Abstracts from the
16th Annual Congress of the American College of Phlebology
November 7 - 10, 2002 Fort Lauderdale, Florida
Несмотря на 4-х летнюю давность абсолютное большинство абстрактов более чем актуальны и сегодня.
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FAMILIAL INQUIRY ON VENOUS DISEASE TRANSMISSION AND THE PREDICTIVE VALUE OF THE CEAP RATE OF MOTHERS
Francois ALLAERT, MD, PH D
Many studies describe the venous status of ascendants of people consulting for CVI but very little information is available on the transmission from mother to daughter or son. This study describes the venous status of the descendants of mothers with CVI.
OBJECTIVE: To conduct a familial inquiry on chronic venous insufficiency (CVI) transmission in order to determine if the venous status of the mother may predict the venous status of theirs sons and daughters.
METHODS: cross sectional study conducted by family practitioners. Each medical practitioner includes the next ten women presenting venous insufficiency and having children. For each case, they describe the venous status of the mother and children.
RESULTS: the study covers 4294 women 57,6 � 13,9 years old with CVI 21,3% were CEAP rate 1, 36,5% CEAP rate 2, 23,5% CEAP rate 3, 11,8 CEAP rate IV, 5,2 CEAP rate V and 1,6% CEAP rate VI. The statistical analysis shows that:
- in 49,0%, at least one of the descendants of these women presents a CVI;
- the sex ratio of the descendants with CVI is 6 women for a man;
- after adjustment on age and number of children, the percentage of CVI transmission is statistically linked to the ceap rate of the mother; 43,8% by CEAP I, 56,8% by CEAP II, 60,3% by CEAP III and 69,1% CEAP IV and more.
- CVI symptoms appear earlier by the children of women presenting early CVI;
- after age adjustment by mother and children, CVI CEAP rates are significantly higher by descendants of mother presenting the highest CVI CEAP rate.
CONCLUSION: The venous status of the mother appears to have some predicting value of the venous status of the daughter.
Coagulation Disorders for the Phlebologist
James Altizer, MD
TITLE: Coagulation Disorders for the Phlebologist
OBJECTIVE(s): To review the most common coagulopathies likely to be seen in the Phlebologist's practice, determine who needs to be tested, decide which tests are most appropriate, and determine whether a positive test will influence treatment.
METHOD(s): Review of current literature pertaining to coagulopathies.
RESULT(s):
CONCLUSION(s): Coagulopathies are more common than previously recognized. New tests are now available to screen patients for these disorders. Because certain treatments for varicose veins, i.e. sclerotherapy, carry a small risk for DVT, it is important to screen patients who may be at higher than average risk and alter therapy in those cases.
Compression therapy before and after venous surgery
Jean-Patrick BENIGNI, MD
Objective : Presentation of recommendations of the international consensus conference on compression therapy (Paris 2002)
Methods: Methodology recommended by ANAES
Results:
Compression therapy before surgery
. The leg should be treated with compression, when necessary, in order to minimise, edema, inflammation, and leg tissue changes at the time of the operation.
. Compression is tailored to the condition of the patient. The more chronic and severe the condition, the more intense the compression therapy needs to be.
Compression therapy during surgery
One study showed that bandaging of the leg immediately before stripping does not reduce hematoma formation.
Compression therapy after surgery
. Prolonged use of compression might provide benefits that include decreased incidence of recurrent varicosities, and a reduced incidence of recurrent superficial and deep venous thrombosis. The progression of chronic venous disease may also slowed by the chronic use of compression. These ideas are conceptual, and supported by little data.
Compression Therapy For Superficial Venous Surgery In Primary Varicose Disease
. The panelists recommend (grade b recommendation) that firm bandages be used immediately after surgery to reduce bleeding complications.
. The panelists feel (grade c recommendation) that compression therapy may keep the incidence of VTE low after surgery. They also feel that patients at high risk may also benefit from postoperative LMWH prophylaxis in addition to compression therapy.
. Based on the available evidence the commission recommends (grade b) the use of light (15mmHg) stockings during the first week to reduce leg symptoms (leg symptoms include pain, tenderness, discomfort, and a variety of vague leg sensations).
. Based on the level of evidence the commission feels that there is no difference between 10-15 mmHg, and 30-40mm Hg elastic stockings in terms of patient mobility (grade c). Strong bandages, on the other hand, seem to impair mobility unnecessarily during the first week.
. The commission recommends on the basis of available data (grade b) that one week of compression should be used. In some cases longer periods of compression may be necessary.
. The commission feels that the time away from work depends more on the type and extent of surgery performed as well as the nature of the individual patient than on compression therapy alone.
. Compliance with compression : the commission recommends that elastic stockings be used since they are helpful for a variety of reasons, and easy to use.
. Duration of compression: the commission feels that there is little current evidence to recommend the prolonged use of compression stockings after uncomplicated primary varicose vein operations.
Conclusions: Theses recommendations of the commission in terms of compression therapy before and after venous surgery are susceptible to change the medical practice.
Polidocanol 400 foam injection and migraine with visual aura
Jean-Patrick BENIGNI, MD; Herilavitra RATINAHIRANA, MD; Marie-Germaine BOUSSER, MD, FACS
Objective : Reporting of side effects with foam sclerotherapy
Polidocanol 400 foam (PF) has been recently developed as a sclerosing agent for the treatment of reticular varicose veins and telangiectasis. Although usually well tolerated, some side general effects have been reported such as " visual problem ".
Methods : We report 4 consecutive cases seen in 6 months in whom the injection of Polidocanol foam in reticular or telangiectasis triggered a typical attack of migraine with visual aura.
Results: Description of patients' side effects
. A 45 year old female : ten minutes later an second injection of 2 ml of PF at 0.15%, she saw a white spot in the lower part of her visual associated with moving broken lines and blurred vision. This visual symptom lasted 23 min and was followed by a 2 hour bitemporal pulsatile headhache without nausea, vomiting and photo-phonophobia. After the previous injection, she also had a blurred vision followed by an headache.
. A 43 year old male : 10 min after an injection of 2 ml of PF (0.15%), he saw as through a kaleidoscope for 30 min and suffered for 2 hours a fronto-temporal headache.
. A 47 year old female : she had a typical history of migraine with aura since the age of 12 with 3-4 attacks a year, she described 10 min after a 2 ml of PF injection (0.15%) her usual scintillations for 25 min followed by an headache.
. A 53 year old male : three minutes after a first injection of 2 ml of PF at 0.2%, he saw a central blurring of vision, which turned into a typical scintillating scotoma, spreading the periphery without subsequent headache, lasting 20 min.
Conclusion:These 4 patients presented a typical visual migrainous aura followed or not by headaches 3 to 10 min after the injection a low concentration of PF in telangiectasis or reticular veins. The mechanism remains unknown : direct toxicity of the drug, liberation of vaso-actives substances due to the massive disruption of the endothelium, migration of foam through a patent foramen ovale ? Further works should help to elucidate the mechanism of these unusually triggered visual migrainous aura.
