Endovenous laser treatment vs conventional surgery for great saphenous vein varicosities: A propensity score matching analysis

BACKGROUND Varicosis is a common venous condition,which is typically treated surgically.However,selection of the optimal surgical approach can be challenging.Previous studies comparing endovenous laser treatment(EVLT)and conventional surgery were retrospective and observational in nature and the results may therefore have been influenced by selection bias and the presence of other confounding factors.In this study,we used propensity score matching to reduce selection bias when comparing EVLT and conventional surgery for the treatment of varicose great saphenous veins.METHODS We retrospectively reviewed the records of 1063 patients treated for primary varicosis of the great saphenous vein at the Second Affiliated Hospital of Xuzhou Medical University between January 2009 and December 2019.Among them,56 patients were excluded owing to additional small saphenous varicose vein involvement,81 owing to recurring varicose veins,83 owing to complicated varicose veins(CEAP clinical classification C5-C6),and 6 owing to perioperative phlebitis.Finally,772 patients were enrolled in this study.Standard demographic and clinicopathological data were collected from the medical records of the patients.For propensity score matching,522 patients(261 who underwent EVLT and 261 who underwent conventional surgery)were randomly matched 1:1 by age,sex,onset time,smoking status,presence of diabetes,family history,stress therapy,C class,and the affected leg.RESULTS Of the 772 patients included in the study,467 underwent EVLT and 305 underwent conventional surgery.There were significant differences in age,onset time,smoking and diabetes status,and family history between the two groups.Following propensity score matching,no significant differences in patients’characteristics remained between the two groups.ELVT was associated with a shorter operation time and hospital stay than conventional surgery,both before and after propensity score matching.There were no differences in complications between the two groups after propensity score matching.Patients who underwent EVLT had a higher recurrence rate during the two-year follow-up period than those who underwent conventional surgery(33.33%vs 21.46%,χ^(2)=11.506,P=0.001),and a greater percentage of patients who underwent EVLT experienced pain one week after the procedure(39.85%vs 19.54%,P=0.000).CONCLUSION EVLT may not always be the best option for the treatment of great saphenous vein varicosis.

Higher Energy Does Not Mean Better Outcome Following Endovenous Laser Ablation of Great Saphenous Vein

Background: Endovenous laser ablation is a relatively newer alternative to treat great saphenous vein insufficiency. We evaluated the efficiency and safety of treatment endovenous laser procedures on the different saphenous vein diameters with different energy levels. Methods: Data regarding endovenous laser ablation of symptomatic chronic great saphenous venous insufficiency in 209 patients were prospectively recorded. Patients were grouped into two main groups based on their diameters as 5 to 7 millimeters (Group A) or more than 7 millimeters (Group B). Patients in each group was randomized into two groups as >90 J/cm (A1 and B1) or 80-90 J/cm (A2 and B2). Postoperative outcome and complications were recorded during follow-ups at 1st week;1st, 3rd and 6th months to examine the venous reflux and recanalization. Results: Perioperative complaints as pain, cramps and ankle swelling were more commonly observed in A1 group. Fatigue was more common in A2 and B2 groups. No major complications as deep vein thrombosis or skin burns were observed. Conclusions: Endovenous laser ablation is a safe and effective procedure with a high satisfaction rate shortening hospitalization durations and early ambulant activity. Pain, ankle swelling and fatigue are the most common minor complaints in the early postoperative period.

Combined subfascial endoscopic perforator surgery and endovenous laser treatment without impact on the great saphenous vein for management of lower-extremity varicose veins

Background Conventional high ligation and stripping of the great saphenous vein （GSV） has a good curative effect but is highly traumatic with a considerable relapse rate. Subfascial endoscopic perforator surgery （SEPS） plus endovenous laser treatment （EVLT） could be applied as individual therapy. This study aimed to evaluate the feasibility of performing combined SEPS and EVLT without impacting GSV in the management of valvular insufficiency of the lower-limb venous perforators. Methods Placement of lower-limb venous perforator insufficiency was marked by ascending phlebography in 83 affected limbs from September 2010 to June 2011. After randomization, SEPS was performed on 41 limbs to address the insufficiency of the venous perforators under the deep fascia, in combination with EVLT to close the superficial varicose veins without impacting the GSV. The remaining 42 limbs were treated using traditional GSV phlebectomy as controls. Results Postoperatively, all varicose veins were resolved, with lightening of the pigmentation and healing of the ulcer. Within a follow-up period of 5-11 months, no symptoms had recurred. Compared with the control group, the operation time, the number of incisions sutured, and the in-hospital time decreased on average by 1.5 hours, 4.7, and 6.8 days, respectively （P 〈0.01 in all cases）. Conclusion Combined SEPS and EVLT for treatment of valvular insufficiency of the lower-limb venous perforators offer the advantages of microtrauma and rapid cure.

