АССОЦИАЦИЯ ФЛЕБОЛОГОВ РОССИИ

Еще немного воды на ту же мельницу, но в игру включились и более серезные игрушки......

J Vasc Surg. 2005 Sep;42(3):494-501; discussion 501. Links
Endovenous laser treatment combined with a surgical strategy for treatment of venous insufficiency in lower extremity: a report of 208 cases.Huang Y, Jiang M, Li W, Lu X, Huang X, Lu M.
Department of Vascular Surgery, Ninth People's Hospital, affiliated to Shanghai Second Medical University, China. yvhuang772@yahoo.com

BACKGROUND: We assessed the safety and efficacy of endovenous laser treatment (EVLT) of the saphenous vein combined with a surgical strategy for treatment of deep venous insufficiency in the lower extremity. METHODS: Two hundred thirty venous insufficiencies of the lower limbs in 208 consecutive patients (93 men and 115 women; mean age, 54.15 years) were treated with EVLT combined with surgical strategies. All patients were symptomatic. There were 84 limbs (36.5%) in C(2), 25 (10.9%) in C(3), 109 (47.7%) in C(4), 1 (0.4%) in C(5), and 9 (3.9%) in C(6) (CEAP), and Klippel-Trenaunay syndrome was present in 2 limbs. A total of 119 (51.7%) had perforator vein incompetence. Four therapeutic methods were included in this series according to symptoms, CEAP classification, and venous reflux. Simple EVLT was performed for 15 patients with only great saphenous vein (GSV) incompetence or Klippel-Trenaunay syndrome in 19 lower limbs. EVLT combined with high ligation of the GSV and open ligation of perforators was performed for 5 patients with GSV and perforator incompetence in 5 lower limbs. [b]EVLT was combined with high ligation of the GSV for 76 patients with GSV incompetence in 94 lower limbs. EVLT was combined with external banding of the first femoral venous valve and high ligation of the GSV for 112 patients with primary deep venous insufficiency in 112 lower limbs. All patients were followed up on an outpatient basis for physical examinations and postoperative complaints, and duplex ultrasonography was performed 2 weeks, 6 months, and 1 year after operation. RESULTS: All patients tolerated the procedure well and returned to normal daily activities immediately, achieving a 100% immediate clinical success rate. Spot skin burn injuries occurred in 2 patients (1.0%). Paresthesia in the gaiter area was noted in 15 patients (7.2%). No postprocedural symptomatic deep venous thrombosis or pulmonary embolism occurred. Three patients had local recurrent varicose veins in the calf (1.4%) during a 2- to 27-month follow-up (mean, 6.12 months). Postoperative clinical classes were significantly improved between 2 weeks and 24 months (P = .0001 at 2 weeks and 3 to 18 months; P = .0055 at 24 months compared with before operation), especially in preoperative C(2) to C(3) stage patients, who achieved complete amelioration. CONCLUSIONS: EVLT is a novel minimally invasive treatment with advantages of safety, effectiveness, and simplicity, and it leaves no scars. Its indications can be expanded by combining EVLT with surgical strategies.[/b]

А вот нашел текст всей публикации:

Endovenous laser treatment combined with a surgery strategy for treatment of venous insufficiency in lower extremity: A report of 208 cases





Background



We assessed the safety and efficacy of endovenous laser treatment (EVLT) OF the asthenias vein combined with a surgical strategy for treatment of deep venous insufficiency in the low extremity.

Methods: Two hundred thirty venous insufficiencies of the low limbs in 208 consecutive patients were treated EVLT combined with surgical strategies. All patients were symptomatic. There were 84limbs, and Klippel-Trenaunay syndrome was present in 2 limes total of 119 had perforator vein incompetence. Four therapeutic methods were included in this series according to symptoms, CEAP classification, and venous reflux, Simple EVLT was performer for 15 patients with only great sphenoid vein (GSV) incompetence or Klippel-Trenaunay syndrome in 19 lower limbs with GSV and perforator incompetence in 94 lower limbs, EVLT was combined with high legation of the GSV for 76 patients with SGV incompetence in 95 lower limbs, EVLT was combined with external banding of the first femoral venous valve and high legation of the GSV for 112 patients with primary deep venous insufficiency in 112 lower limbs. All patients were followed up on an outpatient basis for physical examinations and postoperative complaints, and duplex ultrasonography was performed 2 weeks,6 months, and 1 year after operation.

Results: All patients tolerated the procedure well and returned to normal daily activities immediately, achieving a 100% immediate clinical success rate. Spot skin burn injuries occurred in 2 patients (1.0%). Parenthesis in the gaiter area was noted in 15 patient��s (7.2%). No post procedural symptomatic deep venous thrombosis or pulmonary embellish accrued. Three patients had local recurrent varicose veins in the calf (1.4) during a 2 to 27-month follow-up (mean,6.12 months). Postoperative clinical classes were significantly improved between 2 weeks and 24 months, especially in preoperative C2 to C3 state patients, who achieved complete amelioration.

Conclusions: EVLT is a novel minimally in evasive treatment with advantages of safety, effectiveness, and simplicity, and it leaves no scares. Its indications can be expanded by combining EVLT with surgical strategies.



Superficial varicosity in the lower extremity is a common disorder in the Chinese population. Its most frequent causes are primary deep venous insufficiency (PDVI) and great saphenous vien ((GSV) incompetence. The classic surgical strategies include reconstruction of the GSV, legation of perforators, excision of superficial varicosities, and so on. The drawbacks of surgery include risks associated with surgical complications, increased in-hospital costs, and prolonged recovery periods. Also surgery does not ensure freedom from recurrence. In recent years, with the development of minimally invasive techniques and the advent of new surgical apparatus, less invasive alternatives to surgical treatments of superficial varicose veins have emerged. From June 2001 to 2003 to September 2003,208 consecutive patients were successfully treated by endovenous laser treatment (EVLT) combined with surgical interventions in our department. Herein we report our experience and a retrospective study to evaluate the safety of this method.



METHODS



Patients, all patients were selected from our department as they came for their symptomatic varicositities. Thorough history and physical examinations were performed. All patients were frit screened by air plethysmography and ankle-brachial index measurement, and those with normal venous outflow in air plethysmography and an ankle-brachial index greater than 0.9 underwent further testing .Duplex scanning was performed to document further testing. Duplex scanning was performed to document potency of the deep veins and to evaluate the value reflux time. Venous reflux was defined as reverse flow of more than 0.5 seconds. Combined with the reflux index, a value greater than 2.5 would be considered a severe reflux. Perforators were considered incompetent if the diameter was 4mm or more and/or had an outward directional flow exceeding 0.5 seconds. On account of certain limitations in the abovementioned testing, ascending venography was performed to confirm the diagnosis and further exclude postthrom botic syndrome with total recanalization and the manythurner syndrome, which might be missed in ultrasonic raphy.

The contour of deep veins, valves, and perforators could be visualized, and the function of the first valve of the femoral vein was tested by the Valsalva maneuver.Perforators could be localized under duplex scanning combines with venography. The severity of venous insufficiency was categorized according to the CEAP classification. On the basis of duplex scanning, ascending venography, and CEAP classification, patients with PDVI were stratified into mild, moderate, and severe groups so implify the choice of therapeutic modalities. The mild group was defined as patients at stage C2 to C3 with venous reflux to the knee level in ultrasonogrphy, mild reflux but nearly normal contour in the frist valve of the femoral vein, mildly dilated deep veins, and nearly normal configuration of other valves in the deep veins as visualized by venography. The moderate group were patients at stage C4 to C5, with venous reflux to below the knee level in ultrasonography, moderate reflux in the first valve of the femoral vein( with its vale contour being retained),dilated deep veins, and less definitive visualization of the contours of the other valves in deep veins on venography. the severe group were patients at stage C6 with venous reflux to the ankle level in ultrasonography, severe reflux in the first valve of the femoral vein (with obscure valve contour), more dilated deep veins, and other valves in the deep veins poorly visualized by venography, patients with actuate superficial thrombophlebitis, aneurysmal veins pulses, or deep venous feeding,or in poor general condition were not candidates for EVLT.

Procedures: All patients were treated with EVLT or EVLT combined with surgery under epidural or lumbar anesthesia. The 810nm diode laser was used togenerate heat sufficient to cause thermal damage to the venous endothelium. Four therapeutic strategies were included simple EVLT was performed fr 15 patients with GSV incompetence or Klippel-Treat syndrome (KTS) in 19 lower limbs during our early stage of EVLT. Procedures were followed as previous reported and were bases on the technoques of Navarro et al. In some patients who had significant enlargement of the sapherous trunk, the technique was improved for the treatment of GSV trunk. After introduction of the optical fiber to the GSV from the ankle level to the varicose veins was fully evacuated30, and blood in the varicose veins was fully evacuated. A laser-emission power of 12 or 14w in continuous mode was chosen to treat GSV from below the saphenofemoral joint (SFJ) to the knee level, and then 12w and I pulse duration was used in the GSV from the knee level to the ankle level. A wavelength of 810nm of diode laser energy was delivered along the course of the GSV as the laser fiber and catheter were slowly withdrawn in 3-to 5 mm increments. During the procedure, manual compression was applied over the red aiming beam, which could be visualized thought the skin, to improve the vein wall apposition around the laser fiber tip; thus, better laser fiber-endothelial contact and even emission by laser energy were achieved to completely shrink and occlude the venous trunk. For mild or moderate varicosities caused by tributaries of the GSV,EVLT with multiple percutaneous introductions of the laser fiber through n 18-gauge needle was performed.

EVLT was combined with high legation of the GSV and open legation of perforators for 5 patients with GSV and perforator incompetence in 5v lower limbes. This intervention was performed after we realized that pulmonary embolism (PE) might occur though the SFJ and that the perforator could be obliterated by direct EVLT through an 18-gauge needle. EVLT was combined with high legation of the GSV for 76 patients with GSV incompetence in 94 lower limbs. EVLT was combined with external banding of the first femoral venous valve and high legation of the GSV for 112 patients with PDVI in 112 lower limbs Femoral banding was indicated for patients of C4 to C6 with axial reflux in duplex and venography examinations or with complex skin changes but in whom the configuration of the frist valve had not been totally destroyed. Among those, 25 limbs underwent additional phlebectomy because of extensive varicose masses in the calf region. The indications for intervention are shown in Table I All operated limbs were managed with compressive bandaging after the procedure. All patients were compressive bandaging fret the procedure. All patients were followed up on an outpatient basis for physical examinations and postoperative complaints, and duplex ultrasonography was performed 2 weeks, 6 months and 1 year after operation.

