Amanda C. Shepherd

Randomized clinical trial of VNUS® ClosureFAST™ radiofrequency ablation versus laser for varicose veins

Endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) are both associated with excellent technical, clinical and patient‐reported outcomes for the treatment of varicose veins. The aim of this study was to compare the techniques in a randomized clinical trial.

Pain Following 980-nm Endovenous Laser Ablation and Segmental Radiofrequency Ablation for Varicose Veins: A Prospective Observational Study:

Objectives: The aim of this study was to evaluate postoperative pain following endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) and identify risk factors for increased pain. Methods: Patients undergoing either segmental RFA (VNUS Closure Fast TM, VNUS Medical Technologies, San Jose, California) or EVLA (980 nm) for varicose veins completed a preoperative disease-specific quality-of-life questionnaire (Aberdeen Varicose Vein Questionnaire [AVVQ]) and a diary card recording postoperative pain, return to normal activities, and return to work. Median 3- and 10-day pain scores were calculated. Results: In all, 81 patients returned diary cards (RFA = 45, EVLA = 36). Patients receiving RFA reported less postoperative pain than those receiving EVLA at 3 days (14.5 vs 25.8 mm, P = .053, Mann-Whitney U test) and 10 days (13 vs 23.3 mm, P = .014, Mann-Whitney U test) and returned to work earlier than those receiving EVLA (median 5 vs 9 days, P = .022). Conclusions: Patients treated with segmental RFA had less postoperative pain and returned to work quicker than those treated with EVLA.

Hypoxia-Inducible Factor-1 in Arterial Disease: A Putative Therapeutic Target

Hypoxia-inducible factor-1 (HIF-1) is a nuclear transcription factor that is upregulated in hypoxia and co-ordinates the adaptive response to hypoxia by driving the expression of over 100 genes. In facilitating tissues to adapt to hypoxia, HIF-1 may have a role in reducing the cellular damage induced by ischaemia, such as that seen in peripheral arterial disease (PAD), or following acute ischaemic insults such as stroke and myocardial infarction. This therefore raises the possibility of HIF-1 modulation in such contexts to reduce the consequences of ischaemic injury. HIF1 has further been implicated in the pathogenesis of atherosclerosis, abdominal aortic aneurysm (AAA) formation, pulmonary hypertension and systemic hypertension associated with obstructive sleep apnoea. Through a better understanding of the role of HIF-1 in these disease processes, novel treatments which target HIF-1 pathway may be considered. This review summarises the role of HIF-1 in arterial disease, specifically its role in atherosclerosis, ischaemic heart disease, in-stent restenosis following coronary revascularisation, stroke, PAD, AAA formation, pulmonary artery hypertension and systemic hypertension. The potential for exploiting the HIF-1 signalling pathway in developing therapeutics for these conditions is discussed, including progress made so far, with attention given to studies looking into the use of prolyl-hydroxylase inhibitors.

Variations in the Pharmacological Management of Patients Treated with Carotid Endarterectomy: A Survey of European Vascular Surgeons

OBJECTIVES The peri-operative use of antiplatelet, anticoagulant and other drugs for patients undergoing carotid endarterectomy (CEA) is unclear and consensus is lacking. This study aimed to assess the current peri-operative practice of European vascular surgeons with respect to antiplatelet and other medications for patients undergoing CEA. DESIGN Online questionnaire study. METHODS Members of the Vascular Society of Great Britain & Ireland and European Society for Vascular Surgery were invited to complete an online survey in March 2008. Surgeons were asked about their preferences for the peri-operative administration of antiplatelet, statin and other medications for patients undergoing carotid endarterectomy. RESULTS Partial or complete responses were received from 399/650 (61.4%) surgeons with a collective annual throughput of >11500 CEA procedures. For symptomatic and asymptomatic patients, 20/392 (5%) and 47/392 (12%) of surgeons would stop aspirin before surgery and 170/392 (43%) and 217/392 (55%) of surgeons would stop Clopidogrel prior to CEA. Of surgeons who would stop Clopidogrel, 84/170 (49%) and 124/217 (57%) would do so >7 days before surgery for symptomatic and asymptomatic patients respectively. 12/393 (3%) surgeons would prescribe one 75 mg dose of Clopidogrel on the evening before surgery. Intra-operative Dextran was used selectively by 40/395 (10%). Only 78/393 (20%) would delay surgery to commence a statin. Intra-operatively, 348/394 (88%) used intravenous heparin, which was reversed routinely by 47/348 (13%) and selectively by 60/348 (17%). CONCLUSIONS There appears to be broad consensus between vascular surgeons in the pharmacological management of patients undergoing carotid endarterectomy, although some variations do exist. Further clinical studies may help clarify the optimum management strategy in this patient group.

A study of patient satisfaction following endothermal ablation for varicose veins.

