vitro, ^99mTc did not influence foam stability; after 2.6 min all foam had reduced to liquid, regardless of whether ^99mTc had been added or not. In vivo trials showed that all patients showed a decrease in the cumulative amount of ^99mTc detected in the GSV following polidocanol-^99mTc mixture injection. However, the decrease of radioactivity was slightly reduced when compression or ligation of the SF junction was performed.ConclusionsBlocking the SF junction during UGFS using either manual compression or ligation does not prevent, but may reduce the flow of foam into the femoral vein.     

大隐静脉属支结扎与否对微波腔内闭合术疗效的影响

目的:观察大隐静脉5大属支结扎与否对微波腔内闭合术治疗大隐静脉曲张疾病效果的影响.方法:对600例大隐静脉曲张疾病患者行微波腔内闭合术,其中,400例(635条患肢)采取大隐静脉高位结扎加主干微波腔内闭合术,经皮穿刺微波闭合下肢浅表曲张静脉与病变交通静脉(观察组);200例(313条患肢)除以上处理外,结扎大隐静脉5个属支(对照组).结果:两组患者术后均获满意疗效.两组间浅静脉曲张、患肢肿胀、色素沉着、溃疡的改善情况及术后并发症发生率、5年复发率等均无明显差异(均P＞0.05).超声影像学显示,观察组术后股总静脉流速较术前明显减慢,内径明显减小(均P＜0.05);而对照组术后股总静脉流速较术前明显减慢(P＜0.05),但内径减小未达统计学意义(P＞0.05).结论:大隐静脉5大属支结扎与否不影响微波腔内闭合术治疗大隐静脉曲张疾病的效果.     

Anatomical Patterns of the Above Knee Great Saphenous Vein and its Tributaries: Implications for Endovenous Treatment Strategy

Objective: The aim of the present study was to analyse the anatomical patterns of the above knee great saphenous vein (GSV) and its tributaries in limbs with varicose veins in view of potential suitability for endovenous treatment. Methods: Limbs of a consecutive series of new patients with varicose veins presenting at the phlebologic clinic during a 4 month period were studied. In 73 limbs of 56 patients with varicose veins and both saphenofemoral junction and GSV reflux, anatomical patterns of the above knee GSV were defined as :

-‘complete’ GSV: main trunk visualised within the saphenous compartment from the groin to the knee

-‘incomplete’ GSV: main trunk partially visualised from the groin to mid thigh with a non-refluxing mostly hypoplastic distal GSV and a superficial tributary vein (STV) parallel to the GSV.

Results: 51 limbs (70 %) had a ‘complete’ GSV. In 4 of these 51 limbs reflux passed from the main GSV trunk to a STV at mid thigh level leaving a non-refluxing part of the GSV from mid thigh to the knee.

Conclusion: In only 64% of limbs with varicose veins the entire above knee GSV was involved in the disease. This may have implications for endovenous treatment strategy.     

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.     

Efficacy and safety of great saphenous vein sclerotherapy using standardised polidocanol foam (ESAF): a randomised controlled multicentre clinical trial.

AIM: To assess the safety and efficacy of sclerotherapy of the great saphenous vein (GSV) comparing standardised polidocanol foam to liquid polidocanol in a randomised controlled trial (RCT). METHODS: A multicentre randomised controlled clinical trial was carried out in which saphenous trunks were treated by sclerotherapy. 106 patients with primary varicose veins due to an incompetent GSV were treated with either standardised 3% polidocanol foam or 3% liquid polidocanol. The primary efficacy criterion was elimination of reflux (<0.5 sec) measured 3 cm below the sapheno-femoral junction (SFJ) by duplex ultrasonography 3 months after the last injection. RESULTS: A significantly greater number of patients were successfully treated by foam sclerotherapy resulting in 69% elimination of reflux compared to 27% patients treated with liquid sclerosant. The secondary endpoints of vein occlusion, reflux time, refilling time and patient satisfaction also improved significantly more in the foam group. The mean number of treatment sessions was 1.3 in the foam group compared to 1.6 in the liquid group. Differences between study centres occurred with a mean of 96% reflux elimination in 6 centres versus 39% in 4 other centres. Centres with a high response rate injected a higher mean volume (4.3 vs. 3.6 ml) in the first session in a vein with a smaller diameter (7.5 mm vs. 8.4 mm). No difference in adverse drug reactions was observed between treatment groups. CONCLUSIONS: Standardised 3% polidocanol foam is more efficient and equally safe compared to 3% liquid polidocanol for treatment of GSV. In comparison to other studies a relatively small volume was injected into relatively large veins.     