Parameters: The diode laser fiber in the treatment of GSV and superficial varicosities is normally 400 to 600 um in diameter; the 600um-diameter fiber and a wavelength of 810nm were chosen in our series. pulses ranging from 80 to 500 seconds were used for the entire procedure, with a mean of 205,According to the severity of varicosities, it took 0.5 hours to 1 hour to perform entire procedure, with a mean of 50 minutes.

Postoperative management: Ambulatory activities were encouraged after operation. Elastic compressive bandaging was instructed for at least 14 days or was changed to graduated compression stocking 3 days after operation. A thing or pantyhose stocking was recommended. Oral administration of aspirin 75 mg was recommended for 1 to 2 months.

Statistical analysis: SAS software was used, Statistical analysis of the data was performed with decriptive statistics and the Wilcoxon rank sum test for comparison of preperative and postoperative C classes.



RESULT



Patient characteristics: Two hundred thirty venousinsufficient lower limbs in 208 consecutive patients were included in this series. Among those, two limbs had had previous treatment of sclerotherapy,and another three had previos treatment of sclerotherapy, and another three had had GSV and varicose vein ablation. Their ages ranged from 7 to 79 years, with a mean of 54.15 years, their courses of disease were 1.5 to 30 years, with a mean of 12.61 years. According to the CEAP classification and more than half had a class 4 or higher clinical stage (15.7%) Patients�� demographic data and CEAP classifications are listed in Tables II and III.

Therapeutic effects: Successful percutaneous access and endovenous placement of laser fibers were achieved in all patients�� .All patients tolerated the procedure well and recovered uneventfully, with dissappearance of varices. Patients without venous banding were encouraged to undertake ambulatory activates the day after operation. They returned to their normal daily activities 3 days after the operation and returned to work 14 days after operations, The duration for patients with venous banding were 3,14,and 28 days after operation, respectively. Patients who received only EVLT had no incision, and the others had stage I would healing, Gaiter ulcerations in all 9 npatients were healed in 2 to 5 weeks after the procedure., on the basis of a quetionnaire that measures preperative and postoperative venous symptoms, all patients had relief of their symptoms and were satisfied with EVLT and the corresponding combines surgery.

Complications: Symptoms such as indurations, pain, paresthesia,skin burn injury, leg swelling ,cough, thoracicpain, hemoptysis, and fever were investigated after operation and in follow-up to evaluate operation of DVT or PE occurred, further investigations including duplex scan, pulmonary radiograph, computed tomography, and isotope scan were performed to diagnose and guide treatment.

Follow-up: Patients were followed up from 2 to 6 months, with a median of 6 months, Duplex ultrasonophy was performed 2 weeks after operation with the find .that there was no detectable flow and that total closure of the GSV was achieved in all 230 limbs. Three patients had local recurrent various veins in the calf (1.4) 3 weeks after operation and were successfully treated with EVLT under local anesthesia. No recurrence was seen in other patients, No patient experienced sympotoms of DVT or PE.Postoperative clinical classes of patients are listed in Table IV They were significatly improved between 2 weeks and 24 months, especially preoperative C2 to C3 patients, who achieved complete amelioration at a mean of 6 months of follow-up. Duplex ultrasonography 1 year after operation demonstrated a thin, fibrous cord along the original GSV.



DISCUSSION



Compared with classic surgery for PDVI and GSV incompetence, the objective of less invastive treatment alternative is to reduce risk, morbidity, and cost while leading to acceptable shprt-and long-term results; cosmetic reasons are important as well. Techniques such as miniphlebectomy, cryotherapy, sclerothapy, and electrocautery have been developed as less invasive means for the treatment of superficial varicosities in the lower extremities. Among all minimally invasive treatments, subfascial endoscopic perforator surgery, endoluminal radiofrequency, and EVLT have shown promise .EVLT seen particularly promising in the minimally invasive treatment of varicose veins. EVLT consists of percutanceous transvenous catheter-guided laser fiber introduction, a minimal access site size, transmission of laser energy through a small-diameter and flexible fiber, and direct operation through skin visualization of the laser tip by its red aiming beam light. This cause contributes to procedural case and safety, improved effectiveness, and an absence of surgical scarring.

The endovenous laser generates bursts of hear enough to form steam bubbles, which cause thermal injury to the venous target vein. EVLT is indicated in which the clinical manifiestations are superficial varicose veins. Navarro et al reported a 100% rate of GSV closure in 40 limbs after EVLT by using 810nm with a mean numbers and only short-term data ,the efficacy of EVLT for the treatment pf incompetent GSV has been reported to be greater than 95%,our results showed the same successful rate. Priestley reported a series of 77 patients who received EVLT of 106 GSVs in which 6 GSVs (10%) were not occluded at 3 months and indicated the EVLT failure might be related to the administration of low laser fluence,its unit is J/cm2.

To achieve optimal effects, the selection of patients is most important, Patients with potential risks for DVT and PE should be excluded .Duplex scanning combined with ascending vanography was performed routinely, because the latter can directly visualize the configuration of deep veins, valves, and perforators and can compensation of the draebacks of duplex scanning. The duplex scan has its predominant advantage in reflux detection and quantitative evaluation. Complete recanalization of deep veins in patients with postthrombotic syndrome and may-Thurner syndrome were excluded in this series to prevent possible postoperative DVT and subsequent PE. Because of examiner preference, some cases were detected only in venography, although it��s invasive and requires contrast media.

To decrease the postprocedural recurrence of both the GSV and tribitaries for other than technical reasons,we performed different therapeutic strategies according to symptoms,CEAP classification,and venous reflux,Duplex and ascending venography were performed to evaluzte the deep vien patency,venous reflux,valve cntour,and perforator localization .For patients with PDVI and deep reflux,especially those with obvious skin changes,EVLT combined with external banding of the frist femoral venous valve and high ligation of GSV was performed at one stage.In 1975,Kistner advocated the femoral valve repair operated tha method of PDVI .In 1982,Jones et reported the method of triangual venous valvuoplasty.From 1982 to 1987,more than 200 patients were operated on with these2 methods in our department.We found that satisfactory results were most likely to be expected in lower limbs with mild and moderate deep venous reflus.In a study of 50 adult cadavers (100 lower extremities),it was suggested that the valves of the common femoral vein could withstand a retrograde pressure of 180 to 250mm Hg,the valves of the femoral vein,260 to 350mm Hg;the valves of the femoral vein,260 t350mm.

Reconstruction of the frist valve of the femoral vein seemed to be more effective in patients of C4 to C6 with total deep venous reflux only if the valve was not totally destroyed.To avoid the postoperative complication of thrombosis due to intravenous manipulation,this abnding valvulopasty operation was chosen and clinically applied,with excellent results.Camilli and Guarnera,Guarnera et,and Belcaro et have reported their successful experience with external banding valvuloplasty,Thus,external banding of the frist femoral venous valve was chosen for valve recomstruction in this series.For bothGSV and perforator incompetence,to avoid recurrence,high lighation and ligation were perforatored,repectively ,in our early cases;localization of perforators by ultrasonography and direct puncture to permit EVLT obliteration was used after we gained experience with this technique.Also,ultiplw puncture of tributary varices for EVLT was performed,for patients who had an enlarged mass in the GSV or its tributaries,phlebectomy was used.

Although the postoperative clinical classes were significantly improved in our follow-up study,especially those in the C2 to C3classes before operation, limbs in preoperative C4 to C 6 showed no significant change in clinical classes after operation.Advanced cases with skin changes are unlikely to change significantly after treatment,and the healing of an active ulcer would drop the patient from C6 to C5 thus,venous severity scoring seems to be more accurate than the CEAP classification for assessing the efficacy of the treatment.

Most cases in our study were treated by EVLT combined with syrgical strategies .The advantages are as follows .Using a longitudinal incision of 6 to 8 cm at the inner side of the upper thigh for the external banding operation and a 2-cm incision along the dermatoglyph in the groin region just over the SFJ for high ligation of the GSV,placement of the fiber could be accurately confirmed by direct visualization.This is a simple procedure for a vascular surgeon.Intradermic suture was performed with absorbable suture.The incision was sheltered,with no scar left,and was easily accepted by patients .High ligation of the GSV was performed with EVLT except for 15 patients in our early stage.High ligation of the GSV was used to decrease the risk of thrombus in the deep vein and GSV recanalization caused by SFJ reflux and to facilitate complete GSV thrombosis and fibrosis.We had no complications of clinically apparent DVT or PE in our patient cohort and had varices in the calf region and more advanced skin changes in the gaiter area than those reported in the literature,we treated the entire incompetent GSV from groin to ankle in all cases.To avoid thermal injury to the saphenous nerve during the procedure,12W in discontinuous mode with a 1-second pulse duration,1-second intervals,and relatively quick withdrawal was used in the GSV from the knww to ankle level,and subcutancous tumescence of saline along the course of the GSV was recommeded.EVLT combined with surgical strategies can be used to broaden the clinical application .For patients with PDVI,especially those with total deep reflux ,deep venous valvuloplasty can be performed and followed with EVLT ,This combined therapeutuc method was performed to achieve better efficacy.In our 208 cases,EVLT combines with external banding of the first femoral venous valve was performed for 112 patients in 112 lower limbs .In our experience,EVLT combined with high ligation of the GSV,perforator ligation,and valvular repair,when complicated with PDVI,could reduce recurrence and recanalization due to blood reflux and further enhance the shrinkage and fibrosis of treated varicoses.Reports of clinical results of GSV surgery in the presence of deep reflux are not consistent,and recently,the definition of deep axial reflux was advocated to be of great importance in the choice of surgery.Two cases of KTS were reported in our series.KTS with superficial varicose veins and deep veins is optimal for EVLT.

