Lowell S. Kabnick

Prospective randomized study of endovenous radiofrequency obliteration (closure procedure) versus ligation and stripping in a selected patient population (EVOLVeS Study).

PURPOSE This study was designed as a prospective multicenter randomized comparison of procedure-related complications, patient recuperation, and quality-of-life outcomes between patients undergoing vein stripping with high ligation and patients undergoing great saphenous vein (GSV) obliteration with temperature-controlled radiofrequency ablation without adjunctive high ligation (Closure procedure). METHODS Eighty-five patients (86 limbs) from five sites (France, 2; Austria, 1; United States, 2) were randomly allocated to undergo radiofrequency obliteration (RFO) or stripping and high ligation (S&L). Final analysis included data for 44 limbs in the RFO group and 36 limbs in the S&L group. Follow-up examinations were performed at 72 hours, 1 week, 3 weeks, and 4 months. All patients completed the CIVIQ2 quality-of-life (QOL) questionnaire and underwent clinical and ultrasound examinations at each follow-up visit. RESULTS Immediate success on the day of treatment was reported for 95% (42 of 44) of limbs in the RFO group and 100% (36 of 36) of limbs in the S&L group. In seven RFO limbs (16.3%) a scan obtained 72 hours after the procedure showed flow in the proximal GSV. Five of these segments had reflux in the open segment. At 1 week two of these closed, and an additional segment closed at 3 weeks. In no cases did flow reappear after complete occlusion of the GSV. Time to return to normal activities was significantly less in the RFO group (mean, 1.15 days; 95% confidence interval [CI], 0.05-2.34) compared with the S&L group (mean, 3.89 days; CI, 2.67-5.12; P =.02). In the RFO group, 80.5% of patients returned to routine activities of daily living within 1 day, compared with 46.9% of patients in the S&L group (P <.01). Patients in the RFO group were able to return to work in 4.7 days (CI, 1.16-8.17), compared with 12.4 days (CI, 8.66-16.23) for the S&L group (P <.05). Analysis of the QOL surveys showed statistically significant differences in favor of the RFO group for global score and pain score during follow-up. The magnitude of the difference, however, progressively decreased between 1 week and 4 months. CONCLUSIONS In the absence of significant complications, such as deep vein thrombosis and pulmonary embolism, severe neuritic sequelae, and skin burns, there are significant early advantages to endovascular obliteration of the GSV compared with conventional vein stripping.

Treatment of Primary Venous Insufficiency by Endovenous Saphenous Vein Obliteration

The objective of this paper is to evaluate treatment of primary venous insufficiency by endovenous saphenous vein obliteration. Three hundred one limbs were treated in 206 women and 67 men with a mean CEAP Clinical Class of 2.4 ±0.9. Endovenous obliteration was combined with high ligation in 67 limbs (22%) and with stab avulsion phlebectomies in 181 (60%). Acute occlusion was achieved in 290 limbs (96%). Obliteration failures in 11 limbs were treated by saphenous stripping or managed expectantly. Paresthesias followed 15% of treatments confined to the thigh and upper leg and affected 30% of limbs when treatment extended to the ankle (p < 0.001). Eight potentially preventable thermal skin injuries occurred, five in particularly superficial venous segments, of which four were in men. At a mean follow-up of 4.9 months, 21 (7.2%) of successfully treated veins have partially or totally (n = two) recanalized, but only 11 (3.8% of 290) have Doppler-detectable reflux. Ninety-one patients have been followed up for 6 months to 1 year, showing significant improvement in CEAP class and progressive relief from clinical symptoms. At their latest visit, 94% rated themselves as being symptom-free or substantially improved. These midterm results with endovenous obliteration in the treatment of primary varicose veins suggest that it may be as effective as surgical stripping in eliminating greater saphenous vein reflux and delaying the appearance of new varicose veins. Simple procedural modifications, such as not treating to the ankle, prophylactic infiltration about superficially placed veins, and early duplex surveillance should diminish the complications observed in this early experience.

Scoring system to aid in diagnoses of appendicitis.

