АССОЦИАЦИЯ ФЛЕБОЛОГОВ РОССИИ

Исследование наших авторов посвященное ЭВЛК лазером длиной волны 1560 nm
К сожалению не нашел отечественного варианта
Исследование неконтролируемое - описательное


Angiol Sosud Khir. 2009;15(1):69-76.
[Endovascular laser ablation with wavelength 1,560 nm for varicose veins]
[Article in Russian]

Sokolov AL, Liadov KV, Lutsenko MM, Lavrenko SV, Liubimova AA, Verbitskaia GO, Minaev VP.

In 2002 - 2008 more than 1000 patients with lower limb varicose veins were treated with endovenous laser coagulation (EVLC) of subcutaneous and perforating veins in the Therapeutic Rehabilitation Center. Usually we used laser wavelength between 915 and 980 nm; but recently 1,560-nm laser, which physical properties are quite different, was used for 43 patients, including 49 EVLCs for great (GSV) and lesser (LSV) saphenous veins and 15 EVLCs for perforating veins (PV). Interventional technique was similar to previously used. Postoperative period for 1,560-nm laser ablations was characterized by earlier resolution of mild pain syndrome, more than twice less ecchymosis, and pain absence along the coagulated veins. These resulted of obliteration. in the decrease of postcoagulative period severity, thus enabling patients to ambulate earlier. No complications occurred. Ultrasonic picture of 1,560-nm laser coagulation showed uniform wall thickening, intimal induration and circular narrowing of venous lumen. Histological examination of GSV revealed significant thickening of venous wall due to edema and circular shrinkage, focal necrobiosis and caryolysis. Twenty three patients (who underwent total 35 EVLCs for GSV, LSV and PV) were followed up for 4-6.5 months. In all cases treated veins were completely obliterated; no segments with preserved blood flow and pathological refluxes were revealed. In conclusion, EVLC with wavelength that is actively adsorbed by water is characterized by mild postoperative period and higher efficacy of obliteration.

PMID: 19791577 [PubMed - indexed for MEDLINE]

Спасибо за статью.
Остаюсь при своем мнении - статья несет описательный характер - как обзор: контроль неточный ретроспективный, статистического анализа нет
Фото красивые
Выводы сомнительные.

PS Чего проще провести контролируемое исследование даже без рандомизации (проверочный метод), чтобы получить хоть какие бы то нибыло данные

Земляки Ганса Христиана не видят различий между стриппингом и ЭВЛК вен:

Eur J Vasc Endovasc Surg. 2010 Jan 9. [Epub ahead of print]
Randomised Clinical Trial Comparing Endovenous Laser Ablation with Stripping of the Great Saphenous Vein: Clinical Outcome and Recurrence After 2Years.
Rasmussen LH, Bjoern L, Lawaetz M, Lawaetz B, Blemings A, Eklöf B.

The Danish Vein Centres - Areknudeklinikken Naestved and Copenhagen and Surgical Centre Roskilde, Denmark.
OBJECTIVE: This study aims to compare the outcome 2years after treatment of varicose veins by endovenous laser ablation (EVLA) or surgery by assessing recurrence, venous clinical severity score (VCSS) and quality of life. METHODS: A total of 121 patients (137 legs) were randomised to either EVLA or saphenofemoral ligation and stripping of the great saphenous vein (GSV). Follow-up included clinical and duplex ultrasound examinations, VCSS and quality of life questionnaires. RESULTS: A total of 18 (26%) and 25 patients (37%) in the EVLA and surgery group, respectively, developed recurrent varicose veins (not significant (NS) between groups). The source of reflux was not significantly different between the groups. Technical failure occurred in three EVLA and two surgery patients, reflux in the anterior accessory GSV, the groin, thigh and calf perforators was found in six, two, four, and three EVLA patients, and in three, three, nine and six surgery patients. VCSS, Aberdeen Varicose Vein Severity Score and several domains of the Medical Outcomes Study Short Form 36 (SF36) quality of life score improved significantly in both groups.

CONCLUSIONS: No significant differences in clinical or ultrasound recurrences were found between EVLA and surgery groups. Our study also shows that similar improvements in clinical severity scores and quality of life were gained in both treatments.

PMID: 20064730 [PubMed - as supplied by publisher]

Вот вроде все понятно, но что конкретно? Откуда у почти 40% хирургических больных рецидив в течение 2 лет наблюдения? Указано 25 хир. пациентов с проблемами, а если суммировать проблемы "поштучно" - получается 23. (Может разьяснения в полном тексте - у одного пациента было по две или больше проблем?). Что там за перфоранты на голени, что они из себя представляли до лечения? Вообще сравнивать клинические исходы на таком сроке наблюдения, ИМХО, не совсем корректно, лучше бы внятные суррогатные точки отследили. В общем, по абстракту у меня вопросов больше, чем ответов.

Ждем полного текста...