Objective: To evaluate patient satisfaction following endothermal ablation for varicose veins (VVs). Methods: A 12-question survey was sent to consecutive patients treated with endothermal ablation—questions related to preprocedure symptoms, recurrence, further treatments, and patient satisfaction. Results: Questionnaires sent a median 12 (range 6-22) months postintervention were returned by 177 (60.0%) of 295 patients; 63 (35.6%) of 177 received treatment for recurrent VVs. Preintervention symptoms included aching (141 [79.7%] of 177), swelling (86 [48.6%] of 177), and heaviness (72 [40.7%] of 177). Improvements in preoperative symptoms were reported by 82.5% (146 of 177). Postintervention recurrence was reported by 87 (49.4%) of 177; 61 (70.1%) of 87 reported a few recurrent varicosities only. Further treatment was required by 11 (6.2%) of 177; 79 (44.6%) of 177 of patients reported no complications. The majority (151 [85.8%] of 176) were satisfied with their treatment. In all, 16 (25.4%) of 62 of patients treated for recurrent VVs were dissatisfied versus 9 (7.9%) of 114 of those with primary VVs (P = .0026). Conclusions: The majority of patients are satisfied with results following endothermal ablation. Dissatisfaction may be more likely following treatment for recurrent VVs.

Endovenous treatments for varicose veins--over-taking or over-rated?

Objectives A variety of endovenous therapies for the treatment of superficial venous incompetence are currently available. The aim of this study was to evaluate the prevalence of endovenous techniques used by consultant vascular surgeons in the United Kingdom. Methods An anonymous online survey of 16 multiple choice questions relating to the nature and provision of treatment for varicose veins was devised. Consultant members of the Vascular Society of Great Britain and Ireland were invited to participate by email. Results A total of 108/352 (31%) surgeons completed the survey. The majority offered surgery as the first-line treatment for primary great saphenous vein (GSV) and small saphenous vein (SSV) incompetence (69% and 74%, respectively). Endovenous procedures were offered as first-line treatment by 32/108 (29.6%) for GSV reflux, 36/51 (70.6%) surgeons performed these under local anaesthetic and 21/51 (41.2%) were performed as an outpatient procedure. The most important factor influencing treatment decisions was considered to be patient preference by 77/108 (71.3%) surgeons, although 48/61 (78.7%) respondents were restricted by primary care trusts with regard to endovenous treatments, and 33/108 (30.6%) offered different treatments to private patients. Conclusion Traditional surgery remains the most commonly offered treatment for patients with varicose veins. The provision of endovenous therapies varies greatly, and there are significant differences in local availability regarding these treatments.

Ambulatory varicosity avulsion later or synchronized (AVULS): a randomized clinical trial.

OBJECTIVE A randomized clinical trial assessing the difference in quality of life and clinical outcomes between delayed and simultaneous phlebectomies in the context of endovenous truncal vein ablation. BACKGROUND Endovenous ablation has replaced open surgery as the treatment of choice for truncal varicose veins. Timing of varicosity treatment is controversial with delayed and simultaneous pathways having studies advocating their benefits. A previous small randomized study has shown improved outcomes for simultaneous treatment. METHODS Patients undergoing local anesthetic endovenous thermal ablation were randomized to either simultaneous phlebectomy or delayed varicosity treatment. Patients were reviewed at 6 weeks, 6 months, and 1 year with clinical and quality of life scores completed, and were assessed at 6 weeks for need for further varicosity intervention, which was completed with either ultrasound-guided foam sclerotherapy or local anesthetic phlebectomy. Duplex ultrasound assessment of the treated trunk was completed at 6 months. RESULTS 101 patients were successfully recruited and treated out of 221 suitable patients from a screened population of 393. Patients in the simultaneous group (n = 51) showed a significantly improved Venous Clinical Severity Score at all time points, 36% of the delayed group required further treatment compared with 2% of the simultaneous group (P < 0.001). There were no deep vein thromboses, with 1 superfificial venous thrombosis in each group. CONCLUSIONS Combined endovenous ablation and phlebectomy delivers improved clinical outcomes and a reduced need for further procedures, as well as early quality of life improvements.