If the GSV was too toruous to allow a catheter to pass multiple puncture was indicated and ultrasound-guided catheterization was used if necessary.If vericosities were very close or the dermis,then subcutaneous tumescence of saline over the treated vein was indicated to form a protectitve barrier between varicosities and the skin,thus preventing skin burn injury,Quick withdrawal was important as well.Two skin burn injuries occurred at an early stage in our series.Because subcutaneous tumescence of saline and rhe terminal highligh were used,such complication were seldom seen.The diode laser is an endovenous one that has a contact efect.We suggest that elevation of the involved limbs before the emission of laser energy,to fully empty venous blood and collapse the venous wall by compression,will help to obtain better fiber endothelial contact and reduce the postoperative reaction of thrombophlebitis as well,In addition,laser power of 12 to 14w in continuous to knee level for increasing laser energy to completely achieve a therapeutic effect.

Induration along the course of the GSV or over treated varicose veins will cause local pain,such a tissue reaction in most distinct 1 to 2 weeks after operatin and then gradually subsides and diminishes in 3 to 6 weeks,The more complete the emptying of the vein lumen,the less tissue reaction will be produced ,and better results will be achieved ,in addition,postoperative compressive bandaging or compressive stockings are most important after EVLT to avoid early recanalization and enhance the therapeutic effect.

Early results with EVLT have been impressive with very effective closure of incompetent GSV and varicose veins, but its long-term evaluation awaits long-term follow-up and multimember investigations. On the basis of continuous improvement of this technique, EVLT will render favorable prospects for extensive application because of its advantage of safety, effectiveness, minimal invasiveness, fewer complications, and easy operation.

For an extraordinarily enlarged GSV unmatching of the laser fiber caliber to the venous caliber should be considered. Radiofrequency is another endovascular technique for the elimination of saphenofemoral reflux and truncal GSV. Because we now perform both EVLT and radiofrequency in our department, further study to compare EVLT vs. radiofrequency in the treatment of GSV is under way to achieve better selection of these two minimally invasive techniques.

This report from one of china��s leading centers for venous disease is of special importance because it��s indicative of the series have high level of venous practice currently used in china,where patients in this series have been well studied and carefully observed after surgery with clinical and ultrasound scans.

The Chinese apparently harbor a high percentage of primary reflux cases. The aggressive management of reflux espoused in this article differs from the usual practice in the west and may be useful in stimulating healthy debate. Regardless of the differences in management between east and west, the disease processes are clearly the same, and the diagnostic workups are similar. The CEAP classification is used to good advantage in this study to identify the patient population being treated ,and this will make it possible to compare results from this source with different theories of management in other parts of the world. As the difference are defined ,investigations to study and resolve the newly recognized problems will emerge.

Participation of the Chinese in the discourse concerning management of chronic venous disease provides many advantages that will increase the opportunity for progress in the field .With the realization that we are now using the same instruments to measure the same aspects in patients who have the same diseases, it is possible to reap some of the benefits that were predicted to flow from progress in noninvasive diagnosis and from uniformity of classification.
Ссылка:http://www.gigaalaser.com/clinical_application/detail.asp?id=73&classid=4

Ann Vasc Surg. 2007 Mar;21(2):155-8. Links
Adjunctive proximal vein ligation with endovenous obliteration of great saphenous vein reflux: does it have clinical value?Gradman WS.
Beverly Hills Vein Center, Beverly Hills, California 90210, USA. wayne@gradman.com

The risk of clot extension to the deep venous system or pulmonary embolism following endovenous great saphenous vein (GSV) obliteration is possibly related to the size of the proximal GSV. Some practitioners therefore exclude endovenous GSV obliteration for veins greater than an arbitrary size, starting as little as 15 mm. Others provide adjunctive proximal GSV ligation either routinely, or in selected patients with large veins. The clinical value of adjunctive proximal GSV ligation is unknown. A survey of either the American Venous Forum or the American College of Phlebology, selected for their pedagogic or long-time experience with endovenous GSV obliteration. Respondent characteristics included obliteration technique (laser, radiofrequency [RF], or foam sclerotherapy), academic status, surgical training, indication for and frequency of adjunctive proximal GSV ligation, and society membership. The incidence of pulmonary embolus (PE) and deep vein thrombus (DVT) was also tallied. Twenty-one thousand nine hundred sixty-five endovenous GSV obliteration cases were reported, 10,290 with a laser (46.8%), 6,275 (28.6%) with RF, and 5,400 (24.6%) with foam. Only two PEs were reported. Of the 34 patients with DVT, at least 11 had only asymptomatic ultrasound evidence of thrombus extension into the femoral vein, and at least five had only calf vein thrombosis. Comparing ligators (7) with non-ligators (15), the only characteristic significantly correlating with adjunctive proximal GSV ligation was whether the respondent had complete general or vascular surgical training; non-surgeons never ligated the saphenous vein (p < .001). There was no difference between outcomes of ligators and non-ligators. Endovenous obliteration of the GSV poses little risk of PE or DVT, no matter what size the proximal GSV. Although these adverse events may be reduced with adjunctive proximal GSV ligation, the results of this study suggest that adjunctive proximal GSV ligation is superfluous in most patients.

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Zhongguo Yi Xue Ke Xue Yuan Xue Bao. 2006 Jun;28(3):457-9.Links
[Endovenous laser combined with ligation and striping therapy for varicose saphenous][Article in Chinese]


Ye W, Liu CW, Guan H, Liu B, Li YJ, Zheng YH, Wang S, Li WJ.
Department of Vascular Surgery, PUMC Hospital, CAMS and PUMC, Beijing 100730, China. yewill18@sina.com

OBJECTIVE: To evaluate the curative effect of the combination of endovenous laser treatment of varicose saphenous vein (ELVS) and classic ligation and stripping treatment. METHODS: We retrospectively analyzed the clinical data of 21 patients with varicose saphenous vein (VS) who were treated with ELVS alone or combined with ligation and stripping in our hospital. RESULTS: All the patients got good therapy result. The early symptom relief rate was 82.4%, while the late symptom relief rate was 100%. No infections, haematoma of wound, and any other major complications were reported. The common complications included pain induced by remains of the thrombosis phlebitis (n = 2, 11.7%), minor skin burn (n = 1, 5.9%), residue vein varicose (n = 1, 5.9%), numbness of the calf (n = 1, 5.9%), and mild peri-phlebitis (n = 1, 5.9%). All the complications were resolved after proper management. The 1-year follow-up showed no recurrence. CONCLUSION: The combination of ELVS and classic ligation and stripping is safe and effective in the treatment of varicose saphenous.
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Случайная подборка абстрастов -EVLT

J Vasc Surg. 2005 Sep;42(3):488-93.
Comment in:
J Vasc Surg. 2006 Mar;43(3):642; author reply 642-3.
Endovenous laser therapy and radiofrequency ablation of the great saphenous vein: analysis of early efficacy and complications.
Puggioni A, Kalra M, Carmo M, Mozes G, Gloviczki P.
Division of Vascular Surgery, Mayo Clinic, Rochester, MN 55905, USA.
BACKGROUND: Endovenous laser therapy (EVLT) and radiofrequency ablation (RFA) are new, minimally invasive percutaneous endovenous techniques for ablation of the incompetent great saphenous vein (GSV). We have performed both procedures at the Mayo Clinic during two different consecutive periods. At the time of this report, no single-institution report has compared RFA with EVLT in the management of saphenous reflux. To evaluate early results, we reviewed saphenous closure rates and complications of both procedures. METHODS: Between June 1, 2001, and June 25, 2004, endovenous GSV ablation was performed on 130 limbs in 92 patients. RFA was the procedure of choice in 53 limbs over the first 24-month period of the study. This technique was subsequently replaced by EVLT, which was performed on the successive 77 limbs. The institutional review board approved the retrospective chart review of patients who underwent saphenous ablation. According to the CEAP classification, 124 limbs were C2-C4, and six were C5-C6. Concomitant procedures included avulsion phlebectomy in 126 limbs, subfascial endoscopic perforator surgery in 10, and small saphenous vein ablation in 4 (EVLT in 1, ligation in 1, stripping in 2). Routine postoperative duplex scanning was initiated at our institution only after recent publications reported thrombotic complications following RFA. This was obtained in 65 limbs (50%) (54/77 [70%] of the EVLT group and 11/53 [20.8%] of the RFA group) between 1 and 23 days (median, 7 days). RESULTS: Occlusion of the GSV was confirmed in 93.9% of limbs studied (94.4% in the EVLT [51/54] and 90.9% in the RFA group [10/11]). The distance between the GSV thrombus and the common femoral vein (CFV) ranged from -20 mm (protrusion in the CFV) to +50 mm (median, 9.5 mm) and was similar between the two groups (median, 9.5 mm vs 10 mm). Thrombus protruded into the lumen of the CFV in three limbs (2.3%) after EVLT. All three patients were treated with anticoagulation. One received a temporary inferior vena cava filter because of a floating thrombus in the CFV. Duplex follow-up scans of these three patients performed at 12, 14, and 95 days, respectively, showed that the thrombus previously identified at duplex scan was no longer protruding into the CFV. No cases of pulmonary embolism occurred. The distance between GSV thrombus and the saphenofemoral junction after EVLT was shorter in older patients (P = .006, r(2) = 0.13). The overall complication rate was 15.4% (20.8% in the EVLT and 7.6% in the RFA group, P =.049) and included superficial thrombophlebitis in 4, excessive pain in 6 (3 in the RFA group), hematoma in 1, edema in 3 (1 in the RFA group), and cellulitis in 2. Except for two of the three patients with thrombus extension into the CFV, none of these adverse effects required hospitalization. CONCLUSION: GSV occlusion was achieved in >90% of cases after both EVLT and RFA at 1 month. We observed three cases of thrombus protrusion into the CFV after EVLT and recommend early duplex scanning in all patients after endovenous saphenous ablations. DVT prophylaxis may be considered in patients >50 years old. Long-term follow-up and comparison with standard GSV stripping are required to confirm the durability of these endovenous procedures.


