Recurrent Varicose Veins after Endovascular Laser Ablation

Aim: Endothermal heat-induced thrombosis (EHIT) is defined as propagation of a thrombus from a superficial vein into a deeper vein and is generally considered clinically insignificant if the thrombus does not propagate to the deep venous system. The condition can be treated with anticoagulation therapy, although monitoring may be sufficient, especially in less severe cases. Endovascular laser ablation (EVLA) have become popular techniques for treating varicose veins. Endothermal heat induced thrombosis is a complication unique to endovenous ablation. It reflects the extension of the thrombus from the ablated saphenous vein into deep venous system. Endovenous laser ablation in patients with diabetes mellitus is not well published. To compare the endothermal heat induced thrombosis incidence rate after EVLA performed with three different energy densities. The outcomes of the 140 patients with diabetes after EVLA were analyzed. Material and Methods: 80-100 J/cm energy was applied in the 1st group (n=60), 100-120 J/cm in the 2nd (n=40), and 120-140 J/cm in the 3rd group (n=40) patients. All patients received Enoxaparin 40mg subcutaneously, for thrombose prevention after EVLA for 7 days. Results: There were 32 EHIT cases (22.86%) detected with duplex US investigation 7 days after EVLA. The incidence rate among groups was 31.7%, 20%, and 12.5% accordingly. Conclusion: The analyses show that 120-140 J/cm energy density is the most safe and effective treatment mode for EVLA in patients with diabetes mellitus.

Summary Background: Neovascularisation (NV) at the saphenofemoral junction (SFJ) is an important cause of recurrent great saphenous varicose veins. Unfortunately up to now no surgical technique at the SFJ could prevent neoreflux completely. We present a new technique at the SFJ with the aim to reduce the rate of neoreflux. Material and Methods: In a prospective study 100 patients (100 SFJ ligations) with extensive crossectomy were included. Extensive crossectomy means: Flush ligation of the SFJ, oversewing the endothelium stump with Prolene®(4 x 0), ligation of the side branches as far away as possible from the SFJ and electrocoagulation of the free endothelium of these side branches. Mean age 47 years (18–65), female/ male 69 %/31 %, ASA-classification I–II (100 %), CEAP-classification C2 59, C3 25, C4 16. All patients could be examined by colour duplex scan after two/three days, three months and one year and 68 patients after two years. Results: Duplex imagines identified neoreflux at the SFJ in two patients (2 %) after one year and in only one patient (1.5 %/ 68 patients) after two years. This female patient was pregnant (31st week) and had recurrent varicose veins with origin mostly from an insufficient Dodd perforator vein. The other patient with reflux at the first examination showed no more reflux after two years. Conclusion: Recurrent reflux in the groin by neovascularisation was strongly reduced by our technique of extensive crossectomy. Up to know no other technique to prevent NV (patch, barrier technique) has shown such favourable results. The technique is easily performed and has no further complication than a simple ligation of the SFJ.