Delayed Hepato-Spleno-Renal Bypass for Renal Salvage following Malposition of an Infrarenal Aortic Stent-Graft

Purpose: To report a salvage maneuver for accidental coverage of both renal arteries during endovascular aneurysm repair (EVAR) of an infrarenal aortic aneurysm (AAA) and survey our surgical colleagues in the UK for their use of this bypass procedure. Methods: A 74-year-old woman who had an EVAR complicated by renal failure secondary to malposition of the stent-graft underwent successful delayed renal revascularization with hepatorenal and splenorenal bypasses. This case prompted a literature review and preparation of an online 6-part questionnaire regarding the incidence and management of renal impairment following EVAR. The survey invitation was sent to all listed members of the Vascular Society of Great Britain and Ireland. Results: Responses from 68 (10.5%) of the 650 vascular surgeons invited to participate in the survey were analyzed. The combined experience of those who completed the survey was >1500 EVAR procedures per annum. Forty percent (27/68) of the respondents had experienced a case of bilateral renal artery occlusion during EVAR. Two thirds (67%, 18/27) of these surgeons stated a preference for revascularizing the kidneys endovascularly, 7 surgeons would convert to open repair, 1 surgeon favored iliorenal bypass, and another suggested splenorenal bypass. Following intervention, 15 (56%) of 27 surgeons achieved revascularization that resulted in a return to baseline serum creatinine, 7 (26%) achieved partial recovery of the patients serum creatinine, 3 (11%) had a patient on permanent dialysis, and 2 (7%) had patients who died (after open repair and endovascular procedure, respectively). Conclusion: Bilateral renal artery occlusion caused by malposition of a stent-graft is probably underreported. If revascularization of the kidneys by endovascular techniques fails, there is no consensus as to the optimal approach. Delayed revascularization should be considered if the kidneys show concentration of imaging contrast. Hepato-spleno-renal bypass, which has not heretofore been indicated for renal salvage post EVAR, can provide a good functional result in this situation.

Who benefits the most from varicose vein intervention: can we predict treatment outcomes?

Varicose veins impose a huge burden on a patient’s quality of life. The reported symptoms of unsightly cosmesis, heaviness, aching, itching or burning and the potential complications that include leg ulcers, infections, stasis changes and thrombosis have contributed to considerable morbidity and cost to the health service. Approximately more than 50,000 varicose vein operations are performed each year in England and Wales, with an estimated annual cost at £400–600 m. At present, the vast diversity of new treatment options for varicose veins have led to many questions and disputes among physicians as to which is the most efficacious. However, as long-term success rates of new interventions are still awaited, reliable and validated outcome measures are required in order to evaluate these modalities. An outcome measure allows the evaluation of health-care delivery and has traditionally looked at mortality and morbidity but is now increasingly incorporating the concept of ‘patient satisfaction’. Patient reported outcome measures (PROMs) are intended to measure patients’ baseline health status, assist in monitoring their journey through intervention and allow comparison of varying treatment modalities and treatment centres. To date, various quality-of-life assessment tools have been developed and validated for use in venous disease, each with their own strengths and weaknesses. There are two classes of outcome measures: generic and disease specific. Generic tools currently utilized to assess varicose vein treatment include the 36 Item Short form Health Survey and Nottingham Health Profile. These are usually applied across broad range of diseases and are a measure of patients’ subjective wellbeing. Health economic questionnaires such as the Euroquol currently allow calculation of the cost-effectiveness of interventions in Quality of life Adjusted Years, which governs whether or not treatments are recommended on the National Health Service. It has, however, been suggested that they may not be sensitive enough to fully evaluate improvements in outcomes in some disease states and that a more sensitive tool is required. Conversely, disease-specific instruments such as Aberdeen Varicose Vein Questionnaire (AVVQ), Venous insufficiency epidemiological and economic study, Chronic Venous Insufficiency Questionnaire and Specific Quality of life Outcome Response Venous are specific for venous disease. They allow patients to report their own symptoms and are thought to be more sensitive to changes following interventions; however, at present we do not have a disease-specific questionnaire to measure cost-effectiveness or disease burden and therefore cannot say who’s score is worthy of treatment. Currently PROMs are being used by the Department of Health in the UK in order to evaluate service provision. Perhaps we could analyse the PROMs to elucidate who would benefit most from intervention. Would those who score very highly be the ones who reap the most benefit, whether it be physical or cosmetic-related improvement? Conversely, would those who have low scores tolerate delay in treatment on a non-urgent basis, if indeed are likely to benefit at all? If so, could we use these PROMs as a tool to offload the pressure on the use of scarce health-care resources, particularly for interventions of uncomplicated varicose veins and also to prioritize scheduling for waiting lists? At present, there is a lack of evidence in the published literature supporting this notion. Data from a small study presented by Beresford et al. have shown patients with moderate varicose vein disease, i.e. AVVQ 12.5–25, gained significant and long-term benefit from varicose vein surgery, although patients with mild disease were unlikely to benefit significantly. However, other studies have found that even patients with low preoperative scores gained improvements following intervention, although they were more likely to report a worsening of their symptoms compared with those with more severe disease. Although PROMs have shown to be sensitive tools in the evaluation of treatment outcomes, there is no convincing evidence to support their use to predict who will benefit from intervention. In addition, not all clinician’s and patients have sufficient interest in using formalized assessments as a tool to evaluate treatment success or predict outcome. The system would also be open to significant bias if