MMW Fortschr Med. 2002 Dec 5;144(49):47-50.
[Crossectomy--exhairesis--stripping--laser therapy. How even refractory varicose veins respond to treatment]
[Article in German]
Welter HF, Mosa T, Kettmann R.
Chirurgischen Klinik, Kreiskrankenhaus Rinteln.
Chronic venous insufficiency affects more than 50% of the German population. Major factors involved in its development are age, family disposition, female sex and an occupation involving much standing. Together with the clinical presentation, Doppler and duplex ultrasonography in particular enable a reliable pre-operative diagnosis, and deep venous thrombosis can also be definitively excluded. Indications for surgical treatment are in particular varicosis of the greater and lesser saphenous vein and perforating vein insufficiency. Commonly used procedures are crossectomy, restrictive stripping of pathological vein segments, resection of varicose side branches, and the endoscopic discission of perforating veins. Recent developments are deep-freezing and extraction of the vein and endovenous laser treatment (EVLT), requiring only tiny incisions. In most cases, these interventions can be performed on an outpatient basis.


J Vasc Surg. 2007 Aug;46(2):308-15. Epub 2007 Jun 27.
Randomized trial comparing endovenous laser ablation of the great saphenous vein with high ligation and stripping in patients with varicose veins: short-term results.
Rasmussen LH, Bjoern L, Lawaetz M, Blemings A, Lawaetz B, Eklof B.
Danish Vein Centre, Naestved, Denmark. larshrasmussen@yahoo.com
BACKGROUND: Endovenous laser (EVL) ablation of the great saphenous vein (GSV) is thought to minimize postoperative morbidity and reduce work loss compared with high ligation and stripping (HL/S). However, the procedures have not previously been compared in a randomized trial with parallel groups where both treatments were performed in tumescent anesthesia on an out-patient basis. METHODS: Patients with varicose veins due to GSV insufficiency were randomized to either EVL (980 nm) or HL/S in tumescent anesthesia. Miniphlebectomies were also performed. Patients were examined preoperatively and at 12 days, and 1, 3, and 6 months postoperatively. Sick leave, time to normal physical activity, pain score, use of analgesics, Aberdeen score, Medical Outcomes Study Short Form-36 quality-of-life score, Venous Clinical Severity Score (VCSS), and complication rates were investigated. The total cost of the procedures, including lost wages and equipment, was calculated. Cost calculations were based on the standard fee for HL/S with the addition of laser equipment and the standard salary and productivity level in Denmark. RESULTS: A follow-up of 6 months was achieved in 121 patients (137 legs). The groups were well matched for patient and GSV characteristics. Two HL/S procedures failed, and three GSVs recanalized in the EVL group. The groups experienced similar improvement in quality-of-life scores and VCSS score at 3 months. Only one patient in the HL/S group had a major complication, a wound infection that was treated successfully with antibiotics. The HL/S and EVL groups did not differ in mean time to resume normal physical activity (7.7 vs 6.9 calendar days) and work (7.6 vs 7.0 calendar days). Postoperative pain and bruising was higher in the HL/S group, but no difference in the use of analgesics was recorded. The total cost of the procedures, including lost wages, was euro 3084 ($3948 US) in the HL/S and euro 3396 ($4347 US) in the EVL group. CONCLUSIONS: This study suggests that the short-term efficacy and safety of EVL and HL/S are similar. Except for slightly increased postoperative pain and bruising in the HL/S group, no differences were found between the two treatment modalities. The treatments were equally safe and efficient in eliminating GSV reflux, alleviating symptoms and signs of GSV varicosities, and improving quality of life. Long-term outcomes, particularly with respect to recurrence rates, shall be investigated in future studies, including the continuation of the present.

Ann Vasc Surg. 2007 Mar;21(2):155-8.
Adjunctive proximal vein ligation with endovenous obliteration of great saphenous vein reflux: does it have clinical value?
Gradman WS.
Beverly Hills Vein Center, Beverly Hills, California 90210, USA. wayne@gradman.com
The risk of clot extension to the deep venous system or pulmonary embolism following endovenous great saphenous vein (GSV) obliteration is possibly related to the size of the proximal GSV. Some practitioners therefore exclude endovenous GSV obliteration for veins greater than an arbitrary size, starting as little as 15 mm. Others provide adjunctive proximal GSV ligation either routinely, or in selected patients with large veins. The clinical value of adjunctive proximal GSV ligation is unknown. A survey of either the American Venous Forum or the American College of Phlebology, selected for their pedagogic or long-time experience with endovenous GSV obliteration. Respondent characteristics included obliteration technique (laser, radiofrequency [RF], or foam sclerotherapy), academic status, surgical training, indication for and frequency of adjunctive proximal GSV ligation, and society membership. The incidence of pulmonary embolus (PE) and deep vein thrombus (DVT) was also tallied. Twenty-one thousand nine hundred sixty-five endovenous GSV obliteration cases were reported, 10,290 with a laser (46.8%), 6,275 (28.6%) with RF, and 5,400 (24.6%) with foam. Only two PEs were reported. Of the 34 patients with DVT, at least 11 had only asymptomatic ultrasound evidence of thrombus extension into the femoral vein, and at least five had only calf vein thrombosis. Comparing ligators (7) with non-ligators (15), the only characteristic significantly correlating with adjunctive proximal GSV ligation was whether the respondent had complete general or vascular surgical training; non-surgeons never ligated the saphenous vein (p < .001). There was no difference between outcomes of ligators and non-ligators. Endovenous obliteration of the GSV poses little risk of PE or DVT, no matter what size the proximal GSV. Although these adverse events may be reduced with adjunctive proximal GSV ligation, the results of this study suggest that adjunctive proximal GSV ligation is superfluous in most patients.

J Vasc Surg. 2006 May;43(5):1056-8.
Comment in:
J Vasc Surg. 2006 Oct;44(4):912-3; author reply 913.
Diffuse phlegmonous phlebitis after endovenous laser treatment of the greater saphenous vein.
Dunst KM, Huemer GM, Wayand W, Shamiyeh A.
Department of General Surgery, Allgemeines Krankenhaus, Linz, Austria. karin.dunst@gmx.at
Endovenous laser treatment (EVLT) has become a valuable and safe option in the treatment of varicose veins. Although long-term results are lacking, most patients seem to benefit in the short-term from EVLT. Reported postoperative complications are limited, consisting usually of pain, ecchymosis, induration, phlebitis, or spot skin burn injuries. The most feared complication is an extension of the saphenous thrombus into the femoral vein, with possible pulmonary embolism. Here we report a septic thrombophlebitis after EVLT resulting in a phlegmonous infection of the whole leg that was treated by surgical drainage. Aggressive local therapy and antibiotic treatment resulted in complete resolution of symptoms and eventual satisfactory healing.
Ann Vasc Surg. 2007 Sep;21(5):637-9. Epub 2007 May 17.
Cutaneous hyperpigmentation after endovenous laser therapy: a case report and literature review.
Mekako A, Chetter I.
Academic Vascular Surgery Unit, Hull Royal Infirmary, Anlaby Road, Hull HU3 2JZ, UK. Anthony.mekako@hey.nhs.uk
Endovenous laser therapy (EVLT) for the treatment of varicose veins has been shown to be effective and relatively safe. Reported complications are few and transient. Whereas it is not uncommon to have cutaneous hyperpigmentation following treatment modalities such as sclerotherapy, only a few reports of transient hyperpigmentation following EVLT have been mentioned in the literature. We report a case of persistent hyperpigmentation following successful varicose vein treatment by EVLT.


J Endovasc Ther. 2005 Dec;12(6):731-8.
Is there recanalization of the great saphenous vein 2 years after endovenous laser treatment?
Disselhoff BC, der Kinderen DJ, Moll FL.
Department of Surgery, Mesos Medical Centre, Utrecht, The Netherlands. bcvmdisselhoff@mesos.nl
PURPOSE: To report the 2-year single-center results of endovenous laser treatment (EVLT) for reflux in the great saphenous vein (GSV). METHODS: From January 2002 to January 2003, 85 symptomatic patients (56 women; mean age 49 years, range 27-80) underwent EVLT in 100 limbs. All patients were symptomatic, and the majority (67, 79%) had CEAP clinical class C2 venous disease. After treatment, they were monitored by clinical evaluation and duplex imaging. RESULTS: The initial treatment was completed in 93 limbs. Complications consisted of bruising (31%), tightness (17%), pain (14%), induration (2%), and superficial thrombophlebitis (2%). No severe complications were observed. Over a mean follow-up of 29 months (range 24-37), 3 patients died and 14 were lost to follow-up, leaving 88 (95%) and 76 (82%) limbs available for imaging surveillance at 1 and 2 years, respectively. At 3 months, treatment was anatomically successful in 84% of cases (78 complete occlusion, 7 partial occlusion, and 8 nonocclusion) and functionally successful in 89% (83 no reflux, 10 reflux). All technical failures and 73% (n=11) of the treatment failures occurred in the first half of the studied population, indicating a learning curve effect (p=0.015). Mean energy delivered per unit length was 39+/-8 J/cm (range 25-65) for successful treatment (n=78) and 30+/-10 J/cm (range 21-50) for failed treatment (n=15). No recanalization or recurrent GSV reflux after anatomically and functionally successful treatment was observed in 73 and 61 limbs at 1 and 2-year follow-up, respectively. CONCLUSIONS: EVLT is a feasible, safe, and fast procedure for eliminating GSV reflux and has excellent cosmetic results. Despite the learning curve, we believe that the treatment results are promising. When successful treatment is achieved by EVLT, a prospective follow-up of 2 years demonstrates durable results.