Problems related to the diagnosis of appendicitis are evidenced by the significant negative laparotomy rate. The present study sought to assess the feasibility of decreasing this diagnostic error by studying two groups of patients and identifying and weighing details of history, physical examination and laboratory findings utilizing 23 predictive factors. One hundred consecutive cases of proven appendicitis (AAp) were retrospectively reviewed and compared with 100 consecutive cases that had normal appendices removed because of erroneous preoperative diagnosis of appendicitis (NAp). Rates of occurrence for each predictive factor were determined separately for both groups. These were converted into weights which were then added to yield a diagnostic score for each patient. A cutoff point established the score which designated one group for observation and the other for surgery. Scores were assessed at three different points by balancing risks of missed diagnoses against benefits of avoiding unnecessary operations. Seven predictive factors had differentiating weights and reached statistical significance (p ≤ 0.05):-sex, age, duration of symptoms, GU symptoms, involuntary right lower quadrant muscle spasm, right-sided rectal mass, and white blood cell count. Using these seven predictors, at a “—3” cutoff, 38% NAPs would have been spared laparotomy and about 5% of the AAps would have been indicated for observation. Analysis indicated little risk in observing the 5% AAp (5/7 history ≤ 1 day), and progressive improvement for NAps with increasing time. This simple scoring system could have eliminated over one third of the unnecessary laparotomies in the present sample, indicating potential value as an aid in surgical decision-making.

Blood-pancreatic juice barrier to antibiotic excretion

Antibiotics were given intravenously to dogs with chronic pancreatic fistulas, and serum and pancreatic juice levels were measured. Despite adequate serum values, gentamicin, tetracycline, clindamycin, and moxalactam did not appear in the pancreatic juice, which suggested a barrier to their excretion. In contrast, chloramphenicol reached a peak concentration in the pancreatic juice that amounted to 36 percent of the peak serum value. In the pancreatic juice, ampicillin, cefoxitin, and cefamandole reached only 5 percent of the peak serum values but were still within the therapeutic range. We have concluded that there is a blood-pancreatic juice barrier to some antibiotics, which leads to selective excretion.

Laser Saphenous Ablations in More Than 1,000 Limbs With Long-Term Duplex Examination Follow-Up

BACKGROUND The goal of this study was to evaluate the duplex results of endovenous laser ablation in the treatment of incompetent great saphenous veins (GSV) and small saphenous veins (SSV) with at least 1-year follow-up. METHODS A retrospective registry was entered by 11 centers from Europe and America, organized by the International Endovenous Laser Working Group. Data concerning 1,020 limbs in patients with incompetence of the GSV and/or SSV, treated with the Endovenous Laser Ablation (EVLA) procedure, were collected. EVLA failures were defined on duplex imaging as reflux confined to the saphenofemoral or saphenopopliteal junction, reflux confined to the main saphenous trunk, or reflux of both junction and main trunk (totally patent saphenous vein) were analyzed at one or more years postoperatively. RESULTS The mean age of patients was 54 ± 5 years (range: 18-91 years). The average body mass index was 25. There was a paucity of severe complications: One case of third-degree skin burn, six patients with postsurgical deep vein thrombosis (0.6%), and 27 cases of sensory nerve damage (2.7%). At 1-year, the rate of complete occlusion of the saphenous trunk was 93.1%. There were 79 cases of treatment failures as evidenced by duplex: 22 isolated junction failures (2.2%), 44 isolated trunk failures (4.4%), and 13 totally patent veins (1.3%). Two-year duplex results were reported for 329 limbs with the identification of 19 new cases of failure. No new cases of failure were reported at 3-year follow-up of 130 limbs. Cumulative failure rates estimated by Kaplan-Meier analysis were 7.7% at 1-year and 13.1% at 2- and 3-year follow-up. CONCLUSIONS On the basis of a duplex scan performed at least 1-year post-treatment, this multicenter registry confirms the safety and efficacy of the EVLA procedure in the treatment of GSV and SSV reflux. Considering the continued failure rate documented in the present study, an annual follow-up by duplex is recommended to 2 years after EVLA.