Background Chronic venous insufficiency of the lower extremities is a condition in which blood stagnates in the venous system, causing symptoms of pain, fatigue, leg edema, and cramps. Although this disease progresses slowly and is not fatal, its symptoms lead to a decline in quality of life, affecting the patient's work.One of the current surgical treatment methods for patients with indications for surgical removal of the saphenous vein is endovenous laser ablation (EVLA). After EVLA, besides evaluating the effectiveness of surgery, and the rate of complications, one of the aspects that need attention is improving quality of life. The objective of this study was to assess the quality of life of patients with chronic venous insufficiency of the lower extremities before and after endovascular laser intervention, analyzing changes in ChronIc Venous Insufficiency Quality of Life Questionnaire 20 (CIVIQ-20) scores in each domain of quality of life. Methodology A total of 41 patients with chronic venous insufficiency of the lower extremities were enrolled in this study, who were classified as C2 to C6 and were treated by endovenous laser ablation. QoL was measured by using the ChronIc Venous Insufficiency Quality of Life Questionnaire 20 (CIVIQ-20) questionnaire pre- and post-operatively. Pain scores and clinical severity were also evaluated using the visual analog scale (VAS) and the venous clinical severity score (VCSS) one month after EVLA. Results The mean age was 52.17 ± 11.23 years. The mean duration of symptoms was 7.29 ± 3.58 years, the median laser ablation time was 40 minutes, and the mean time to return to normal activities was 5.7 ± 1.8 days. The CIVIQ-20 score at baseline was 47.8 ± 7.4 and 31.1 ± 3.9 after one-month laser ablation. The quality of life has significantly improved after intervention using laser treatment (p < 0.001). The VAS and VCSS scores after laser treatment were lower than the baseline (p < 0.001). In our study, there was a statistically significant correlation between the change of CIVIQ-20 and the change of VCSS (r = 0.63, p < 0.001). Conclusion CIVIQ-20is a reliable toolkit to assess the quality of life of patients with chronic venous insufficiency of the lower extremities. The patient's quality of life improved markedly after the intervention.

Background Recurrent varicosities after endovascular laser ablation (EVLA) of the great saphenous vein (GSV) are frequently due to varicose transformed, initially unsealed major ascending tributaries of the saphenofemoral junction (SFJ). Preventive ablation of these veins, especially the anterior accessory saphenous vein, is discussed as an option, along with flush occlusion of the GSV. However, few related data exist to date. Methods A consecutive case series of 278 EVLA procedures of the GSV for primary varicosis in 213 patients between May and December 2019 was retrospectively reviewed. The ablations were performed with a 1470 nm dual-ring radial laser and always included flush occlusion of the GSV, and concomitant ablation of its highest ascending tributaries by additional cannulation and ablation when this seemed anatomically appropriate. The initial technical success, comprising occlusion of the GSV and its major tributaries, was set as the primary endpoint. Possible determinants were explored using downstream multiple logistic regression analysis. Results The early technical success was 92.8%, with the GSV occluded in 99.6% and the highest ascending SFJ tributary, if present, in 92.4%. Additional ablations of ascending tributaries were performed in 171 cases (61.5%), the latter being associated with success (OR 10.39; 95% CI [3.420–36.15]; p < 0.0001). Presence of anterior as opposed to posterior accessory saphenous vein was another positive predictor (OR 3.959; 95% CI [1.142–13,73]; p = 0.027), while a confluence of the tributary in the immediate proximity to the SFJ had a negative impact (OR 0.2253; 95% CI [0.05456–0.7681]; p = 0.0253). An endothermal heat-induced thrombosis (EHIT) ≥ grade 2 was observed in three cases (1.1%). Conclusions A co-treatment of the tributaries is feasible and could improve the technical success of EVLA if a prophylactic closure of these veins is desired, especially if their distance to the SFJ is short. Its effect on the recurrence rate needs further research.