J Vasc Surg. 2004 Sep;40(3):500-4.
Comment in:
J Vasc Surg. 2005 Apr;41(4):737; author reply 737-8.
J Vasc Surg. 2005 Feb;41(2):374; author reply 374.
J Vasc Surg. 2005 May;41(5):915-6; author reply 916.
Deep venous thrombosis after radiofrequency ablation of greater saphenous vein: a word of caution.
Hingorani AP, Ascher E, Markevich N, Schutzer RW, Kallakuri S, Hou A, Nahata S, Yorkovich W, Jacob T.
Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY 11219, USA. ahingorani@maimonidesmed.org
PURPOSE: Radiofrequency ablation (RFA) of the greater saphenous vein (GSV; "closure") is a relatively new option for treatment of venous reflux. However, our initial enthusiasm for this minimally invasive technique has been tempered by our preliminary experience with its potentially lethal complication, deep venous thrombosis (DVT). METHODS: Seventy-three lower extremities were treated in 66 patients with GSV reflux, between April 2003 and February 2004. There were 48 (73%) female patients and 18 (27%) male patients, with ages ranging from 26 to 88 years (mean, 62 +/- 14 years). RFA was combined with stab avulsion of varicosities in 55 (75%) patients and subfascial ligation of perforator veins in 6 (8%) patients. An ATL HDI 5000 scanner with linear 7-4 MHz probe and the SonoCT feature was used for GSV mapping and procedure guidance in all procedures. GSV diameter determined the size of the RFA catheter used. Veins less than 8 mm in diameter were treated with a 6F catheter (n = 54); an 8F catheter was used for veins greater than 8 mm in diameter (n = 19). The GSV was cannulated at the knee level. The tip of the catheter was positioned within 1 cm of the origin of the inferior epigastric vein (first GSV tributary). All procedures were carried out according to manufacturer guidelines. RESULTS: All patients underwent venous duplex ultrasound scanning 2 to 30 days (mean, 10 +/- 6 days) after the procedure. The duplex scans documented occlusion of the GSV in 70 limbs (96%). In addition, DVT was found in 12 limbs (16%). Eleven patients (92%) had an extension of the occlusive clot filling the treated proximal GSV segment, with a floating tail beyond the patent inferior epigastric vein into the common femoral vein. Another patient developed acute occlusive clots in the calf muscle (gastrocnemius) veins. Eight patients were readmitted and received anticoagulation therapy. Four patients were treated with enoxaparin on an ambulatory basis. None of these patients had pulmonary embolism. Initially 3 patients with floating common femoral vein clots underwent inferior vena cava filter placement. Of the 19 limbs treated with the 8F RFA catheter, GSV clot extension developed in 5 (26%), compared with 7 of 54 (13%) limbs treated with the 6F RFA catheter (P =.3). No difference was found between the occurrence of DVT in patients who underwent the combined procedure (RFA and varicose vein excision) compared with patients who underwent GSV RFA alone (P =.7). No statistically significant differences were found in age or gender of patients with or without postoperative DVT (P = NS). CONCLUSION: Patients who underwent combined GSV RFA and varicose vein excision did not demonstrate a higher occurrence of postoperative DVT compared with patients who underwent RFA alone. Early postoperative duplex scans are essential, and should be mandatory in all patients undergoing RFA of the GSV.



Dermatol Surg. 2005 Dec;31(12):1685-94; discussion 1694.
Comparison of endovenous treatment with an 810 nm laser versus conventional stripping of the great saphenous vein in patients with primary varicose veins.
de Medeiros CA, Luccas GC.
Department of Surgery, University of Campinas, Brazil. charlesangotti@directnet.com.br
BACKGROUND: Patients with varicose veins seek medical assistance for many reasons, including esthetic ones. The development of suitable and more flexible instruments, along with less invasive techniques, enables the establishment of new therapeutic procedures. OBJECTIVE: To compare endovenous great saphenous vein photocoagulation with an 810 nm diode laser and the conventional stripping operation in the same patient. METHODS: Twenty patients selected for operative treatment of primary great saphenous vein insufficiency on duplex scanning were assigned to a bilateral random comparison. In all cases, both techniques were performed, one on each lower limb. Clinically, evaluation was assessed on the seventh, thirtieth, and sixtieth postoperative days. Patients underwent examination with duplex ultrasonography and air plethysmography during the follow-up. RESULTS: Patients who received endovenous photocoagulation presented with the same pain but fewer swellings and less bruising than the stripping side. Most patients indicated that the limb operated on by laser received more benefits than the other. There was only one recanalization and no adverse effects. The venous filling time showed better hemodynamics in both techniques. CONCLUSION: The endovenous great saphenous vein photocoagulation is safe and well tolerated and presents results comparable to those of conventional stripping.

Некоторые пишут уже в завтра...


Eur J Vasc Endovasc Surg. 2008 Jan;35(1):88-95. Epub 2007 Oct 24.
Technical review of endovenous laser therapy for varicose veins.
van den Bos RR, Kockaert MA, Neumann HA, Nijsten T.
Department of Dermatology, Erasmus MC, Rotterdam, The Netherlands.
BACKGROUND: In the last decade, several new treatments of truncal varicose veins have been introduced. Of these new therapies, endovenous laser therapy (EVLT) is one of the most widely accepted and used treatment options for incompetent greater and lesser saphenous veins. OBJECTIVE: The objective of this report is to inform clinicians about the EVLT procedure and to review its efficacy and safety in treatment of truncal varicose veins. Also, we discuss some of the underlying theoretical principles and laser parameters that affect EVLT. METHODS: We carried out a literature review of EVLT;s efficacy and safety. We included reports that included 100 or more limbs with a follow-up of at least 3 months. The principals and procedure of EVLT are described. Of the laser parameters, mode of administration, wavelength, fluence, wattage and pullback speed are discussed. CONCLUSION: EVLT appears to be a very effective and safe option in the treatment of varicose veins but large randomized comparative studies are needed.

Roland L, Dietzek AM. Related Articles, LinkOut



Perspect Vasc Surg Endovasc Ther. 2007 Sep;19(3):309-14.
PMID: 17911563 [PubMed - indexed for MEDLINE]

Позиционируется как первая публикация о эндовазальной лазерной коагуляции вен на верхних конечностях. Интересно, спользовал ли кто из форумчан лазер в этом регионе?

Plast Reconstr Surg. 2007 Dec;120(7):2017-24.
Laser ablation of unwanted hand veins.
Shamma AR, Guy RJ.
Brevard Plastic Surgery and Skin Treatment Center, Melbourne, Fla. 32901, USA.


PMID: 18090768 [PubMed - indexed for MEDLINE]

[quote="Евгений Илюхин"]Позиционируется как первая публикация о эндовазальной лазерной коагуляции вен на верхних конечностях. Интересно, спользовал ли кто из форумчан лазер в этом регионе?
=========================================
За всю свою профессиональную карьеру видел лишь, двух больных у которых с натяжкой, можно было счесть данную патологию как варици на руке, да еще несколько со смешанными артерио-венозными аномалиями.
Может стоило бы у одного из последних произвести лазерную обработку венозного русла.

Уважаемый Виктор! Я так понял, что речь идет не о варикозной трансформации. Помнится, Вадим Юрьевич делился опытом минифлебэктомии на руках пациентке, работающей моделью. Вены были здоровы, но внешний вид являлся для нее серьезной проблемой.

[quote="Евгений Илюхин"]Уважаемый Виктор! Я так понял, что речь идет не о варикозной трансформации.
======================================

Да, Евгений, в моем случае речь шла не о настоящем варикозе. Это были множественные артерио-венозные фистулы, которые распространялись даже на область груди. Кажется снимков не делали, иначе стало бы ясно, что ни мини-ни макрофлебэктомиями дело бы не обошлось.