RANDOMISED COMPARISON OF COSTS AND COST-EFFECTIVENESS
OF CRYOSTRIPPING AND ENDOVENOUS LASER ABLATION FOR VARICOSE VEINS: 2-YEAR RESULTS
Disselhoff BCVM, Buskens E, Kelder JC, der Kinderen DJ, Moll FL. Eur J Vasc Endovasc Surg. 2009;37:357-363.
REVIEWED BY
Marc Vuylsteke, Deinze, Belgium
Although endovenous laser ablation for varicose veins is replacing
surgical stripping, proper economic evaluation with adequate follow-up
in a randomized clinical trial is considered important for policy
decisions regarding the implementation of new techniques.
In this randomized, controlled, prospective trial, endovenous laser
ablation using a 810 nm diode laser was compared with cryostripping in
120 patients. Short Form (SF) 6D outcome, costs and cost-effectiveness
2 years after treatment were added to the study. Incremental cost per
quality-adjusted life year (QALY) gained 2 years after treatment was
calculated using different strategies, and uncertainty was assessed with
bootstrapping. Over the total study period, mean SF-6D scores
improved slightly from 0.78 at baseline to 0.80 at 2 years for patients
who underwent cryostripping and from 0.77 to 0.79 for patients who
underwent endovenous laser. QALY (SF-6D) was 1.59 in patients who
underwent cryostripping and 1.60 in patients who underwent
endovenous laser 2 years after treatment. The costs of cryostripping and
endovenous laser per patient were €2651 and €2783, respectively.
Bootstrapping indicated that cryostripping was associated with an
incremental cost-effectiveness ratio of €32 per QALY gained. The use
of the EVLA kit was a cost-driver (314€). With regard to different
strategies, outpatient cryostripping was less costly and more effective 2
years after treatment.
COMMENTARY
This is a well constructed, scientific, randomized, comparative trial. The
authors did a cost-effective analysis of EVLA compared with
cryostripping. Nevertheless, there are some comments. As stated by the
authors, patients treated with EVLA have better cosmetic results, lower
rates of postoperative morbidity, and less impairment of normal
activities up to 2 years. The quality of life scores (SF-6D) were recorded
at 6, 12, and 24 months of follow-up. The score only improved slightly
at 2 years and was not significantly different between the two groups.
The benefit of EVLA compared with (cryo)stripping in terms of side
effects and quality of life is most significant over the short term. This
difference is missed if the first follow-up review is at 6 months.
Sick leave was 2.2 days in the cryostripping group and 1.3 days on
average in the EVLA group. This sick leave is short, as stated by the
authors, because this study included many self-employed people, who
return significantly faster to work than employees. The cryostripping
group (12/60) contains more self-employed people than the EVLA
group (7/60). This difference was not taken into account and could have
made the cost of lost of productivity more different (now 17 812€ and
10 262€, respectively, for cryostripping and EVLA).
The use of a sterile laser kit augmented the cost of EVLA by 314€
(2003). This is very expensive. The authors state that even using
a half-price EVLA kit (172€) the cost-effectiveness ratio (for
outpatients) is still in favor of cryostripping, although the difference
becomes minimal.
EVLA kits of less than 100€ (incl tax) are now available and the price
should drop to less than 80€ in the near future.
In this study, the cost of using a duplex ultrasound system—23 940€—
has only been calculated for the EVLA group (additional equipment cost
of 20€ per patient). In our experience, using a duplex ultrasound system
for preoperative mapping is also very useful in surgery(stripping). So
maybe this cost can also be added to the stripping group.
Concerning the surgical technique used (cryostripping), it is not clear if
tumescent liquid was injected around the saphenous vein. This
minimizes the postoperative appearance of hematoma where the vein
has been stripped, and so also reduces postoperative pain and incapacity
to work.
No recanalization of the GSV or GSV tract was observed at 24 months.
There was no significant between-group difference in duplex-defined
varicose vein recurrence.
No difference in outcome at 2 years was found. This study
showed that outpatient cryostripping in terms of cost per QALY (SF-
6D) appeared to be the best treatment, but EVLA yielded comparable
outcomes for relatively little additional cost (2003-2005). Since EVLA
kits are much cheaper now, EVLA could probably be more costeffective.

Спасибо, Виктор! Эта статья вошла в рассылку Сервье с абстарктом и рецензией на русском языке. Если нужно поделюсь. Правда, к нашим реалиям исследования по стоимости лечения не подходят - все не так.

...................................................................................................................................
Привет Евгений, я получаю эту рассылку, но без рецензии на русском, так что для меня представляет интерес.