Exposure to oxygen-enriched environments accelerates wound healin
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Cheryl Bongiovanni, PhD, RVT, FACA; Cynthia Robinson, CNA
Objective: Chronic wounds often occur in patients with diabetes mellitus, venous insufficiency, paralysis or whose skin integrity is otherwise compromised. Exposure of these lesions to an oxygen-enriched environment, accompanied by appropriate wound toilet and nutritional support, greatly accelerates the healing rate.
Methods: From 1/1/02 - 6/30/02, 41 patients (28 women, 13 men; ages 17-97 years) presented with nonhealing wounds that had been present from 6 weeks to 22 years. For those who were long-term care facility residents, the wounds were isolated and exposed to 10 L/m of humidified, 100% oxygen accompanied by 10 L/m of oxygen by mask for two hours, twice daily. Outpatients were given similar treatments for three hours, once daily. Treatments were continued until the wounds were closed completely.
Results: Time to healing averaged 4 weeks for Braden Stage 4 decubiti (ischial, sacral, scapular, heel and elbow, 2-3 weeks for venous stasis ulcers and 4-6 weeks for ischemic plantar, toe and heel lesions.
Conclusions: The addition of exposure to oxygen-enriched environments is a clinically effective means of accelerating the healing of difficult wounds. The treatments are inexpensive and are not labor intensive. The cost effectiveness of this approach to healing chronic wounds is unparalleled.
Cryo-Stripping of the LSV under Local Anesthesia
Edzard Braam, MD
TITLE: Cryo-Stripping of the LSV under Local Anesthesia
OBJECTIVE(s): we describe a new method of LSV stripping based on the use of cryo-surgery
METHOD(s): the author introduced this technique in 1994 in the Netherlands. Since then more than 4000 consecutive patients (m : w = 1 : 4 ; age 18 to 84 ) were operated in this way by the author. All patients were treated ambulatory.
RESULT(s): the author will discuss the benefits, (dis)advantages and complications of this method and report the opinion of patients who underwent this operation. This procedure is nowadays more and more followed by other vascular surgeons in the Netherlands.
CONCLUSION(s): stripping of the LSV by means of cryo-surgery under local infiltration anesthesia has proven to be a safe, less time-consuming, much more cost effective and cosmetically attractive alternative with less complications compared with conventional procedures
Duplexguided sclerotherapy of the short saphenous vein
Yolande I. J. M. Bullens-Goessens, MD; Joep C. J. M. Veraart, PhD, MD; Anja Sommer, PhD, MD; H.A.M. Neumann, Prof, PhD, MD
OBJECTIVE(s): Varicosity of the legs is a common disease due to malfunction in the veins. Treatment consists of surgery for the greater veins and sclerocompression therapy for side branches and smaller veins.
METHOD(s): Recently a new sclerotherapy technique was developed with which it is possible to treat also greater veins. This technique consists of sclerocompression under duplex guidance (duplex guided sclerotherapy, DGS). DGS is a minimal invasive technique to create obliteration of the insufficient vein. Especially the short saphenous vein is suitable for the treatment with ultrasound guided sclerocompression therapy because of the frequent complication after surgery.
RESULT(s): We treated in this retrospective study 121 insufficient short saphenous veins with ultrasound guided sclerotherapy. After 6 months 78% of the insufficient veins were almost or completely obliterated; after 12 months this was 81%. In total the patients needed 1 to 2 treatments. The costs of ultrasound guided sclerotherapy is substantially lower than that of venous surgery (287 versus 975 Euros).
CONCLUSION(s): Ultrasound guided sclerotherapy seems to be a useful new treatment for especially short saphenous vein insufficiency.
THE MICROPHLEBEXTRACTION: NEW CHALLENGE IN THIS MILLENIUM
Jose Campos, MD
OBJECTIVE(s): The understanding of the Pathophysiology of Chronic Venous Disease (CVD) with different diagnostic method of choice and modern surgical techniques to compare results with standard surgical treatment.
METHOD(s): Unwanted leg, hand, veins and varicose vein and marked telangiectases, are extracted with ambulatory microphlebextraction techniques.
RESULT(s): Surgery was effective in all cases. Patient resumes activities within 24 hours, there was minimal pain and no infection was noted.
CONCLUSION(s): Preliminary work demonstrates that microsurgical techniques can be safe and effective in all aspects.
INGUINAL RECURRENCE PREVENTION: MYTH OR REALITY?
PAOLO CASONI, MD; GIOACCHINO JAPICHINO, MD
OBJECTIVE: The prevention of inguinal recurrence is one of the goal we look for in varicose vein surgery. The inguinal approach is theoretically based on the flush ligation with interruption of tributaries far from the femoral vein.
This procedure couldn't be safe and sufficient to reduce recanalizzation of missed little veins, in case of limphatic reflux or in prevention of the so called "neoangiogenesis".
Aim of this study is to show that the standard crossectomy isn't enough safe in reducing new refluxes arising from the inguinal fold.
METHODS: 300 crossectomies performed during standard regulated internal saphenectomy were randomized into three homogeneous groups for sex and age. In "ligation, interruption of all tributaries arising from the sapheno-femoral junction (SFJ). In the second (group B n=100 ) flush ligation plus the femoral vein (FV) was checked up and down the SFJ for 2 cm. in order to ligate other vessels haemodinamically indipendent from the saphenous system, the endotelium of the ligated SFJ was coagulated and the "foramen ovale" was closed with two resorbable stitches in order to separate the inguinal limpho-fatty tissue from the SFJ. In the third group (C n=100) the surgical procedure included an infolding suture of the SFJ close to the femoral wall (femoroplasty); in any case the FO was closed with separate stitches. In all cases was done an internal saphenectomy (long or short invaginating stripping depending from haemodynamical data) accompanied with large phlebectomies of all tributaries according to the French school. Inclusion criteria were: Primary varicose vein disease with SFJ true incompetence referred to the ostial valve(OV) with troncular reflux from the groin to the knee and below, absence of short saphenous vein incompetence. All cases were echographically mapped the day before surgery from the same surgeon and digitally recordered. The follow up included two clinical and echo guided studies of the groin at 6 and 12 months from surgery. The recurrences were divided in two groups: clinical and echographic.In the first the recurrence was evident with palpable varices while in the second the reflux was detected only by the echo-color-doppler. Any case who presented inguinal reflux was recorded as positive for recurrence. Inguinal recurrence were divided in : limphatic reflux (LR), residual stump (RS) with comunication with FV, neoangiogenesis (NA) without detectable comunication with FV, inguino-abdominal shunts (IAS), missed tributaries from FV wall (MT),groin cavernoma (GC).
RESULTS: In group A the global percantage of recurrence detected from US study was 21% at 6 months and 74% at 12 months. In group B was 12% and 32% at 6 and 12 months. In group C was 10% and 28% at 6 - 12 months. The clinical recurrence was very low in the group B and C, respectively 4 and 2% while was 14% in group A.
CONCLUSIONS:The results are statistically evaluated and discussed with ?? test and the Authors widely discuss any correlation with preexistent pathological field as obesity, diabetes, hormonal pattern which could explain the reason of some predictable recurrence in order to avoid standard procedures in favour of a more satisfactory personalized surgery.