Varicose vein stripping vs haemodynamic correction (CHIVA): a long term randomised trial.
Carandina S, Mari C, De Palma M, Marcellino MG, Cisno C, Legnaro A, Liboni A, Zamboni P.
Department of Surgical, Anaesthesiological, and Radiological Sciences, Day-Surgery Unit, Vascular Diseases Center, University of Ferrara, Italy.
OBJECTIVES: To compare the long-term results of stripping vs. haemodynamic correction (Ambulatory Conservative Haemodynamic Management of Varicose Veins, CHIVA) in the treatment of superficial venous incompetence resulting in chronic venous disease (CVD). DESIGN: Randomised comparative trial. PATIENTS: 150 patients affected by CVD, CEAP clinical class 2-6, were randomised to saphenous stripping or to CHIVA. METHODS: The clinical outcome was assessed by an independent observer who recorded the Hobbs clinical score for treated limbs. A subjective report of the outcome was provided by the patients. Recurrence of varices was assessed by both clinical examination and duplex ultrasonography. RESULTS: The mean follow-up was 10 years, 26 patients were lost to follow-up. The Hobbs score similar in the stripping and CHIVA groups. However recurrence of varicose veins was significantly higher in the stripping group (CHIVA 18%; stripping 35%, P<0.04 Fisher's exact test), without significant differences in the rate of recurrences from the sapheno-femoral junction. The associated risk of recurrence at ten years was doubled in the stripping group (OR 2.2, 95% CI 1-5, P=0.04). CONCLUSIONS: Recurrent varices occurred more frequently following saphenous stripping than after CHIVA treatment. The deliberate preservation of the saphenous trunk as a route of venous drainage in the CHIVA group may have been a factor reducing the recurrence rate.
Eur J Vasc Endovasc Surg. 2008 Feb;35(2):230-7. Epub 2007 Oct 26.
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Conventional stripping versus cryostripping: a prospective randomised trial to compare improvement in quality of life and complications.
Menyhei G, Gyevnár Z, Arató E, Kelemen O, Kollár L.
Department of Vascular Surgery, University of Pécs, Hungary. gmenyhei@yahoo.co.uk
OBJECTIVES: To assess the improvement in quality of life and complication rates in patients undergoing great saphenous vein (GSV) stripping using two different techniques. DESIGN: A single centre prospective randomised trial. PATIENTS AND METHODS: 160 patients with primary varicose veins and GSV incompetence were randomised to either conventional stripping or cryostripping combined with phlebectomy of varices. Quality of life was assessed as the primary outcome measure prior to surgery and 6 months later, using the SF-36 questionnaire. Operative data, pain score and procedure related complications were evaluated as secondary outcome measures. We assessed the area of bruising and symptoms attributable to saphenous nerve injury. RESULTS: The number of completely analysed patients was 77 in the conventional stripping group and 69 in the cryostripping group. When comparing the preoperative SF-36 scores to the results after 6 months, there was an improvement in all eight domains, which reached statistical significance in six domains in both groups. The mean area of bruising measured in the thigh was significantly greater in the conventional stripping group (161 S.D. 63cm(2) versus 123 S.D. 52cm(2), p=0.010, Student's t test). The number of patients with paraesthesia due to saphenous nerve injury was numerically lower in the cryostripping group at one week [15 (22%), versus 28 (34%), N.S.] but no difference was observed at 6 months. Postoperative pain score evaluation in the evening and 24 hours after the operation revealed no significant difference. CONCLUSIONS: The study confirmed significant improvement in quality of life measured by SF-36 questionnaire after both conventional and cryostripping with no difference between the two stripping techniques. Cryostripping results in less bruising than conventional stripping.
Eur J Vasc Endovasc Surg. 2008 Feb;35(2):218-23. Epub 2007 Oct 26.
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Randomized trial comparing endovenous laser ablation of the great saphenous vein with high ligation and stripping in patients with varicose veins: short-term results.
Rasmussen LH, Bjoern L, Lawaetz M, Blemings A, Lawaetz B, Eklof B.
Danish Vein Centre, Naestved, Denmark. larshrasmussen@yahoo.com
BACKGROUND: Endovenous laser (EVL) ablation of the great saphenous vein (GSV) is thought to minimize postoperative morbidity and reduce work loss compared with high ligation and stripping (HL/S). However, the procedures have not previously been compared in a randomized trial with parallel groups where both treatments were performed in tumescent anesthesia on an out-patient basis. METHODS: Patients with varicose veins due to GSV insufficiency were randomized to either EVL (980 nm) or HL/S in tumescent anesthesia. Miniphlebectomies were also performed. Patients were examined preoperatively and at 12 days, and 1, 3, and 6 months postoperatively. Sick leave, time to normal physical activity, pain score, use of analgesics, Aberdeen score, Medical Outcomes Study Short Form-36 quality-of-life score, Venous Clinical Severity Score (VCSS), and complication rates were investigated. The total cost of the procedures, including lost wages and equipment, was calculated. Cost calculations were based on the standard fee for HL/S with the addition of laser equipment and the standard salary and productivity level in Denmark. RESULTS: A follow-up of 6 months was achieved in 121 patients (137 legs). The groups were well matched for patient and GSV characteristics. Two HL/S procedures failed, and three GSVs recanalized in the EVL group. The groups experienced similar improvement in quality-of-life scores and VCSS score at 3 months. Only one patient in the HL/S group had a major complication, a wound infection that was treated successfully with antibiotics. The HL/S and EVL groups did not differ in mean time to resume normal physical activity (7.7 vs 6.9 calendar days) and work (7.6 vs 7.0 calendar days). Postoperative pain and bruising was higher in the HL/S group, but no difference in the use of analgesics was recorded. The total cost of the procedures, including lost wages, was euro 3084 ($3948 US) in the HL/S and euro 3396 ($4347 US) in the EVL group. CONCLUSIONS: This study suggests that the short-term efficacy and safety of EVL and HL/S are similar. Except for slightly increased postoperative pain and bruising in the HL/S group, no differences were found between the two treatment modalities. The treatments were equally safe and efficient in eliminating GSV reflux, alleviating symptoms and signs of GSV varicosities, and improving quality of life. Long-term outcomes, particularly with respect to recurrence rates, shall be investigated in future studies, including the continuation of the present.
J Vasc Surg. 2007 Aug;46(2):308-15. Epub 2007
Republished in:
Ugeskr Laeger. 2007 Dec 17;169(51):4442-4.
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Endovenous laser ablation for saphenous vein insufficiency: immediate and short-term results of our first 60 procedures.
Yilmaz S, Ceken K, Alparslan A, Sindel T, Lüleci E.
Department of Radiology, Akdeniz University School of Medicine, Antalya, Turkey. ysaim@akdeniz.edu.tr
PURPOSE: To present the immediate and short-term results of our first 60 endovenous laser (EVL) ablation procedures. MATERIALS AND METHODS: Between July 2005 and December 2006, 60 EVL ablations were performed in 36 symptomatic patients (26 females, 10 males; mean age +/- SD, 46 +/- 14 years). The incompetent veins included the great saphenous vein (GSV) (n = 52), small saphenous vein (n = 6), and major branches of the GSV (n = 2). In all cases incompetent veins were punctured under ultrasound (US) guidance and the laser fiber was placed into these veins through a vascular sheath or with the help of a catheter. After tumescent anesthesia was administered, the veins were ablated with laser by delivering 50-100 joules/cm energy to the vein wall. Following EVL ablations, 29 patients also underwent foam sclerotherapy to treat the remaining varicosities. After the EVL ablation +/- sclerotherapy, patients were followed- up with Doppler US at 1 week, and then 3, 6, and 12 months post procedure. RESULTS: In all patients EVL ablation was technically successful. Complications were minor and included transient visual disturbance due to foam sclerotherapy (n = 1), bruising/ ecchymoses (n = 24), postoperative pain (n = 16), and superficial thrombophlebitis (n = 6). All patients returned to normal activity within 2 days. During the 7 +/- 5 months (mean +/- SD) of follow-up, recurrent reflux was seen in only one patient, in both GSVs, which was successfully treated with foam sclerotherapy. CONCLUSION: EVL ablation is a safe and effective method for the management of saphenous vein insufficiency.Diagn Interv Radiol. 2007 Sep;13(3):156-63.


Полнотекстовая версия здесь:http://www.dirjournal.org/text.php3?id=136
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The appropriate length of great saphenous vein stripping should be based on the extent of reflux and not on the intent to avoid saphenous nerve injury.
Kostas TT, Ioannou CV, Veligrantakis M, Pagonidis C, Katsamouris AN.
Vascular Surgery Department, University Hospital of Heraklion, University of Crete Medical School, Heraklion, Crete, Greece.
OBJECTIVE: To investigate the effect of stripping the below knee great saphenous vein (GSV) segment on varicose vein recurrence as well as any disability induced after saphenous nerve injury (SNI) during a 5-year period. METHODS: One hundred and six limbs (86 patients, 64 female, mean age 46 years), that underwent GSV stripping, to the knee or ankle level, were prospectively followed up at 1 month and 5 years postoperatively with clinical examination and color duplex imaging (CDI), in order to evaluate SNI and the development of recurrence. The extent of GSV stripping complied with preoperative CDI in 84 limbs (79%) that were subjected to GSV stripping to the ankle and full abolishment of duplex-confirmed reflux. Furthermore, 19 limbs (18%) underwent stripping restricted to the below knee level since the distal GSV was competent. On the contrary, in three limbs (3%), the extent of stripping did not comply with preoperative CDI due to the absence of varicosities in the tibia, and stripping was restricted to the knee level, although they had reflux along the whole GSV length. RESULTS: Overall recurrence was found in 24 out of 106 operated limbs (23%) after 5 years. Recurrence was found to be 20% (17/84) in the limbs with total GSV stripping and 32% (7/22) in the limbs with restricted GSV stripping (P > .05). However, the recurrence rate in the tibial area was significantly lower in limbs subjected to GSV stripping, which was in compliance with the preoperative CDI (9/103, 9%) compared with those that had undergone GSV stripping that was not in agreement with the preoperative CDI (3/3, 100%; P < .005). Neurological examination at 1 month postoperatively, revealed SNI in 17 limbs (16%). However, at the 5-year neurological reassessment, we found that seven out of these limbs (40%) were alleviated from SNI adverse symptoms presenting only deficits in sensation. In addition, no significance was found concerning SNI between limbs subjected to total and restricted GSV stripping (16/84 vs 1/22; P > .05). CONCLUSIONS: Though SNI may occur after both restricted and total GSV stripping, this does not influence limb disability since any related symptoms seem to regress in almost half of the limbs 5 years postoperatively. Additionally, it seems that recurrence could be reduced in the tibial area if the level of GSV stripping complies with the extent of the ultrosonographically proven GSV reflux. Therefore, the extent of GSV stripping should not be guided by the intent of avoiding SNI.
J Vasc Surg. 2007 Dec;46(6):1234-41.



Endovenous 980-nm laser treatment of saphenous veins in a series of 500 patients.
Desmyttère J, Grard C, Wassmer B, Mordon S.
S.E.L. Angéio-Phlébo Interventionnelle, France.
BACKGROUND: In recent years, endovenous laser treatment (ELT) has been proposed to treat incompetent great saphenous veins (GSV). This study reports the long-term outcome of ELT in a series of 500 patients. METHODS: Incompetent GSV segments in 500 patients (436 women, 64 men) with a mean age of 52.6 years (range, 19 to 83 years) were treated with intraluminal ELT using a 980-nm diode laser (Pharaon, Osyris, France). The GSV diameter was measured by Duplex examination in an upright position in different GSV segments (1.5 cm below the saphenofemoral junction, crural segment, condylar segment, and sural segment). These measurements were used to determine the optimal linear endovenous energy density (LEED) for each segment. During treatment, patients were maintained in the Trendelenburg position. Patients were evaluated clinically and by duplex scanning at 1 and 8 days, 1 and 6 months, and at 1, 2, 3, and 4 years to assess treatment efficacy and adverse reactions. RESULTS: A total of 511 GSVs were treated. The mean diameter was 7.5 mm (range, 2.4 to 15.0). The LEED was tuned as a function of the initial GSV diameter measured in the orthostatic position, from 50 J/cm (3 mm) up to 120 J/cm (15 mm). At the 1-week follow-up, 9.3% of the patients reported moderate pain. In the immediate postoperative period, the closure rate was 98.0% and remained constant during the 4-year follow-up to reach 97.1%. After 1 year, a complete disappearance of the GSV or minimal residual fibrous cord was noted. Major complications have not been detected; in particular, no deep venous thrombosis. Ecchymoses were seen in 60%, transitory paresthesia was observed in 7%. There was no dyschromia, superficial burns, thrombophlebitis, or palpable indurations. Complementary phlebectomy was done in 98% of patients. Failures occurred only in large veins (saphenofemoral junction diameter >1.1 cm or for GSV truncular diameter >0.8 cm) CONCLUSION: ELT of the incompetent GSV with a 980-nm diode laser appears to be an extremely safe technique, particularly when the energy applied is calculated as a function of the GSV diameter. It is associated with only minor effects. Currently, ELT has become the method of choice for treating superficial veins and has almost replaced the treatment of traditional ligation and stripping.J Vasc Surg. 2007 Dec;46(6):1242-7.