Background: Recurrent varicose veins after surgery (REVAS) are a common, complex and costly problem.The possibilities for recurrent varicose veins after correctly ligated SFJ may be due to: dilatation of preexisting venous tributaries from the common femoral vein (CFV) or formation of new veins as a result of angiogenic stimulation termed neovascularisation.Interposition of a prosthetic implant covering the saphenous stump has been called ''patch saphenoplasty."The aim of the present study is to evaluate the use of polytetrajluroethylene (PTFE) patch sutured over the saphenofemoraljunction (PTFE saphenoplasty) to reduce the incidence of recurrent varicose veins.Patients and methods: This study was conducted in General and Vascular Surgery Unit at Mansoura University hospital between March 2007 and November 2010.Patients were included if they had varicose veins from the CEAP clinical classification: C 2-5; recurrent varicose veins and isolated short saphenous vein varicosity were excluded.320 patients (368 limbs) were eligible for the study; The patients were randomized into two groups; group L flush ligation of the GSV was performed at the SFJ without using any technique to contain possible postoperative neovasculorization; group IL underwent PTFE saphenoplasty (rectangular piece (2 x 3cm) of PTFE was sutured on the saphenous stump).Results: Both groups were comparable as regard patients' characteristics.The global incidence of early postoperative complications was higher in-group II than group I (9.4% vs. 3.8%) (PO.OOJ).Two months postoperative clinical and duplex examination revealed no clinical recurrence or neovascularization at the site of SFJ ligation in both groups.One-year postoperative clinical examination revealed recurrent thigh varicosities in 15/187 limbs in-group I (8 %) and in 8/181 limbs (4.4 %) in-group II.By duplex examination neovascularization occurred in 37/187 (19.7%) limbs in-group I (22 limbs grade 2 & 15 limbs grade 3) but in-group II neovascularization occurred in 19/181(10.5%)limbs (11 limbs grade 2 & 8 limbs grade).(P 0.001) Conclusion: Interposition of PTFE implant at the level of the ligated saphenofemoral stump significally reduces the incidences of clinical recurrence and neovascularization.

Objective:To evaluate the clinical relevance of neovascularisation at the saphenous ligation site.Design:Long-term follow-up after previous varicose vein surgery in a single patient group.Setting:Vascular clinic of a university hospital.Patients:Eighty-two patients (106 limbs) with a mean follow-up period of 56 months after correct saphenous ligation were submitted to duplex scanning.Intervention:Clinical assessment and colour duplex scanning of all the operated limbs. Reintervention in 15 limbs with perioperative evaluation of recurrent veins.Main outcome measures:Limbs with and without recurrent varicose veins were classified according to the degree of neovascularisation: grade 0 = no new communicating veins, grade 1 = tiny new vein with diameter 4 mm and pathological reflux. On reintervention the presence of neovascular veins at the site of the previous ligation was checked.Results:In 68 limbs without recurrent varicose veins, grade 0 was observed ...

An “All-Comers” Venous Duplex Scan Policy for Patients with Lower Limb Varicose Veins Attending a One-stop Vascular Clinic: Is It Justified?

The classical radical high ligation (RHL) performed with the Babcock technique is defined as the traditional gold standard technique: superficial tributaries dissection, followed, when possible, back to the secondary branch points, division and ligation; GSV ligation flush to the junction. In the present study the authors analyze, as an alternative, the selective high ligation (SHL) of the Junction with 5/12 years follow-up. The rationale is that SFJ tributary veins coming from the abdominal wall have an important role in draining the venous flow to the deep veins or to the opposite vein network, particularly when the venous abdominal flow is modified for physiological condition (i.e. pregnancy) or external compression or obstruction (i.e. deep venous thrombosis) . In SHL the veins coming from the abdominal wall, as the superior epigastric vein (SEV) or the superior iliac circumflex vein (SICV), are spared, while the superior external pudendal vein (SEPV) and the others tributaries which have an acute angle with the saphenic axis or a T branch from the thigh, are carefully isolated and ligated with 2/0 or 3/0 non absorbable thread; the GSV is ligated and dissected flush the confluence of the spared tributary veins, usually about 1 cm from the SFJ, to maintain its drainage into the GSV stump. The study included a homogenous cohort of 360 patients (mean aged 51.9 years range 18 to 75 years - CEAP C2S Ep), that underwent unilateral varicose vein surgery from January 2001 to December 2008. The neovascularization and the recurrences in the groin were found in seven patients (1.9%) of the total cases: 3 patients were symptomatic, 4 asymptomatic. The recurrences were due to inadequate groin surgery: the anterior lateral thigh vein, the posterior medial thigh or a T branch of tributaries left, a GSV stump exceeding 1 cm. The GSV stumps and the spared tributaries were open to venous flow; no venous reflux in the groin at Valsalva in standing position was present; the compression ultrasonography of the GSV stump was negative in all the patients. During the past 10 years minimal invasive surgery or endovascular approaches with radiofrequency and endolaser ablation have developed. These techniques leave all or nearly all tributaries of the SFJ and the results in terms of recurrences from the saphenous stump seem to be better than the Babcock’s RHL. The selective high ligation is a reliable technique, decreasing the incidence of neovascularization and recurrent varicose veins in the operated groin.