RANDOMIZED TRIAL OF A NEW DRESSING IN THE TREATMENT OF CHRONIC NON-HEALING LEG ULCERS
PAOLO CASONI, MD; GIOACCHINO JAPICHINO, MD
OBJECTIVE : Leg ulcers represents a common source of morbidity in the elderly. A wide variety of methods have been tried but few have been assessed in randomized trials.
The aim of this study is to test if an occlusive dressing with Hyaluronic acid-iodine povidone can improve healing in chronic non-healing leg ulcers .
Methods: Among 394 leg ulcers in 5 years a small group of 65 homogeneus cases with non-healing vascular leg ulcers were randomized 4 weeks after conventional treatment (Unna or multilayer bandage, antibiotic sistemic therapy ) and when the lesion had failed to reduce by 10% of the original size. Patients continued treatment with the Unna bandage changed weekly and randomized to receive either a occlusive dressing with hyaluronic acid and povidone iodine (n= 32 Group A) or a simple non-adherent (NA)dressing (n= 33 Group B). Exlusion criteria as diabete, severe peripheral atherosclerotic disease with ankle index (I.W.). < 0,6, severe cronic cardiac and hepatic failure, nephrosic syndrome with CRI were strictly respected and are widely discussed. The main end point for this trial was the time to complete healing, anyway a comparison of images and of life tables up to 3 months of treatment was done.
Results: At the end of the study 48% of patients treated with occlusive dressing and 24% to an NA pancement had completely healed. Life tables analysis showed a significant difference (p=0,049).
Conclusions: The Author discuss the pathways, goals and pitfalls of a possible new treatment in chronic ulcer disease of the lower limbs.
NOVEL TREATMENT OF INOPERABLE VENOUS MALFORMATIONS
Antonio Martinez de la Cuesta, MD; Pedro Redondo, MD; Juan Cabrera, MD; Juan Jr Cabrera; M� Antonia Garcia-Olmedo
OBJECTIVE(s): Treating venous malformations is difficult: surgery is frequently unsuccessful, sclerotherapy has little to offer, and radiographic embolization has an ill defined role. Limitations of liquid sclerosants are overcome in a novel microfoam form that displaces the blood with little dilution or deactivation of sclerosant. The addition of gas to create microfoam greatly expands the volume and reduces the dose. Microfoam is also highly echogenic and can be accurately followed by real-time ultrasound. We aimed to review our experience treating venous malformations with microfoam.
METHOD(s): Fifty patients with inoperable venous malformations, some giant, were investigated with color duplex ultrasound and angio-MRI. Sodium tetradecyl sulfate or polidocanol prepared as microfoam was injected (20-100 ml) under ultrasound guidance; treatments (range, 1-46) were usually repeated at 14-day intervals.
RESULT(s): In all cases there was progressive reduction in size and in 18 cases complete disappearance, confirmed by MRI. No further extension of lesion was observed in follow-up (6-108 months), In four cases, cutaneous necrosis was resolved conservatively; other patients suffered minor transient pain.
CONCLUSION(s): Microfoam treatment produced good outcomes with few complications and may become the treatment of choice for these difficult cases.
Evaluation and Treatment of Venous Stasis Ulcers utilizing Diagnostic Ultrasound and Image-guided sclerotherapy
Thomas Eaton, MD; Brian McDonagh, MD
OBJECTIVE(s): Venous stasis ulcers represent the end-stage of chronic venous insufficiency.
Principal causes are saphenous reflux disease and/or deep venous reflux.
Predictive factors favoring healing vs. treatment failures.
Efficacy and safety of ultrasound-guided sclerotherapy for long-term stasis ulcer healing.
METHOD(s): Clinical observations of multiple patients presenting to clinic with CEAP Class V Disease. Those with primary deep venous disease were not treated. Those with primary superficial venous disease were treated with image-guided sclerotherapy. Results of all patients who presented over a four-year period.
RESULT(s): The majority of treated patients healed rapidly.
CONCLUSION(s): Duplex ultrasound can provide a clear diagnosis to the etiology of venous stasis ulceration. Image-guided sclerotherapy can be a safe and rapid method leading to cure. Possible reasons for the failure of some patient's ulcers to heal are discussed.
Restoration of Saphenous Vein Function utilizing selective Ultrasound-guided Sclerotherapy
Thomas Eaton, MD; Brian McDonagh, MD
OBJECTIVE(s): At the ACP meeting in Palm Springs, the question was raised; "Can pathologic saphenous vein function be restored?"
Using venous flow mapping with Duplex ultrasound helps clarify simple hemodynamic principles. Selective image-guided sclerotherapy has been shown to restore simple segmental defects within the axial saphenous veins; in one case, function of the saphenofemoral junction was restored. The author will present before and after ultrasound maps confirming restoration of vein function, and discuss the basic hemodynamic principles behind these findings in several patients.
METHOD(s): Duplex ultrasound mapping was performed on all patients presenting for treatment of varicose veins. Every map is evaluated for the possibility to restore normal antegrade flow to axial or branch varicosities. Flowing restoration attempts, the patients were reevaluated with Duplex mapping to evaluate outcome.
RESULT(s): In some patients, we were able to restore normal function to segments of axial or tributary veins. In one patient we were able to restore function of the incompetent saphenofemoral junction.
CONCLUSION(s): The superficial venous network is a complex system. Pathology can occur within the system itself, or from influences from either the deep venous network or the reticular network. Using Duplex ultrasound to evaluate the hemodynamics prior to treatment can lead to selective ablation techniques, surgical or chemical, that may improve outcome by restoring segmental or complete axial vein function.
Gold Award Winner
Transilluminated Miniphlebectomy
Alexander J.C. Flor, MD
Background: Miniphlebectomy according to Varady's technique is acknowledged as a protective and cosmetically high-standard method.
Yet as a blind procedure several attempts maybe required to retrieve the vein, especially in the case of adherent veins, e.g. in the tibial region or following prior thrombophlebitis.
Surgical technique: Owing to transillumination and hydrodissection we dissect the veins in sight: a luminiferous 5mm rod which features at its oblique tip a cannular opening to allow the flow of saline solution is inserted into the subcutaneous tissue. At favorable places such as crossings or perforating veins branching off, stitch incisions are made. The vein can then be prepared and retrieved in sight by Varady's hook.
Results: From January 19, 2002 until July 11, 2002, 113 patients with varicose veins were treated. Transilluminated Miniphlebectomy was employed in 19 patients. The technique takes maximal care of the tissue, lesions of lymphatic vessels and sensitive nerves of the skin can be avoided, the total amount of stitches can significantly be reduced.
Conclusion: In view of its increased technical requirements, the method is certainly not recommended for the treatment of individual lateral saphenous branches.
In cases of larger varicose areas however we consider the Transilluminated Miniphlebectomy as a cost-and-time saving method.
Advances in diagnostic of teleangiectasias: reflection spectrophotometer for objective classification and prediction of treatment's outcome
ALESSANDRO FRULLINI, MD
Advances in diagnostic of teleangiectasias: reflection spectrophotometer for objective classification and prediction of treatment's outcome
Classification of teleangiectasias has been done according to several parameters: shape, localisation, colour etc. Anyway it has been done always only empirically and without any objective-quantitative data. This is mainly related to our poor understanding of this pathology and to pratical problems related to the small dimension of teleangiectasias.