Arteriovenous fistula after endovenous ablation for varicose veins

Endovenous ablation, using radiofrequency or laser, is becoming the mainstay of treatment for symptomatic varicose veins in the setting of saphenous vein incompetency. Both procedures have been shown to produce high rates of truncal vein occlusion with few complications. This article presents three patients who developed arteriovenous fistula (AVF) following great saphenous vein treatment: two following radiofrequency ablation (RFA) and one following laser ablation. This is the first published report of AVF following RFA for which operative details are known. We review the literature and discuss possible causes and management of this rare complication.

Varicose Vein Surgery

The treatment of superficial venous disease and chronic venous insufficiency continues to evolve, and the interest in venous disease has matched that in arterial disease in vascular medicine. A better understanding of venous anatomy and pathophysiology and the development of newer, more efficient diagnostic technology have allowed clinicians to utilize minimally invasive techniques in the treatment of varicose veins. These techniques have reduced recurrence and improved overall quality of life (postoperative pain and bruising) following these procedures. This article provides an overview of basic venous surgical anatomy and pathophysiology, along with several older and newer surgical options in the treatment of superficial venous disease. Advantages and disadvantages of each approach are briefly discussed so that the reader may gain better understanding of the options available in the treatment of chronic venous insufficiency.

Update on Endovenous Laser Ablation 2011

In 2001, the use of endovenous laser ablation (EVLA) was introduced to the United States to treat superficial venous insufficiency. EVLA has subsequently undergone a rapid rise in popularity and usage with a concomitant decrease in traditional operative saphenectomy. Since its inception, the use of EVLA to treat superficial venous insufficiency has advanced significantly. The efficacy of treatment has been validated using both hemoglobin-specific laser wavelength and water-specific laser wavelength lasers. Currently, laser optimization is focusing on reducing postprocedural sequelae. The clinical parameters that correlate best with improved postoperative recovery use lower power/energy settings, water-specific laser wavelength lasers, and jacket or radial-emitting tips. Future study is still required to assess the durability of treatment at lower power and energy settings coupled with jacket or radial-emitting tip fibers. Long-term follow-up using duplex imaging is recommended to ensure persistent treatment success.

Recurrent aortic angiosarcoma--a case report and review of the literature.

Primary aortic tumors are rare; only 86 cases of primary aortic angiosarcoma have been reported since its first description in 1873. The diagnosis of aortic angiosarcoma is usually confirmed by postoperative pathologic examination or postmortem study. The authors present a case of primary aortic angiosarcoma with postresection recurrence.

Inequalities of health insurance guidelines for the treatment of symptomatic varicose veins

Objectives The emerging model of US healthcare delivery is aimed at reducing costs, standardizing care, and improving outcomes. Although it is necessary for healthcare providers and insurance carriers to work together to achieve those goals, insurers have the added duty of assuring physicians and patients that they comprehend the medical evidence and, based on that understanding, construct policies. Are US insurers meeting that responsibility or are they simply creating policies to serve their own needs? Methods The medical policies of several US health insurers were analysed. The goal was to see whether it could readily be determined if these carriers used evidence-based medicine consistently to create uniform policies for the treatment of patients with symptomatic varicose veins. The literature was also reviewed to determine whether increased insurance documentation requirements have affected cost reduction, standardization of care and/or improvement of outcomes related to chronic vein disease management. Results There is a dramatic lack of uniformity among the insurance policies reviewed. Insurers appear to not choose important papers to create policy but use carefully chosen articles to reinforce what they want their policies to say. In so doing, conflicting policy criteria are being created. Complicating this inconsistency, rules for medical necessity are modified frequently, raising frustration levels among vein providers and their patients. What is clear is that costs are not being lowered, care is not being standardized and little is being done to prevent potential complications resulting from chronic vein disease. Conclusions Patients and physicians are increasingly ill-served by, and frustrated with, the clear lack of consistency in the medical policy criteria being created by US insurance carriers in covering the treatment of patients with symptomatic varicose veins. The contradictory coverage requirements, seemingly based on no understanding of evidence-based medicine guidelines, and total variability in reimbursement for various types of treatment options is particularly worrisome. Collaboration between venous treatment providers and insurance carriers, to create evidence-based standards of care, would be timely and beneficial in creating guidelines for optimal patient care.