Endovenous 980-nm laser treatment of saphenous veins in a series of 500 patients.
Desmyttère J, Grard C, Wassmer B, Mordon S.
S.E.L. Angéio-Phlébo Interventionnelle, France.
BACKGROUND: In recent years, endovenous laser treatment (ELT) has been proposed to treat incompetent great saphenous veins (GSV). This study reports the long-term outcome of ELT in a series of 500 patients. METHODS: Incompetent GSV segments in 500 patients (436 women, 64 men) with a mean age of 52.6 years (range, 19 to 83 years) were treated with intraluminal ELT using a 980-nm diode laser (Pharaon, Osyris, France). The GSV diameter was measured by Duplex examination in an upright position in different GSV segments (1.5 cm below the saphenofemoral junction, crural segment, condylar segment, and sural segment). These measurements were used to determine the optimal linear endovenous energy density (LEED) for each segment. During treatment, patients were maintained in the Trendelenburg position. Patients were evaluated clinically and by duplex scanning at 1 and 8 days, 1 and 6 months, and at 1, 2, 3, and 4 years to assess treatment efficacy and adverse reactions. RESULTS: A total of 511 GSVs were treated. The mean diameter was 7.5 mm (range, 2.4 to 15.0). The LEED was tuned as a function of the initial GSV diameter measured in the orthostatic position, from 50 J/cm (3 mm) up to 120 J/cm (15 mm). At the 1-week follow-up, 9.3% of the patients reported moderate pain. In the immediate postoperative period, the closure rate was 98.0% and remained constant during the 4-year follow-up to reach 97.1%. After 1 year, a complete disappearance of the GSV or minimal residual fibrous cord was noted. Major complications have not been detected; in particular, no deep venous thrombosis. Ecchymoses were seen in 60%, transitory paresthesia was observed in 7%. There was no dyschromia, superficial burns, thrombophlebitis, or palpable indurations. Complementary phlebectomy was done in 98% of patients. Failures occurred only in large veins (saphenofemoral junction diameter >1.1 cm or for GSV truncular diameter >0.8 cm) CONCLUSION: ELT of the incompetent GSV with a 980-nm diode laser appears to be an extremely safe technique, particularly when the energy applied is calculated as a function of the GSV diameter. It is associated with only minor effects. Currently, ELT has become the method of choice for treating superficial veins and has almost replaced the treatment of traditional ligation and stripping.J Vasc Surg. 2007 Dec;46(6):1242-7.

Ссылка на систематический обзор из библиотеки Кохрановского сотрудничества по хирургическому лечению несостоятельных глубоких вен нижних конечностей. Здесь

VARICOSE VEIN STRIPPING VS HAEMODYNAMIC CORRECTION (CHIVA):
A LONG TERM RANDOMIZED TRIAL
Caradina S, Mari C, De Palma M, et al. Eur J Vasc Endovasc Surg. 2008;35:230-237.
ABSTRACT AND COMMENTARY BY
Paul Pittaluga, Nice, France
ABSTRACT
This is a randomized prospective study that is in theory of great
interest, by a team that is well known for its work on chronic vein
disease. The goal of this study was to compare the long-term results
of the treatment of varices using CHIVA versus traditional high
ligation/stripping. Two groups of 75 patients, randomly assigned
to CHIVA or stripping, and all with varices with ostial and truncal
incontinence of the great saphenous vein, were followed up for 10
years after treatment. The results indicate equivalence in terms of
overall patient satisfaction and a statistically significant advantage in
terms of recurrence for the CHIVA group as opposed to the
stripping group (18% vs 35%; P<0.038). Examination of the
hemodynamic mechanisms showed that the recurrences were much
more complex in the stripping group than in the CHIVA group.
COMMENTARY
To the best of our knowledge, this is the first prospective,
randomized study to offer a long-term comparison of the results of
CHIVA and of traditional stripping. This scientific advance reflects
favorably on the authors in a field in which very few articles adhere
to this degree of rigor.
Nevertheless, a close examination of the article reveals certain major
methodological shortcomings. Of the 180 patients who met the
inclusion criteria, 30 patients were withdrawn from the study before
randomization because they refused to be included in the stripping
group. It is odd that, conversely, no patients were excluded because
they refused to be included in the CHIVA group. This raises doubts
as to the neutrality of the information about the equivalence of the
two treatments as supplied to the patient prior to randomization.
Furthermore, the two groups of patients were not treated by the
same teams. In particular, they underwent operations under
radically different conditions, ie, local anesthesia on an outpatient
basis for the CHIVA group, as opposed to locoregional or general
anesthesia and hospitalization for the stripping group. These
differences might lead to significant bias in the evaluation of patient
satisfaction with the treatment (and might explain the refusal to be
included in the stripping group). The number of patients lost from
the study was distinctly higher in the stripping group (21 out of 75,
or 28%) than in the CHIVA group (5 out of 75, or 6%), which
severely compromises the reliability of the comparison, as indeed
the authors acknowledge. Moreover, the results do not mention the
performance of any secondary procedures during the follow-up
period, whose mean (10 years) is known, but whose median is not
stated. The most serious criticism appears to pertain to the major
evaluation criterion, ie, varicose recurrence. It is extremely difficult
to understand the definition of this term as provided by the authors,
who combine clinical and echo-Doppler evaluations, despite the
fact that the REVAS consensus1 produced a much simpler and very
widely used definition. Based on a reading of the article, it is almost
impossible to understand how the recurrence rates (18% vs 35%)
were calculated and led to the conclusion that CHIVA was superior
to stripping. Granted, this article’s hemodynamic analysis of the
causal mechanisms of recurrence is valuable, because it shows that
recurrences after stripping are associated with hemodynamic
mechanisms whose treatment is more complex. Nevertheless, this
analysis appears to be extremely difficult to use in comparing the
results of an ablative technique with the results of a technique that
preserves the saphenous vein, in as much as their hemodynamic
goals are different. It appears to us that the only possible
comparison between these two approaches must be made on the
basis of objective varicose recurrence, according to the REVAS
definition (which was not used in this study), and on the basis of
patient satisfaction (for which this study did not report a significant
difference). Thus, we do not believe that CHIVA skeptics would be
persuaded by reading this article.
In conclusion, despite its methodological biases, this paper has the
meritof demonstrating the physiological value of conserving the
saphenous vein as a drainage element of the superficial venous
system, thereby enabling a less anarchic evolution of the varicose
disease over the long term.
We support the same principle using the ambulatory selective
varices ablation under local anesthesia (ASVAL) method,2although
it is worth noting that the ASVAL method directly opposes all of the
pathophysiological and therapeutic foundations of the CHIVA
approach, particularly in terms of the pathophysiological role of the
saphenous vein, the absence of high ligation, the treatment of
perforating veins, and, above all, the importance of the varicose
reservoir, which is a central part of the ASVAL method.
REFERENCES
1. Perrin M, Guex JJ, Ruckley CV, et al; REVAS group. Recurrent
varices after surgery (REVAS): a consensus document. Cardiovasc
Surg. 2000;8:233-245. 2. Pittaluga P, Rea B, Barbe R, Guex JJ.
A.S.V.A.L. method: principles and preliminary results. In:
Becquemin JP, Alimi YS, Watelet J, eds. Updates and controversies
in Vascular Surgery. Torino, Italy: Minerva Medica; 2005:182-189.
Up to 6 tablets daily
Chronic venous insufficiency
Acute hemorrhoids
2 tablets daily detralex®
A decisive therapeutic benefit for patients with venous disease
Micronized, purified flavonoid fraction
Presentation and composition : Box of 30 coated tablets. Micronized flavonoid fraction 500 mg: diosmin 450 mg; hesperidin 50 mg. Therapeutic properties: Vascular protector and venotonic.
Detralex acts on the return vascular system: It reduces venous distensibility and venous stasis; in the microcirculation, it normalizes capillary permeability and reinforces capillary resistance.
Therapeutic indications: Treatment of organic and idiopathic chronic venous insufficiency of the lower limbs with the following symptoms: heavy legs; pain; nocturnal cramps. Treatment of hemorrhoids and
acute hemorrhoidal attacks. Side effects: Some cases of minor gastrointestinal and autonomic disorders have been reported, but these never required cessation of treatment. Drug interactions: None. Precautions:
Pregnancy: experimental studies in animals have not demonstrated any teratogenic effects and no harmful effects have been reported in man to date. Lactation: in the absence of data concerning the diffusion into
breast milk, breast-feeding is not recommended during treatment. Contraindications: None. Dosage and administration: In venous disease: 2 tablets daily. In acute hermorrhoidal
attacks: the dosage can be increased to up to 6 tablets daily. As prescribing Information may vary from country to country, please refer to the complete data sheet supplied in your
country. Les laboratoires Servier – France. Correspondent: Servier International 22, rue Garnier – 92578 Neuilly-sur-Seine Cedex – France.
BULGARIAVARICOSE VEIN STRIPPING VS HAEMODYNAMIC CORRECTION (CHIVA):
A LONG TERM RANDOMIZED TRIAL
Caradina S, Mari C, De Palma M, et al. Eur J Vasc Endovasc Surg. 2008;35:230-237.
ABSTRACT AND COMMENTARY BY
Paul Pittaluga, Nice, France
ABSTRACT
This is a randomized prospective study that is in theory of great
interest, by a team that is well known for its work on chronic vein
disease. The goal of this study was to compare the long-term results
of the treatment of varices using CHIVA versus traditional high
ligation/stripping. Two groups of 75 patients, randomly assigned
to CHIVA or stripping, and all with varices with ostial and truncal
incontinence of the great saphenous vein, were followed up for 10
years after treatment. The results indicate equivalence in terms of
overall patient satisfaction and a statistically significant advantage in
terms of recurrence for the CHIVA group as opposed to the
stripping group (18% vs 35%; P<0.038). Examination of the
hemodynamic mechanisms showed that the recurrences were much
more complex in the stripping group than in the CHIVA group.
COMMENTARY
To the best of our knowledge, this is the first prospective,
randomized study to offer a long-term comparison of the results of
CHIVA and of traditional stripping. This scientific advance reflects
favorably on the authors in a field in which very few articles adhere
to this degree of rigor.
Nevertheless, a close examination of the article reveals certain major
methodological shortcomings. Of the 180 patients who met the
inclusion criteria, 30 patients were withdrawn from the study before
randomization because they refused to be included in the stripping
group. It is odd that, conversely, no patients were excluded because
they refused to be included in the CHIVA group. This raises doubts
as to the neutrality of the information about the equivalence of the
two treatments as supplied to the patient prior to randomization.
Furthermore, the two groups of patients were not treated by the
same teams. In particular, they underwent operations under
radically different conditions, ie, local anesthesia on an outpatient
basis for the CHIVA group, as opposed to locoregional or general
anesthesia and hospitalization for the stripping group. These
differences might lead to significant bias in the evaluation of patient
satisfaction with the treatment (and might explain the refusal to be
included in the stripping group). The number of patients lost from
the study was distinctly higher in the stripping group (21 out of 75,
or 28%) than in the CHIVA group (5 out of 75, or 6%), which
severely compromises the reliability of the comparison, as indeed
the authors acknowledge. Moreover, the results do not mention the
performance of any secondary procedures during the follow-up
period, whose mean (10 years) is known, but whose median is not
stated. The most serious criticism appears to pertain to the major
evaluation criterion, ie, varicose recurrence. It is extremely difficult
to understand the definition of this term as provided by the authors,
who combine clinical and echo-Doppler evaluations, despite the
fact that the REVAS consensus1 produced a much simpler and very
widely used definition. Based on a reading of the article, it is almost
impossible to understand how the recurrence rates (18% vs 35%)
were calculated and led to the conclusion that CHIVA was superior
to stripping. Granted, this article’s hemodynamic analysis of the
causal mechanisms of recurrence is valuable, because it shows that
recurrences after stripping are associated with hemodynamic
mechanisms whose treatment is more complex. Nevertheless, this
analysis appears to be extremely difficult to use in comparing the
results of an ablative technique with the results of a technique that
preserves the saphenous vein, in as much as their hemodynamic
goals are different. It appears to us that the only possible
comparison between these two approaches must be made on the
basis of objective varicose recurrence, according to the REVAS
definition (which was not used in this study), and on the basis of
patient satisfaction (for which this study did not report a significant
difference). Thus, we do not believe that CHIVA skeptics would be
persuaded by reading this article.
In conclusion, despite its methodological biases, this paper has the
meritof demonstrating the physiological value of conserving the
saphenous vein as a drainage element of the superficial venous
system, thereby enabling a less anarchic evolution of the varicose
disease over the long term.
We support the same principle using the ambulatory selective
varices ablation under local anesthesia (ASVAL) method,2although
it is worth noting that the ASVAL method directly opposes all of the
pathophysiological and therapeutic foundations of the CHIVA
approach, particularly in terms of the pathophysiological role of the
saphenous vein, the absence of high ligation, the treatment of
perforating veins, and, above all, the importance of the varicose
reservoir, which is a central part of the ASVAL method.
REFERENCES
1. Perrin M, Guex JJ, Ruckley CV, et al; REVAS group. Recurrent
varices after surgery (REVAS): a consensus document. Cardiovasc
Surg. 2000;8:233-245. 2. Pittaluga P, Rea B, Barbe R, Guex JJ.
A.S.V.A.L. method: principles and preliminary results. In:
Becquemin JP, Alimi YS, Watelet J, eds. Updates and controversies
in Vascular Surgery. Torino, Italy: Minerva Medica; 2005:182-189.
Up to 6 tablets daily
Chronic venous insufficiency
Acute hemorrhoids
2 tablets daily detralex®
A decisive therapeutic benefit for patients with venous disease
Micronized, purified flavonoid fraction
Presentation and composition : Box of 30 coated tablets. Micronized flavonoid fraction 500 mg: diosmin 450 mg; hesperidin 50 mg. Therapeutic properties: Vascular protector and venotonic.
Detralex acts on the return vascular system: It reduces venous distensibility and venous stasis; in the microcirculation, it normalizes capillary permeability and reinforces capillary resistance.
Therapeutic indications: Treatment of organic and idiopathic chronic venous insufficiency of the lower limbs with the following symptoms: heavy legs; pain; nocturnal cramps. Treatment of hemorrhoids and
acute hemorrhoidal attacks. Side effects: Some cases of minor gastrointestinal and autonomic disorders have been reported, but these never required cessation of treatment. Drug interactions: None. Precautions:
Pregnancy: experimental studies in animals have not demonstrated any teratogenic effects and no harmful effects have been reported in man to date. Lactation: in the absence of data concerning the diffusion into
breast milk, breast-feeding is not recommended during treatment. Contraindications: None. Dosage and administration: In venous disease: 2 tablets daily. In acute hermorrhoidal
attacks: the dosage can be increased to up to 6 tablets daily. As prescribing Information may vary from country to country, please refer to the complete data sheet supplied in your
country. Les laboratoires Servier – France. Correspondent: Servier International 22, rue Garnier – 92578 Neuilly-sur-Seine Cedex – France.
BULGARIA