Spectroscopy is the measurement and analysis of electromagnetic radiation absorbed, scattered or emitted by atoms, molecules or other chemical species. The absorption and emission of electromagnetic radiation is associated with changes in energy states of the species. The UV-Vis spectrum is from 200nm to 800 nm. The UV-Vis spectrophotometer then measures the absorption of energy. This means that we can objectively measure the colour of a teleangectasia.
There are three descriptors of the visual sensation of colour: brightness or luminance, hue and saturation or chroma (the colourfulness of a sample relating to saturation relative of the range from a pure hue to a neutral color having no hue).
The association of three given values of H,S and L univocally identifies a colour. This system is called COLOR GAMUT.
I have used a portable spectrophotometer (Pikkio MHT) widely used by dentist and dental technicians for matching correct tooth colours.
The limitations of such method are mainly due to the size of the target compared with the reading area of the device but this can be easily overcame using a black adhesive tape with a fissure or an hole of given dimension. The pression exerted on the skin can be an additional problem because it can change the amount of blood in the vessel and then change the result. Moreover targeting the same teleangiectasias two times can be sometimes difficult.
From my initial experience with reflection spectrophotometry in teleangectasias classification I can state that this could be a revolutionary tool in the treatment of this pathology. Laser user will benefit the most from mathematical definition of the colour of the lesions the will treat but also sclerotherapy could benefit if will be found a relation between colour and doses. A dedicated spectophotometer with on screen visualisation of the reading area and the possibility to choose the vessel to measure could be the next step and, hopefully, the next advance in teleangectasias treatment.
Venous ulcers and compression therapy
Jean-Pierre Gobin, MD
OBJECTIVE(s): Presentation of recommandations of the international consensus conference on compression therapy (Paris 2002).
METHOD(s): Methodology recommended by the consensus conference.
RESULT(s):
Usefulness of compression therapy in treatment of venous ulcer : Compression therapy was associated with an increased healing rate of venous leg ulcers which was statistically significant in five randomised controlled trials, and did not achieve statistical significance in a sixth one of smaller sample size and low power. Compression therapy is the most important part of the treatment of patients with legs ulcers, but the correction of venous refluxes and the kind of local dressing (Blair-1988) should be considered in every single case.Recommendation: Compression therapy should be recommended as the basic treatment in patients with venous leg ulcers (Grade A).
Interest of 4-layer bandage, inelastic bandage, short stretch, medium stretch, long stretch bandage, compression stockings : From the literature (3 studies and meta-analysis), devices supposed to produce high compression are more effective than those giving low compression, but the interface pressure itself was not measured. Severe arterial disease has to be excluded. No clear evidence was found from the literature regarding a difference between the 4-layer bandage, other high-pressure compression systems and Unna's boot. Compression stockings may also be effective (Hendricks, Horakova). Other types of bandaging are widely used by experts (e.g. adhesive bandage) although with no validating study.In the absence of such evidence, the choice of the bandaging should take into account the status of the limb (stage of the ulcer's healing), the patients status, and the habits and expertise of the nursing staff.Recommendation: High level of compression should be achieved in the compression therapy of patients with venous leg ulcers (Grade B).Further studies should include a documentation of the sub-bandage pressure.
Interest of dressing pads : To increase local pressure (e.g. behind the inner ankle or on flat portions of the leg), according to Laplace's law, compression pads made of different materials may be used. The physical effect of this procedure was demonstrated; the clinical benefit is not documented in the literature but receive a large professional agreement.
Compression in healed leg ulcer : Two RCT demonstrated lower ulcer recurrence rates in patients with high pressure elastic stockings. Not wearing compression was associated with recurrence in both studies. Patients should be offered the strongest compression with which they can comply depending on the general condition and the ability of the patient to apply the compression device. (Nelson, Cochrane 2001) . Systematic follow up of the patient with evaluation of the compression procedure and the compliance is required (Mayberry, Surgery 1991).Recommendation: Compression therapy is strongly recommended to prevent the relapse of healed ulcers and the occurrence of new ulcers (Grade B).
Economic impact of compression in treatment of venous ulcer : The direct cost of leg ulcers for the society is huge and was documented in USA, UK, Germany and France. The indirect costs related to time lost from work, permanent disability and early retirement up to 12.5% (53 Da Silva, 1992) are even higher.There is no measurement of the cost-effectiveness of compression therapy in venous leg ulcers in the literature. However, the substantial improvement of the healing rate, and reduction of recurrence should result in important savings.
CONCLUSION(s): Compression therapy should be recommended as the basic treatment in patients with venous leg ulcers.
Endolumenal Closure of the Greater Saphenous Vein with the 810 nm Diomed Laser: Intermittent Pulse versus Continuous Treatment
Mitchel Goldman, MD; Shilesh Iyer, MD
Background: Intermittent pulses of the 810 nm diode laser every 1-2 mm is effective in treating greater saphenous veins (GSV) incompetence but is associated with significant pain and possible venous perforation. We hypothesize that continuous thermal destruction rather than intermittent pulses can be used to produce more uniform heating with lower risk of perforation and less pain.
Materials and Methods: Twenty eight GSV's were treated with the 810 nm Diomed diode laser with intermittent pulses and 15 GSV's were treated with continuous heating under tumescent anesthesia. Patients were assessed at a 24 hour postoperative visit for pain and complications.
Results: In the group treated with intermittent pulses, 7 of 28 patients (25.0%) complained of pain or had tenderness on examination. In the group treated with continuous heating, 4 of 15 patients (26.7%) complained of pain. Histologic examination of selected veins demonstrated perforations in both continuous and pulsed segments.
Conclusions: We propose a novel method of endolumenal closure with the diode laser, namely controlled continuous thermal destruction. Compared with the pulsed technique, continuous heating appears to be associated with comparable rates of pain and risk of venous perforation. One year follow-up data comparing both techniques will be presented.
CLINICAL AND HAEMODINAMICAL OUTCOMES OF DUPLEX GUIDED FOAM SCLEROTHERAPY (DGFS): A 24 MONTH FOLLOW UP STUDY
Rodrigo Gonzalez, MD. FACP.
Purpose: Assess the clinical and hemodynamic outcomes of duplex guided foam sclerotherapy in the treatment of primary superficial venous insufficiency.
Material and Method: Patients Cs 0 - 5 Ep As 2, 3 or 4 P r, evaluation consisted of: clinical classification, symptoms assessment and Color Duplex scan. Patients should have NO contraindications for sclerotherapy and gave informed consent.
93 patients were included, a total of 155 DGFS were completed, 106 incompetent LSV and 69 SSV. DGFS consisted of guided injection using Polidocanol 6% or 3% foam with a Tessari's technique and Class I compression stockings. We looked for complications 1 and 4 weeks after the treatment and followed up patients at 12 and 24 months. Duplex scan, clinical classification and symptoms were registered.
Results: Complications for each procedure were minor (matting, pigmentation, moderate pain), only one DVT (0, 6%) and no intra-arterial injections. Reflux was observed: 12 month in 9,4 % of LSV and 4,3% of SSV, 24 month 14 % of LSV and 10% of SSV. There was a substantial positive change in CEAP Clinical classification and symptom relieve, from a 38% of symptoms average at the beginning, to 8% at 12 month and 13% at 24 month evaluations.