Introduction: Subfascial Endoscopic Perforator Surgery (SEPS) is a minimally invasive technique to treat incompetent perforating veins. Incompetent perforators are implicated in venous ulcer and in varicose veins recurrence. Complete closure of all perforating veins is the only predictor of ulcer healing. Analysis of our results is the objective of this study. Methods: Fifty (50) patients with incompetent perforating veins were submitted to unilateral SEPS. Class CEAP C2-C6 patients were included. Ulcer-healing rate, ulcer recurrence rate, and complications rate were analysed. Results: CEAP distribution was: C1–0; C2–5; C3–20; C4–11; C5–2; C6–12. An ulcer-healing rate of 92% (11/12) was found at 6 months, with an average of 2.5 months until complete cicatrisation. Only one patient suffered an ulcer recurrence (9%). Complications occurred in 4 patients (8%), including 2 cases of surgical site infection (4%). Discussion: SEPS has a better ulcer-healing rate than other perforator ablation techniques. Our data match other studies data. The inclusion of patients submitted to SEPS plus GSV stripping and patients submitted only to SEPS can bring some doubts about the role of SEPS in ulcer healing. However from the patients treated only with SEPS, most of them had already been submitted to GSV removal in the past, and were now treated because of venous ulcer development and varicose veins recurrence. Conclusion: These data support the importance of SEPS in perforating veins treatment and the hemodynamic role of perforators in venous ulcer development and varicose veins recurrence.

Recurrence of varicose veins at the sapheno-femoral or sapheno-popliteal junction can not always be explained by technical inadequacy of the original intervention. Its development has also been attributed to neovascularisation in the granulation tissue around the ligated saphenous stump. Already in the 19th century, surgeons had noticed that a new vein channel could be formed after ligation or extirpation of a piece of a vein, which could be responsible for recurrence after surgery. After the introduction of the ‘high ligation’ (crossectomy) in the groin, this theory became less popular. The majority of authors in the 20th century claimed that recurrence was due to the development of incompetence in pre-existing collaterals, which had not been adequately ligated by the previous surgeon. During the period 1960–80’s, Dr Glass (Belfast) was one of the first surgeons to focus again on recurrence of varicose veins through re-growth of veins or ‘neovascularisation’ in interesting series of clinical and experimental work. Neovascularisation seemed to play a crucial role in recurrence after correctly performed sapheno-femoral ligation. With the introduction of duplex scanning, postoperative observation of the phenomena happening at the ligated saphe-no-femoral or sapheno-popliteal stump has nowadays led to a better understanding of the causes of varicose vein recurrence. Neovascularisation at the ligated stump seems to play a key role in recurrence, which explains why ongoing research efforts are mainly directed at mitigating recurrent reflux related to neovascularisation.

Background: The CEAP classification includes classifying varicose veins on the basis of their clinical, etiological, anatomical and pathophysiological classification.Methods: It was a prospective study of 50 patients presenting to a tertiary care hospital, MGM Medical College and Hospital, Kamothe, Maharashtra with varicose veins over a period of 2 years (November 2019 to November 2021). Institute Ethics Committee approval was obtained before start of study. All patients clinically diagnosed of symptomatic or complicated primary lower limb varicose veins with saphenofemoral and/or sapheno-popliteal incompetence with or without perforator incompetence were included. All cases with recurrent varicose veins were excluded. Result was tabulated and analysed at the end of the study using IBM SPSS software.Results: The age group with maximum varicose vein was between 21-30 years and incidence being more common in male population. The majority of the patients had massive varicose veins (C2). Pain was the most frequent presenting symptom. The majority of the study group had both saphenofemoral junction and perforator incompetence. Primary varicose veins are far more common (76%) than secondary and congenital varicose veins.Conclusions: Varicose veins are highly common in the Indian population. The CEAP classification has been a major contributor to advances in the field of varicose veins since its inception, and it has now become universally accepted due to its simplicity and reliability.