Br J Surg. 2009 Mar 12;96(4):369-375.

Randomized clinical trial of concomitant or sequential phlebectomy after endovenous laser therapy for varicose veins.

Carradice D, Mekako AI, Hatfield J, Chetter IC.

Academic Vascular Surgical Unit, University of Hull, Hull, UK.



CONCLUSION: Concomitant phlebectomy with EVLT prolonged the procedure, but reduced the need for secondary procedures and significantly improved quality of life and the severity of venous disease. Copyright (c) 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

==========================================
А теперь сопоставим этот материал с одним из последних в разделе "Эндовазальное лечение....." где цитируется более чем 50% рефлюкса через 3 года и станет ясно, что первые ласточки прилетели.
По моему глубокому убеждению ЭВЛТ преимущественно дамский метод и в скором времени постепенно начнется серьезная селекция, целью которой отсеить "мужиков" от этого лечения, у которых ЭВЛТ будет сочетаться с кросс-эктомией и оставить для ЭВЛТ only полуздоровых хиленьких мужичков и милых дам . Правда, как я уже не раз отмечал, на этот раз все будет гораздо сложнее- слишком много нечистоплотных деньжат витает в доступных облаках.

Иногда весьма интересные сообщения встречаются на страницах газеты "Vascular news". Вот два из них:
Venous News

Tue 17-Mar-2009 09:07



Radiofrequency ablation with the ClosureFAST (VNUS) catheter is superior to endovenous laser ablation, according to new research.

The RECOVERY trial compared 980nm endovenous laser therapy to the ClosureFAST radiofrequency thermal ablation device in the treatment of incompetent great saphenous veins.

Sixty nine patients were randomised to either laser or radiofrequency ablation. Where both legs required treatment, the patient received the same therapy in each. Eighty seven great saphenous veins were treated in all.

The study looked at short-term outcomes, including quality of life, venous clinical severity scores, and adverse events, during a one month period.

Apparatus were covered with a sheet and protective goggles were worn during each procedure to ensure that patients did not know which treatment they were receiving.

Follow-up was performed with duplex ultrasound at 24-72 hours and at one month, and clinical assessment and quality of life questionnaires at 24-72 hours, one and two weeks, and at one month.

Primary outcomes assessed were: Closure of treated vein within 3cm of saphenofemoral juntion; pain, as assessed by the patient on a ten-point scale; ecchymosis, measured by clinical staff on a five-point scale; and adverse sequelae.

Secondary outcomes included venous clinical severity score and quality of life as determined by the CIVIQ2 questionnaire.

There was 100% vein occlusion and elimination of reflux in both groups, but the ClosureFAST group of 46 patients reported only two adverse events (one case of hyperpigmentation and one of paresthesia), whereas the laser ablation group (41 patients) reported nine.

Patients also reported experiencing less post-procedural pain with radiofrequency treatment and were assessed to have higher venous clinical severity scores in the earlier stages of follow-up.

By one month, however, both groups demonstrated similar outcomes.

These results were presented to the 34th Annual Scientific Meeting of the Society of Interventional Radiology, San Diego, USA, in March 2009, by John Kaufmann of the Dotter Interventional Institute, Portland, USA.
....................................................................................................
Laser vein closure nearly pain free

Fri 20-Feb-2009 11:11



Using a radial-firing 1470nm laser could result in more specific targeting of the vein wall and has several beneficial outcomes, including the possibility of avoiding use of anaesthetics, according to research presented data at the American Venous Forum in Arizona this month.


Jose Almeida and his team found that it was possible to reduce delivered energy to the vein wall from 60-80J/cm to 30 J/cm by more specific targeting.

The decreased energy delivery meant that significant volumes of perivenous tumescent anaesthesia to compress and reduce the vein diameter, and creation of a heat sink, were not required. However, small quantities of local anaesthesia were applied.

The study aimed to evaluate whether a water-specific laser wavelength would close incompetent saphenous veins without perivenous tumescent anaesthesia using minimal energy dosing.

The researchers say that the first 24 hours were virtually painless for patients, and eccymoses was absent. Also, they state that the primary closure rate (90.3%) is comparable to current thermal ablation benchmarks.

"Our hypothesis," said Almeida, "was that because of the high affinity of water to 1470nm wavelength, vein closure could be achieved with less energy, less heat production, less perforation, less pain and bruising, and perhaps, closure could be achieved without anaesthesia."

Больше подробностей на линке ниже:

http://www.cxvascular.com/vn-venous-news