Conclusion: Duplex guided foam sclerotherapy is a safe procedure with few recurrences to 24 month that allows improving clinical signs, symptoms and hemodynamics of superficial venous insufficiency.
Bronze Award Winner
Evaluation of the efficacy of polidocanol in the form of foam versus liquid form in sclerotherapy of the long saphenous vein
Claudine HAMEL-DESNOS, MD; Pierre OUVRY, MD; Philippe DESNOS, MD; Serge MAKO, MD
OBJECTIVE(s): To compare foam sclerotherapy versus liquid sclerotherapy for long saphenous vein incompetence using echo-guided sclerotherapy
METHOD(s): a comparative, prospective, multicenter clinical trial
RESULT(s): will be available before the ACP congress
CONCLUSION(s): For several years now, foamed sclerosing agents have widely been used with great enthusiasm. Any type of varicose veins, wheather truncular or not, are subjected to this new technique. Using empiric criteria, numberous publications praise the advantages and benefits of the new utilisation of sclerosing agents. They often emphasize the description of techniques to prepare a "good" foam. In order to gain objective and precise arguments into the abundance of information, a group of angiologists conducted the first comparative, prospective, multicenter trial in the Normandie/France comparing foam versus liquid sclerotherapy for long saphenous veins. It is a randomised study with approval of the CCPPRB (Comit� Consultatif de Protection des Personnes dans le Recherche Biom�dicale) and under the patronage of AFFCA (Association Fran�aise de Formation Continue en Ang�iologie). In this study, the reference sclerosing agent was Polidocanol in a 3% solution. The technique of preparing the foam is new, standardised and uses sterile air (DSS Method). Sclerotherapy is performed with direct puncture under duplex guidance. After completing experience with the methodology of echo-guided sclerotherapy, the author prepared the study protocol, including the method of foam preparation, the efficacy criteria (results at one year) and the secondary efficacy criteria. The study is planned to last 2 years (and may be
Antegrade Stripping of the Greater Saphenous Vein with Retrograde Passage of the Tretbar Stripper
Stanley Hirsch, MD; Maria Lu, PA-C
OBJECTIVE(s): to allow easier utilization of the Tretbar stripper
METHOD(s): invagination stripping of the greater saphenous vein is now commonly done using the Oesch stripper inserted at the groin and brought out through a stab wound at the distal thigh or knee. The Tretbar stripper is an adaptation using a flexible wire. This allows passage of the stripper through more tortuous veins. However, the lack of rigidity makes it difficult to locate the distal tip. We mark the greater saphenous vein by duplex scan and through a small phlebectomy incision below the knee insert the Tretbar stripper and pass it retrograde to the groin, fix the vein to the stripper and perform an antegrade stripping. An additional feature of the Tretbar stripper is the large opening in the tip that allows two or three throws of the suture, reducing the incidence of the suture breaking away from the stripper, a problem with the Oesch stripper.
RESULT(s): From July 8, 2001 through March 31, 2002 we performed 142 greater saphenous vein strippings in our office. We were able to use the above technique in 71 (50%). Difficulty in accessing the vein or passage of the stripper accounted for most failures. Further details of the technique, advantages and disadvantages will be discussed
CONCLUSION(s): the above technique allows easier utilization of the Tretbar stripper. With experience a higher success rate can be achieved.
New Endolaser Venous System (980 nm) Treatment of Long Saphenous Vein Reflux: Efficacy and Safety
Lowell S. Kabnick, MD, FACS
OBJECTIVE(s): Evaluate efficacy and safety treating LSV reflux with new Endolaser Venous System (ELVS) Biolitec, East Longmeadow, Mass; AngioDynamics, Queensbury, NY, 980 nm diode and 600 micron bare-tipped fiber.
METHOD(s): Patients (Pts.) undergoing diagnostic duplex revealing LSV reflux where included. 20 consecutive limbs (LSV) 15 Pts. were treated. 600-micron fiber was passed through a percutaneously placed 45 cm (5Fr) sheath positioned by ultrasound just below the saphenofemoral junction (SFJ). Using continuous power, 12 W, the fiber was pulled back 10-12 cm/min. Post procedure Pts. were evaluated by duplex and the author.
RESULT(s): 20/20 limbs (LSV) were closed and showed no SFJ reflux. Average age, 50.5 (33-68). 14 Pts. were female; 1 Pt. was male. Complications: ecchymosis, discomfort/pain, superficial phlebitis. 19 Pts. had varying degrees of ecchymosis; 1 Pt. was without ecchymosis. All discoloration disappeared in less than 3 weeks. All Pts. had minimal discomfort, onset approximately 4-5 days post procedure. 1 Pt. complained of pain from superficial phlebitis. There were no burns, hypoesthesia, or DVT. All Pts. resumed activities of daily living on day one.
CONCLUSION(s): Early results using ELVS employing continuous energy with rapid laser fiber pull back, appears efficacious and safe. Long term observation and trials with decreasing continuous energy are planned.
Combination Therapy for the Treatment of Recurrent Varicose Veins after Ligation and Stripping using Transcatheter Sclerotherapy, Endovenous Laser and Phlebectomy
Edward Mackay, MD
OBJECTIVE(s): Recurrent Varicose Veins after previous vein surgery often appear many years after the treatment and is often more complex in anatomy then the usual saphenous insuffiency. The most common findings are neovascularization and perforator incompetence. This study retrospectively evaluates the results of combination therapy using transcatheter sclerotherapy, endovenous laser and stab-avulsion phlebectomy as a single in-office procedure.
METHOD(s): 13 patients under the combination therapy on 14 limbs using either sotradecol or polidocanol for the transcatheter sclerotherapy usually using air foam in 2:1 ratio for better visualiztion, 810 nm diode Diomed laser for the EVLT and stab-avulsion pblebectomy. The patients were then followed up at less than one week, one month, three months, six months and one year with duplex evaluation and physical examination.
RESULT(s): All 14 limbs showed occlusion of the lasered portion of the vein and significantly reduced neovascularization on the follow-up which ranges from one month to one year. there were no major complications and significant improvement in symptoms.
CONCLUSION(s): Combination therapy using transcatheter sclerotherapy, Endovenous laser and stab- avulsion phlebectomy for the treatmen of recurrent varicose allows for a single office procedure to treat this complex and diverse group of patients. Long term follow-up will be needed to determine the durability of the procedure.
Transcatheter Ablation of the Lessor Saphenous Vein with Endovenous Laser
Edward Mackay, MD
OBJECTIVE(s): Endovenous Laser Therapy(EVLTtm) has been shown to be a safe and effective treatment for greater saphenous vein(GSV) insuffiency. The purpose of this study is to evaluate the safety and efficacy of this technology in the treatment of lessor saphenous vein(LSV) insuffiency.
METHOD(s): During the period of May 2001 to June 2002 23 patients had 25 llimbs treated for LSV insuffiency by Endovenous Laser. The LSV was treated at six watts of energy with one second pulses. Follow-up was at less than one week, one month, three months, six months and one year. Follow-up included duplex evaluation and physical exam. After the three month follow-up a survey was also sent to the patients for their perspective.