Endovenous laser ablation of great saphenous vein with ultrasound-guided perivenous tumescence： early and midterm results

Background Endovenous laser ablation （EVLA） is an improved method to treat varicose great saphenous veins （GSV） with a high satisfactory rate. This study aimed to evaluate the efficiency and safety of treatment by EVLA procedures with ultrasound-guided perivenous tumescence. Methods Thirty-one patients （31 limbs） with symptomatic varicose vein primary to chronic venous insufficiency （CVI） treated with EVLA were prospectively studied. The entire procedure was performed under ultrasound-guided tumescent local anesthesia. The patients were evaluated with a 18 month follow-up postoperation using clinical examination and venous duplex ultrasonography. Pain scores and quality of life （QOL） were recorded using visual analog scale （VAS） and the chronic venous insufficiency questionnaire （CIVIQ） at 1 week, 1 month, and 12 months after operation. Results All patients tolerated EVLA procedure well. The overall success occlusion rates of GSV were 92%, 94%, and 94% at 1, 12, and 18 months follow-up, respectively. The score of CIVIQ one week preoperation was 69.14±11.44 while that of CIVIQ one month postoperation was 85.32±4.89. The life quality has significantly improved after the operation of EVLA （t=12.71, P 〈0.05）. The VAS one month after treatment was lower than 1 week before therapy （t=8.048, P 〈0.05）. Major complications such as deep vein thrombosis and skin burns were not found. Most of the complications were minor and improved quickly. Conclusions This refinement type of EVLA procedure is a safe and effective treatment with a high satisfaction rate; it displayed noteworthy features including shortening hospitalization, early ambulant activity, and preferable occlusion rates.

Microwave Ablation versus Laser Ablation in Occluding Lateral Veins in Goats

Increasing number of endovenous techniques are available for the treatment of saphenous vein reflux and endovenous laser ablation（EVLA） is a frequently used method. A newly developed alternative, based on thermal therapy, is endovenous microwave ablation（EMA）. This study evaluated the effect of the two procedures, in terms of coagulation and histological changes, in occluding lateral veins in goats. Twelve animals were randomized into two group, with 6 treated with EMA（EMA group）, and the rest 6 with EVLA（EVLA group）. Results of coagulation, including coagulation, fibrinolysis and platelet activation, were assessed at three or four different time points： before, immediately after, 24 h（and 48 h） after ablation. The diameter change, a measure of efficacy, was ultrasonographically measured before and 1 month after the ablation. Histological changes were grossly and microscopically evaluated immediately, 1 and 3 month（s） after the ablation. The length of the ablated vein and preoperative average diameter were comparable between the two groups. In both EMA and EVLA groups, several coagulation parameters, fibrinolysis and platelet activation parameters only underwent slight changes. Ultrasound imaging displayed that the diameter reduction of the veins treated by EMA was significantly larger than by EVLA, in consistent with the results of macroscopic examination. Microscopic examination revealed necrosis and thickening of the vein wall, and occlusion of the lumen within 3 months after ablation in both EMA and EVLA groups. It is concluded that EMA is a minimally invasive therapy, which appears to be safe and effective for treatment of lateral veins in goats.

传统手术与激光腔内治疗下肢静脉曲张的临床观察

目的探讨激光腔内治疗下肢静脉曲张的效果和安全性.方法将146例下肢静脉曲张病人分为微创治疗组(激光腔内治疗)74例,传统治疗组(用传统手术)72例.微创治疗组采用小切口大隐静脉高位结扎、血管腔内原位闭合,属支及交通支电凝、结扎;传统治疗组大隐静脉高位结扎、抽剥,属支及交通支切除、结扎.观察术后效果、并发症的情况.结果所有病人下肢肿胀、酸痛、乏力在手术后1个月逐步消失;皮肤色素沉着在术后1个月减轻,3月逐步恢复.传统手术没有皮肤烧灼发生,但其并发症多.小腿皮肤麻木、皮下瘀斑、创口血肿以及踝以下肿胀比较,两组差异有统计学意义,传统治疗组并发症明显多于微创治疗组.全部病例无下肢深静脉血栓形成和切口感染.结论激光腔内治疗下肢静脉曲张,简单可行,微创、疗效确切.

Strategies and challenges in treatment of varicose veins and venous insufficiency

Patients with varicose veins can be treated with conservative or surgical approaches based on the clinical conditions and patient preferences.In the recent decade,the recommendations for managing symptomatic varicose veins have changed dramatically due to the rise of minimally invasive endovascular techniques.The literature was systematically searched on Medline without language restrictions.All papers on the treatment of varicose veins and venous insufficiency with different procedures were included and reviewed.Endovenous laser ablation(EVLA)and radiofrequency ablation(RFA)both are same safe and effective in terms of occlusion rate,and time to return to normal activity.In comparison with RFA or EVLT,Cure conservatrice et Hemodynamique de l’Insufficience Veineuse en Ambulatoire(CHIVA)may cause more bruising and make little or no difference to rates of limb infection,superficial vein thrombosis,nerve injury,or hematoma.In terms of recurrence of varicose veins,there is little or no difference between CHIVA and stripping,RFA,or EVLT.Great saphenous vein recanalization is highest in the ultrasound-guided foam sclerotherapy(FS)group(51%)during 1 year of follow-up.The 2013 National Institute for Health and Care Excellence clinical guidelines recommend surgery as a third-line therapeutic option after EVLA or RFA and sclerotherapy.Although the mechanochemical endovenous ablation(MOCA)is a non-thermal,non-tumescent option and appears to be of similar efficacy to stab avulsion with no potential risk of nerve damage,the overall success rate of MOCA is lower than those of other procedures such as EVLA,RFA,or high ligation and stripping.EVLA is the most cost-effective therapeutic option,with RFA being a close second for the treatment of patients with varicose veins.Endovenous thermal ablation(EVLA or RFA)is recommended as a first-line treatment for varicose veins and has substituted the high ligation of saphenofemoral junctional reflux and stripping of varicose veins.Ultrasound-guided FS is associated with a high recurrence rate and can be used in conjunction with other procedures.MOCA and cyanoacrylate embolization appear promising,but evidence of their effectiveness is required.