Pneumatic phlebography: a possible new technique for the assessment of recurrent varicose veins

Objective. To study the effectiveness of endovascular laser coagulation in patients with recurrent varicose veins in their lower extremities.Material and methods. Outcomes after the treatment of 54 patients with varicose vein relapses in the lower extremities were analyzed. Under the tumescent anesthesia, endovascular laser coagulation was made: in 5 patients – stump of the great saphenous vein; in 22 patients – recanalized, residual and preserved subcutaneous venous trunks; in 27 patients – insufficient communicating veins of the thigh and lower leg.Results and discussion. In average, surgery lasted for 31 ± 0.6 minutes; intensity of the postoperative pain syndrome was 3.4 ± 0.4 points. Early postoperative complications were registered in 1 (1.8 %) patient, side effects in the form of hyperpigmentation and paraesthesia – in 4 (7.4 %). In 12 months, all operated patients demonstrated an improvement in all parameters of their quality of life by 29.2– 40 %; cosmetic outcome after surgery was 7.8 points out of a ten-point scale. The long-term observation revealed the relapse in varicose veins only in 1 (1.8 %) patient.Conclusion. The justified use of endovasal laser coagulation in patients with relapses of varicose veins in the lower extremities allows to avoid manipulations in the area of scar-altered tissues, to reduce tissue damage and duration of surgery, to improve patients’ quality of life, to avoid additional incisions as well as to improve cosmetic outcomes after surgery.

Recurrence of varicose veins after surgery is a common problem. Many surgeons have a pessimistic view on the outcome of surgery for varicose veins and consider recurrence inevitable. The problem is confounded by the inability to clearly define recurrence. Variations in the definition of recurrent varicose veins result from the multiple modalities of interventions employed for the initial treatment of chronic venous disorders (CVD). To streamline these issues, an international consensus meeting was held in Paris in 1998 to provide guidelines for the definition and management of recurrent varicose veins after surgery (REVAS).

Background: The goal of this prospective cohort study was to study the different determinants impacting primary varicose vein recurrence rates and patterns after endo venous laser ablation (EVLA) for primary lower limb varicose veins.Patients and Methods: 127 symptomatic patients (127 limbs) with great saphenous vein reflux (>0.5 seconds), GSV diameter> 3mm and pre-operative incompetent perforators were followed up within two years for recurrence after EVLA.Outcomes: Recurrence was defined clinically by venous clinical severity score (VCSS) and CEAP classification and radiologically by patterns of reflux on duplex ultrasound examination. Assessment was done at 1, 6, 12 and 24 months after the procedure. Results: Two-year life table analysis showed varicose vein recurrence in 9 (7.1%) of limbs. Varicose vein recurrence was mostly seen owed to due to BMI more than 30.5 kg/m2 in 77.8 % (p <0.001, 95% CI 1.105 to 1.590) of recurrence patients, refluxing anterior accessory saphenous vein in 77.8% of patients (p <0.001, 95% CI 3.2 to 1669.1) and postoperative incompetent perforators in 77.8% of patients (p <0.001, 95% CI 2.7 to 69.3). Age, gender and pre-operative GSV diameter ≥ 5.5 mm were statistically insignificant in determination of recurrence. Conclusion: BMI, refluxing anterior accessory saphenous vein and postoperative incompetent perforators are the most importantdeterminants of recurrence after EVLA with a statistically significant impact in comparison with age, gender and preoperative dilated GSV diameter ≥5.5 mm.