RESULT(s): There was 100% technical success defined by the abscense of flow at the first (less than one week) follow-up visit. Additional follow-up from one month to one year there were no recanalizations. There were no complications. Patient satisfaction was high.
CONCLUSION(s): Endovenous laser Ablation of the LSV appears to be a safe procedure with good short-term results. Long term follow-up is needed to determine the durability of the procedure.
Transcatheter Greater Saphenous Vein Ablation with Endovenous Laser and Ultrasound Guided Perivenous Tumescent Anesthesia
Edward Mackay, MD
OBJECTIVE(s): Initial results of Endovenous Laser Therapy (EVLT(tm)) reported by Navarro, Min et alperformed on the greater saphenous vein (GSV) was performed with 12 watt one second pulses averaging 5-10 pulses per cm. By using ultrasound guided perivenous tumescent anthesia (UPTA) that compresses the GSV around the laser fiber lower energy has been used to treat the GSV (8 watt one second pulses averging 5-10 pulses per cm). This study retrospectively reviews the efficacy of the lower energy.
METHOD(s): From January 2001 to February 2002 143 limbs underwent technically succesful EVLT of the GSV at the lower energy settings and with UPTA . These charts were reviewed retospectively for treatment results and any complications. In addition a patient satisfaction survey was sent to the patients.
RESULT(s): 143/143 had successful acute occlusion defined by abscense of flow at the first post-op visit (3-4 days post-op). In follow-up 3months to one year there was only 1/143 partial recanalizations. There were no major complcations. Patient satisfaction deemed from the surveys was very high.
CONCLUSION(s): The use of EVLT and UPTA for the treatment of GSV insuffiency allows for lower energy levels with high patient satisfaction. The lower energy levels may reduce perivenous injury and thereby decrease post-op discomfort.
PRIMARY AND RECURRENT REFLUX IN PROFUNDA FEMORAL VEIN.
Magomed-Gadzhi Makhatilov, MD
Aim. Study of the relationship between anatomy of profunda femoral vein (PFV) and resistance of PFV to reflux.
Material and methods. Injection preparation and phlebography of 72 cadavers legs and ascending/ descending phlebography of 253 patients (legs) with primary deep veins insufficiency (68 legs were re-examined for recurrent reflux in unrepaired PFV) results were studied.
Results. The following anatomy variants of PFV were revealed at patients and cadavers:
The different anatomy type of the upper, middle and distal segment of PFV was revealed. Anatomy variants of middle segment of PFV depend on developed postolateral thigh perforator veins and the anatomy of distal segment of PFV depends on the anatomy of middle segment of PFV. The connections between PFV and poplitael vein wasn't revealed in cases with tree-type of middle segment of PFV.
Primary reflux in PFV was revealed in 13,2% legs (patients) that underwent descending phlebography. Recurrent reflux in unrepaired PFV (an isolated reflux below knee in superficial femoral vein was avoided by external valves repair) was revealed at 27,0% of patients (legs). All revealed anatomy variants of PFV (of middle segment) was presented in primary and in recurrent reflux legs.
Conclusion. Primary or recurrent reflux in PFV didn`t depend on anatomy variants of PFV.
THE ROLE OF PHLEBOENDOSCOPY DURING FEMORAL VEIN VALVES
REPAIR FOR PRIMARY CHRONIC VENOUS INSUFFICIENCY (Preliminary Report)
Magomed-Gadzhi Makhatilov, MD
Aim. To compare the cusps abnormalities of superficial femoral vein (SFV) proximal valve and the valve located below the proximal one during surgery under phleboscopy.
Material and methods. 12 legs with primary CVI (an isolated reflux in SFV below knee) in stage C3; C4; C5 (according to CEAP). Angioscopic system. Phleboscope was inserted to SFV according to Hoshino S. technique. The internal diameter of Spirals for SFV cuffing was 7mm.
Results. Different anatomy type of the cusps (Fig. A - mono cusp type; Fig. B - elongated two cusps type; Fig. C- wide separated two cusps type) of SFV two valves located one above other was found during phleboscopy.
Conclusion. In some cases (in one leg) to restitute valve competence combination of internal and external techniques of repair or two valves external cuffing may be used.
PHOTOTHERMOLYSIS VS PHOTOMODULATION - EFFECTS ON TELANGIECTASIA
David McDaniel, MD; Robert Weiss, MD; Linda Ginn, MD; Roy Geronemus, MD; John Newman, MD
The purpose of this study was to investigate and define responses to photomodulation by low energy light sources (LILT) of living cells by non-ablative light therapies and to compare these responses to traditional photothermolytic therapies. These responses were evaluated in terms of effects on skin telangiectasias. Using selected pulse durations, the effects of a single and multiple pulses of light at a range of energy densities from micro, milliJoules/cm2 through energy densities typically associated with vascular/scar therapies (7-10J/cm2) were evaluated and 'dose response' curves were generated for stimulation and inhibition of cellular responses. Clinical trials of various light sources including: visible and infrared lasers, intense pulsed broadband light source and narrow band fluorescent and light emitting diode sources were performed. Digital photography, colorimetry, ultraviolet digital photography, pathology from skin biopsies and other types of non invasive clinical skin analysis were also utilized. Photomodulation can be performed using LED visible light sources. Photomodulation by non-thermal, non injuring pathways can produce significant clinical improvement in photoaged skin and fine telangiectasias and diffuse erythema, but is not effective at very low energies for larger telangectasias . A new expanded overview of light tissue interactions and relevance to leg telangiectatic matting post-sclerotherapy will be presented.
Endovenous radiofrequency obliteration of the short saphenous vein
Robert F. Merchant, MD, FACS
OBJECTIVE(s): Evaluate short-term outcomes when using catheter-based radiofrequency energy for treatment of symptomatic short saphenous venous insufficiency. Measures included presence of complications, relief of symptoms, and persistence of vein occlusion.
METHOD(s): Symptomatic patients with an ultrasound-determined incompetent short saphenous vein received in-situ vein obliteration treatment using a temperature controlled radiofrequency energy delivery system set at 85�C, with a 3 cm/min catheter pullback speed starting below the saphenopopliteal junction. Tumescent infiltration (approximately 90 cc of saline with 0.1% Xylocaine, and epinephrine) was administered along the vein track for the purposes of anesthesia and exsanguination. Conscious sedation was utilized in order to allow patient sensory feedback.
RESULT(s): Eight veins (seven female patients) were treated January through July 2002. One vessel perforation occurred. Pain in the heel, alleviated by momentary faster pullback through the sensitive region, was noted during two treatments. All eight veins were successfully closed. During the follow-up period (one week to three months), no complications were noted, and near complete relief of symptoms was achieved. All veins remained closed at latest follow-up.
CONCLUSION(s): Endovenous obliteration of short saphenous vein reflux can be safely accomplished. Conscious sedation is necessary for monitoring and adjusting energy delivery to prevent nerve injury. Further follow-up will determine the durability of occlusion.