DUPLEX SCANNING FOR RECURRENT VARICOSE VEINS

Background: Most studies of recurrent varicose veins have been based on the findings clinically, at operation, or on phlebog-raphy. Occasionally these findings have been compared with Doppler findings produced by hand-held continuous-wave Doppler. Duplex scanning is a more refined approach to the assessment of recurrent varicose veins. Methods: 202 patients (267 legs) have been examined consecutively for recurrent varicose veins between January 1990 and December 1995 at St George Vascular Laboratory. This was a retrospective study of some aspects and patterns of recurrence of varicose veins in this group. Results: The ratio of female to male was 3 :1. The mean age of the group was 52 years and mean time to recurrence was 13 years (1 year 95% CI). There were six patterns of recurrence accounting for 95.2% of legs. In descending order of frequency, these were: (i) the saphenofemoral junction and long saphenous vein were intact and incompetent (44.6%); (ii) an incompetent thigh perforator and long saphenous vein remained intact; there was no saphenofemoral junction (16.5%); (iii) the long saphenous vein remained intact and incompetent; there was no saphenofemoral junction (10.5%); (iv) there was an incompetent saphenofemoral junction only (9.74%); (v) there was an intact and incompetent saphenopopliteal junction alone (9.74%); and (vi) an isolated thigh perforator was incompetent, with no more proximal site of incompetence detected (4.12%). Incompetent calf perforator (69.2%) and gastrocnemius veins (9.3%) were frequently detected, but rarely existed in isolation (seven legs in total). Conclusions: Duplex scanning is an important recent adjunct to the management of recurrent varicose veins in order to define the ‘pathway of incompetence’. The saphenofemoral junction and long saphenous vein remain the key to recurrence of varicose veins. Calf perforator and gastrocnemius vein incompetence are of secondary importance in recurrent varicose veins.     

Stripping the long saphenous vein reduces the rate of reoperation for recurrent varicose veins: five-year results of a randomized trial

OBJECTIVE: The purpose of this study was to investigate the possible long-term clinical advantages of stripping the long saphenous vein during routine primary varicose vein surgery. METHODS: The study was designed as a 5-year, clinical and duplex scan follow-up examination of a group of patients who were randomized to stripping of the long saphenous vein during varicose vein surgery versus saphenofemoral ligation alone. The study was conducted in the vascular unit of a district general hospital. One hundred patients (133 legs) with uncomplicated primary long saphenous varicose veins originally were randomized. After invitation 5 years later, 78 patients (110 legs) underwent clinical review and duplex scan imaging. RESULTS: Sixty-five patients remained pleased with the results of their surgery (35 of 39 stripped vs 30 of 39 ligated; P = .13). Reoperation, either done or awaited, for recurrent long saphenous veins was necessary for three of 52 of the legs that underwent stripping versus 12 of 58 ligated legs. The relative risk was 0.28, with a 95% confidence interval of 0.13 to 0.59 (P = .02). Neovascularization at the saphenofemoral junction was responsible for 10 of 12 recurrent veins that underwent reoperation and also was the cause of recurrent saphenofemoral incompetence in 12 of 52 stripped veins versus 30 of 58 ligated legs. The relative risk was 0.45, with a 95% confidence interval of 0.26 to 0.78 (P = .002). CONCLUSION: Stripping reduced the risk of reoperation by two thirds after 5 years and should be routine for primary long saphenous varicose veins.     

Systematic review of foam sclerotherapy for varicose veins

BACKGROUND AND METHOD: Foam sclerotherapy is a potential treatment for varicose veins. A systematic review was undertaken to assess its safety and efficacy. RESULTS: Sixty-nine studies were included. The median rates of serious adverse events, including pulmonary embolism and deep vein thrombosis, were less than 1 per cent. The median rate of visual disturbance was 1.4 per cent, headache 4.2 per cent, thrombophlebitis 4.7 per cent, matting/skin staining/pigmentation 17.8 per cent and pain at the site of injection 25.6 per cent. The median rate of complete occlusion of treated veins was 87.0 per cent and for recurrence or development of new veins it was 8.1 per cent. Meta-analysis for complete occlusion suggests that foam sclerotherapy is less effective than surgery (relative risk (RR) 0.86 (95 per cent confidence interval (c.i.) 0.67 to 1.10)) but more effective than liquid sclerotherapy (RR 1.39 (95 per cent c.i. 0.91 to 2.11)), although there was substantial heterogeneity between studies. CONCLUSION: Serious adverse events associated with foam sclerotherapy are rare. There is insufficient evidence to allow a meaningful comparison of the effectiveness of this treatment with that of other minimally invasive therapies or surgery.