Randomised clinical trial comparing endovenous laser ablation with stripping of the great saphenous vein: clinical outcome and recurrence after 2 years.
Rasmussen LH, Bjoern L, Lawaetz M, Lawaetz B, Blemings A, Eklöf B.
The Danish Vein Centres - Areknudeklinikken Naestved and Copenhagen, Denmark. Larshrasmussen@yahoo.com
Abstract
OBJECTIVE: This study aims to compare the outcome 2years after treatment of varicose veins by endovenous laser ablation (EVLA) or surgery by assessing recurrence, venous clinical severity score (VCSS) and quality of life. METHODS: A total of 121 patients (137 legs) were randomised to either EVLA or saphenofemoral ligation and stripping of the great saphenous vein (GSV). Follow-up included clinical and duplex ultrasound examinations, VCSS and quality of life questionnaires. RESULTS: A total of 18 (26%) and 25 patients (37%) in the EVLA and surgery group, respectively, developed recurrent varicose veins (not significant (NS) between groups). The source of reflux was not significantly different between the groups. Technical failure occurred in three EVLA and two surgery patients, reflux in the anterior accessory GSV, the groin, thigh and calf perforators was found in six, two, four, and three EVLA patients, and in three, three, nine and six surgery patients. VCSS, Aberdeen Varicose Vein Severity Score and several domains of the Medical Outcomes Study Short Form 36 (SF36) quality of life score improved significantly in both groups. CONCLUSIONS: No significant differences in clinical or ultrasound recurrences were found between EVLA and surgery groups. Our study also shows that similar improvements in clinical severity scores and quality of life were gained in both treatments. Copyright (c) 2009 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
Eur J Vasc Endovasc Surg. 2010 May;39(5):630-5. Epub 2010 Jan 12.

PMID: 20064730 [PubMed - indexed for MEDLINE]

Надо же...Спасибо, Виктор, надо будет познакомиться с этой работой повнимательнее.

Отличная статья в плане дизайна и четкости конечных точек.

J Vasc Surg. 2010 Aug 27. [Epub ahead of print]
Prospective randomized trial comparing endovenous laser ablation and surgery for treatment of primary great saphenous varicose veins with a 2-year follow-up.
Christenson JT, Gueddi S, Gemayel G, Bounameaux H.

Division of Cardiovascular Surgery, Venous Centre, University Hospital of Geneva and Faculty of Medicine, Geneva University, Geneva, Switzerland.
Abstract
BACKGROUND: Endovenous laser therapy (EVLT) for ablation of the great saphenous vein (GSV) is thought to minimize postoperative morbidity compared with high ligation and stripping (HL/S). Only a few randomized trials have reported early results. This prospective randomized trial compared EVLT (980 nm) and HL/S results at 1 and 2 years after the intervention.

METHOD: Patients with symptomatic varicose veins due to GSV insufficiency were randomized to HL/S (100 limbs) or EVLT (104 limbs). Four EVLT procedures failed primarily and were excluded. Phlebectomy and ligature of incompetent perforators were performed whenever indicated in both groups. Patients were re-examined clinically and by duplex ultrasound imaging preoperatively and at 12 days and at 1 and 2 years after treatment. Closure rate, complication rate, time to return to normal activity, the Aberdeen Varicose Vein Symptom Severity Score (AVVSS), the Varicose Venous Clinical Severity Score (VVCSS), and the Medical Outcome Study Short Form-36 scores were also recorded.

RESULTS: There were no differences in patient demographics, CEAP class, Widmer class, or severity scores between the groups. Simultaneous interventions did not differ between the groups. Similar times for the return to normal activity and scores for postoperative pain were reported. No major complications after treatment were recorded. HL/S limbs had significantly more postoperative hematomas than EVLT limbs, and EVLT patients reported more bruising. Follow-up at 1 year was 100% for HL/S and 99% for EVLT. Two GSVs in the EVLT group reopened and three partially reopened. No open GSVs occurred in HL/S limbs. Ninety-eight percent of the limbs in both groups were free of symptoms. VCSS, AVVSS, and Short Form-36 scores did not reveal any group differences. At 2 years, no differences compared with 1-year results were observed, except that two more GSVs in the EVLT group were partially reopened.

CONCLUSIONS: Abolition of GSV reflux and improvement in quality of life was similar after HL/S and EVLT. After EVLT, however, two GSVs were found completely reopened and five were partially reopened, which was significantly higher than after HL/S. A prolonged follow-up is ongoing.
PMID: 20801608 [PubMed - as supplied by publisher]

Странное на мой взгляд заключение, как может удаленная вена вновь реканализироваться, так сказать сделать reopened?
Пойду поищу полный текст...

Будет интересно узнать, какова методика выполнения ЭВЛО. На счет re-opened: сложно сказать, что имели ввиду авторы, но, думается, речь идет об обнаружении вены интрафасциально в проекции БПВ. Такое может быть, например, при обрыве во время стриппинга, когда оставшийся дистальный участок (иногда с середины бедра) "питается" прямым перфорантом и дает вполне себе приличный рефлюкс, а в перспективе - рецидив. Такое мое ИМХО. Но то, что реопенов не было, говорит о качественно стриппинге
Спасибо, Алексей, очень интересная приличная работа!

Ничего себе! А я не отслеживаю таких больных. На первый взгляд кажется, что шансов "выжить" у оборванного куска ствола (правда не с середины бедра, а в н/3) нет. Хотя, если оборвался, стало быть на крупном притоке, вероятнее всего, кровоток восстановится.