ENDOVENOUS AVULSION OF VARICOSE TRIBUTARIES USING A MINIATURE CRYO-PROBE
Ren� MILLERET, MD; Catherine GARANDEAU, MD
OBJECTIVE(s): TO DEMONSTRATE ADVANTAGES OF CRYO-AVULSION AS COMPARED TO HOOK PHLEBECTOMY
METHOD(s): miniature autoclavable cryo-probes : diameter 1,5 mm/length 120 mm were introduced in the vein under local anesthesia . The vein was catheterized as far as possible. Freezing at -90�C was obtained by N20.The vein segment was removed by evagination from its tip adhering to the probe.
30 patients with bilateral tributaries were operated , one leg by hook phlebectomy , the contra-lateral limb with cryo-avulsion in a randomized selection. Number of incisions and operative time were recorded and compared for 20 cm of vein removed. Bruising , pain and esthetic results were appreciated by the patient on an analog scale at 1 and 3 months post-operatively.
RESULT(s): No complications occurred after surgery. Signicant differences were not observed in pain , but bruising and esthetical results were in favor of cryo. Number of incisions and operative time were significantly lower with cryo.
CONCLUSION(s): Cryo-avulsion of venous tributaries is well tolerated , economical as compared with Trivex and time-saving . It is particularly useful in recurrences , and when the veins have been previously sclerosed .
2-Year Follow-Up Results on Endovenous Laser Treatment Of The Incompetent Greater Saphenous Vein
Robert Min, MD
OBJECTIVE(s): To report 2-year follow-up results of endovenous laser treatment for greater saphenous vein (GSV) reflux due to saphenofemoral junction (SFJ) incompetence.
METHOD(s): 326 GSVs in 289 patients with varicose veins were treated with endovenous laser. Patients were evaluated clinically and with duplex ultrasound (+ color doppler) at 1 week, 1 month, 6 months, 12 months and 24 months to determine treatment efficacy and adverse reactions. 2-year follow-up was obtained in 68 limbs.
RESULT(s): Successful closure of the GSV, defined as vein occlusion with absence of flow on follow-up color doppler, was noted in 98% (320/326) of GSVs at 1 to 30 month follow-up. 91% (62/68) of limbs followed to a minimum of 2 years have remained closed with the treated portions of the GSVs not visible on duplex imaging. Of note, all recurrences have occurred prior to 9 months, with the majority noted within 3 months following endovenous laser. There have been no skin burns, paresthesias, or DVTs.
CONCLUSION(s): 2-year follow-up results available on 68 limbs treated with endovenous laser demonstrate a recurrence rate of less than 9%. These results are comparable or superior to those reported for the other options available for treatment of the incompetent GSV. Endovenous laser appears to offer these benefits with lower rates of complication and avoidance of general anesthesia.
Endovenous Laser Ablation Of Incompetent Short Saphenous Veins and Anterior-Lateral Tributaries
Robert Min, MD
OBJECTIVE(s): To assess the safety and efficacy of endovenous laser for treatment of short saphenous vein (SSV) and anterior-lateral tributary (ALT) reflux.
METHOD(s): Consecutive patients presenting with varicose veins due to SSV or ALT reflux were offered ambulatory phlebectomy vs. endovenous laser treatment. 38 SSVs and 49 ALTs were treated with endovenous laser. Patients were evaluated clinically and with duplex ultrasound (+ color doppler) at 1 week, 1 month, 6 months, 12 months and 24 months.
RESULT(s): The procedure was well tolerated by all patients under strictly local anesthesia. Occlusion of the vein, defined as absence of flow on color doppler interrogation, was noted in 36/38 (95%) SSVs and 47/49 (96%) ALTs at 1 to 24 month follow-up. In the 4 limbs with recurrence, reflux was noted prior to 3 months. There were no skin burns, paresthesias, or DVTs.
CONCLUSION(s): Early results of endovenous laser treatment of incompetent SSVs and ALTs have been promising with success rates comparable to those obtained with endovenous laser ablation of the greater saphenous vein. This minimally invasive technique appears to be safe, easy to perform, and well tolerated. Continued evaluation with larger numbers of patients with longer-term follow-up are needed to further define the role of endovenous techniques as treatment alternatives to ambulatory phlebectomy.
Endovenous Laser Treatment Using Continuous Mode
Robert Min, MD
OBJECTIVE(s): To evaluate the safety and efficacy of "continuous mode" endovenous laser and to report the effect on post-procedure bruising and discomfort.
METHOD(s): 100 incompetent greater saphenous veins (GSVs) in 89 patients were treated with endovenous laser using the following parameters: 14 watts continuous mode, pullback rate of 3 to 5 mm per second. Patients were evaluated clinically and with duplex ultrasound at 1 week, 1 month, 6 months and 12 months.
RESULT(s): Occlusion of the GSV with absence of flow on color doppler was achieved in 98% (98/100) of limbs following initial treatment. All GSVs have remained closed at up to 12-month follow-up. 90% (88/98) noted delayed tightness or tenderness and a "pulling" sensation along the GSV four to seven days post-laser. Both patients whose GSVs were not closed following initial endovenous laser did not experience this discomfort. Non-entry site bruising was noted in 29% (28/98) of limbs at 1 week follow-up. Of the 28 patients with bruising, 86% (24) felt tightness vs. 93% (65/90) of patients without non-entry site bruising. There were no skin burns, paresthesias or DVTs
CONCLUSION(s): Our preliminary results using continuous mode seem to demonstrate improved efficacy of endovenous laser treatment compared to "pulsed" techniques. Vein wall perforation with extravasation of blood has been proposed as the cause of patient discomfort following "pulsed" endovenous laser. Although less bruising was noted with continuous mode, the degree of bruising or absence of bruising did not correlate with the degree of patient discomfort. The delayed pain or pulling sensation felt by patients following successful endovenous laser may be due to vein wall thickening (as seen on duplex imaging) and shortening, and may indicate adequate treatment.
COMPARATIVE STUDY OF RADIOFREQUENCY VS LASER ABLATION OF THE GREATER SAPHENOUS VEIN: ONE YEAR FOLLOW-UP
Nick Morrison, MD, FACS; Diana Neuhardt, RVT
A prospective, non-randomized, direct comparison study of endovenous catheter ablation (EVCA) of the greater saphenous vein (GSV) was completed on 100 legs in 50 patients with GSV insufficiency, utilizing a radiofrequency catheter (RF) on one leg and a laser fiber on the other. The same investigator, ultrasound specialist, and operating team performed all procedures. An Acuson Sequoia duplex ultrasound was used for the initial diagnostic study, pre-operative mapping, intra-operative guidance of tumescent anesthesia, catheter placement, immediate post-operative assessment of the deep venous system, and effectiveness of GSV ablation. The catheters and generators employed were the 5, 6, and 8 Fr RF/ RF 110 generator (VNUS Medical) and the 600 micron laser fiber/ Diode 15 generator (Diomed). Parameters included: patient demographics; venous morphology; access; treatment time; ablation assessment; sequelae and complications; immediate, short, and mid-term follow-up; and comparative costs.
Both methods showed similar rates of successful ablation of the GSV on immediate, short, and mid-term follow-up duplex scans. Both had minor intra-operative challenges, and some post-operative sequelae including transient pain, ecchymosis, bruising, tenderness, and paresthesia.
EVCA is a safe and effective method of ablating the GSV in-situ. RF and laser have technical considerations which are successfully managed with experience. Post-operative complications are minor and comparable. Post-operative sequelae includes more pain and bruising with laser than RF. The mid-term results are encouraging. The long-term follow-up study for vein patency and "recurrence" is in progress, but results are not expected to change dramatically given the complete ablation of the GSV seen with high resolution duplex equipment.
RADIOFREQUENCY CLOSURE TREATMENT OF GREATER SAPHENOUS VEIN REFLUX UTILIZING INCREASED HEAT AND AN INCREASED PULLBACK RATE
Nick Morrison, MD, FACS; Diana Neuhardt, RVT
We treated 381 patients (465 limbs) with symptomatic greater saphenous vein (GSV) reflux over the last 2+ years with radiofrequency (RF) Closure utilizing 5, 6, and 8 Fr RF catheters, and a radiofrequency 110 generator (VNUS Medical Technologies) set at 85�C. Our average catheter pullback time was 14 minutes and was found to be increasing with the use of our preferential catheter (the 6 Fr catheter). The success rate (defined as no flow in the treated segment) has been approximately 92.7% at six month follow-up and 99.7% at twelve month follow-up.
In an attempt to diminish the pullback time, we increased the temperature delivered to the GSV by the 6 Fr catheter to 90�C. The same investigator, ultrasound specialist, operating team, RF generator, tumescent anesthesia, and operative procedures were used. This resulted in a pullback rate average of 9.2 minutes.
The rate of successful ablation using the increased heat setting and pullback time was comparable to those using earlier parameters. There was no increase in patient sensation of heat. There were no thermal injuries. The incidence of phlebitis, pain, erythema, paresthesia, edema, and other complications was small and comparable. Delivering heat at 90�C to the GSV appears to be a safe and effective method of ablation the GSV, given carefully administered tumescent anesthesia into the GSV sheath under ultrasound guidance.
TREATMENT OF ANEURISMAL SEGMENTS OF THE GREATER SAPHENOUS VEIN (GSV) USING A COMBINATION OF RADIOFREQUENCY ENDOVENOUS OCCLUSION AND ULTRASOUND-GUIDED SCLEROTHERAPY (UGS)
Nick Morrison, MD, FACS; Diana Neuhardt, RVT
Patients presenting to our office with signs and symptoms of chronic venous insufficiency, who were found to have greater saphenous vein (GSV) reflux requiring endovenous catheter ablation (EVCA) with ultrasound-guided sclerotherapy (UGS), were frequently treated with a 6 Fr radiofrequency catheter. Many of these patients had GSV's larger than the 8mm maximum diameter suggested by the manufacturer (VNUS Technologies), either over long segments, or in shorter, aneurysmal segments. While we have had an overall experience of successfully treating >500 limbs with RF EVCA and UGS, we have also employed this method to treat large diameter GSV's.
The method utilized a 6 Fr catheter and a radiofrequency 110 generator. The same investigator, ultrasound specialist, and operating team performed all procedures. Duplex ultrasound was used for the initial diagnostic study, pre-operative mapping, intra-operative guidance of tumescent anesthesia, catheter placement, immediate post-operative assessment of the deep venous system, and effectiveness of GSV ablation.
We will report a series of patients who presented with GSV's as large as 21mm, or aneurysmal segments with an average diameter >50% of reference. Parameters of those treated GSV's will be presented in detail. Several technical factors appear to be important in order to achieve complete ablation, the most important of which is careful and complete delivery of tumescent anesthesia, under ultrasound guidance, directly into the saphenous sheath in order to compress the GSV as completely as possible.
Patients were followed at one week, six weeks, and three and six months with examinations, interviews, and duplex scans. The combination of EVCA and UGS was successful in achieving complete ablation of the treated GSV's in >90% of the legs. This method has been found to be highly effective in treating patients with large or aneurysmal veins whose treatment was previously thought to be problematic or impossible.
Endolaser - A Three Year Follow-up Report: Implications on Crossectomy and Ligation and Stripping
Luis Navarro, MD, FACS; Carlos Bone' Salat, MD
OBJECTIVE(s): A three year follow-up report on a group composed of our first 200 cases of Endolaser to determine the midterm efficacy and safety of this methodology in the treatment of truncal varicose veins. Special attention is given to the post-treatment hemodynamics of the saphenofemoral junction (SFJ) and its branches to determine its implications on the actual need for crossectomy and ligation and stripping. Report includes evaluation of recurrences.
METHOD(s): This methodology has been used in patients with varicose veins due to greater saphenous vein (GSV) and SFJ incompetence as determined by continuous wave Doppler and color Duplex Ultrasound, including mapping of the GSV.
A 600 micron bare-tipped laser fiber is passed through a previously placed catheter in the GSV and positioned 1-2 cm below the SFJ. Vein access is achieved by one of two methods: percutaneous needle approach or stab-wound/Mueller-hook approach. After perivenous local anesthesia, Diode laser energy at 810, 940, or 980 nm is applied in short pulses to close the GSV. A concurrent mini-phlebectomy or later sclerotherapy of branch varicosities completes the treatment.
Patients have been followed with color duplex ultrasound at 24 hours, one week, and various monthly intervals.
RESULT(s): Results on our first 200 Endolaser procedures of the GSV, followed for up to three years (mean: 23.6 months), indicate a recanalization rate of 2.6% (all occurring within the first 6 months of treatment). To date, all 200 cases show an absence of reflux at the SFJ with no evidence of neoangiogenesis and no progressive incompetence of the SFJ branches left in place.
There were two early cases of post-treatment branch varicosity superficial phlebitis but no late cosmetic, heat-related, or thrombogenic complications.
CONCLUSION(s): Recurrences with Endolaser, aside from progression of the disease, are due to recanalization and not to neoangiogenesis or progressive incompetence of SFJ branches. With proper pre-treatment, operator-administered ultrasound diagnosis, crossectomy and ligation and stripping are only very occasionally specifically indicated. At three years, the safety and low recanalization rates of Endolaser are superior to the safety and recurrence of ligation and stripping, making it an effective alternative or possibly the current primary treatment choice.
The role of Selective Estrogen Receptor Modulators (SERM's) in Sclerotherapy and post-treatment complications
Jerry Ninia, MD, FACOG
Despite its potential health benefits, long-term use of estrogen-progesterone derived hormone replacement therapy (HRT) remains low mainly because of fears about breast cancer. Additionally, HRT is felt to play an important role in the etiology of telangiectatic and varicose vein disease as well as diminished sclerotherapeutic treatment results with an increased incidence of capillary matting.
SERMs, with tissue specific effects, represent an exciting category of therapeutic agents used for improving the health of the post-menopausal patient. SERMs bind with high affinity to estrogen receptors and activate them, eliciting a mixed agonist/antagonist response depending on tissues involved. For example, SERMs act as antagonists in breast tissue yet are estrogen agonists in skeletal tissue by preventing and treating osteoporosis. SERMs also improve lipid levels and decrease the risk of coronary heart disease.
This is the first randomized, prospective study re: sclerotherapy treatment results on estrogen skin receptors in patients on a SERM.
10 menopausal patients (amenorrhea > 1 year, ^ FSH levels)
½ on Raloxifene (Ev
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