M. de Maeseneer

Duplex Ultrasound Investigation of the Veins of the Lower Limbs after Treatment for Varicose Veins – UIP Consensus Document

OBJECTIVES Duplex ultrasound has become the reference standard in assessing the morphology and haemodynamics of the lower limb veins. The project described in this article was an initiative of the Union Internationale de Phlébologie (UIP). The aim was to obtain a consensus of international experts on the methodology and terminology to be used for assessment after treatment of incompetent superficial and perforating veins in the lower limb by ultrasound imaging. DESIGN The study design was consensus meetings leading to a consensus document. METHODS The UIP invited group submitted relevant literature references and written contributions concerning the methodology, terminology and value of duplex imaging after treatment. The authors prepared a draft document that was circulated to a larger group of experts and revised according to the comments received. Eventually, all participants agreed upon the final version of the article. RESULTS Formal analysis of the results of interventions for varicose veins relies on adequate preoperative assessment and a careful description of the procedure employed. The timing of investigations of outcome should be classified as immediate (1-4 weeks), short-term (1 year), midterm (2-3 years) and long-term (5 years or more). The examination should employ standard methodology and formally described variables, which can be tailored to the intervention that was undertaken. The experts have made detailed recommendations concerning the methods to be used for duplex ultrasound examination and reporting after various treatments for varicose veins, including novel treatments under scientific study. CONCLUSIONS Duplex ultrasonography is a fundamental component of the investigation of the lower limb venous system after treatment for varicose veins.

Five-year results of a randomized clinical trial of conventional surgery, endovenous laser ablation and ultrasound-guided foam sclerotherapy in patients with great saphenous varicose veins

A variety of techniques exist for the treatment of patients with great saphenous vein (GSV) varicosities. Few data exist on the long‐term outcomes of these interventions.

Long-term results of primary stenting for long and complex iliac artery occlusions.

Abstract Objectives: To evaluate the long-term results of recanalization with primary stenting for long and complex iliac artery occlusions. Design: Retrospective non-randomized study. Methods: Between 1996 and 2004, 38 patients underwent recanalization of an occluded iliac artery with subsequent stenting for TASC B lesions in 12 patients, TASC C in 10 and TASC D in 16. Thirty-one patients had Fontaine stage 2 B, four patients had stage 3 and one patient had stage 4. Two patients (5.4%) presented with acute ischemia and received trombolysis before recanalization. Patency results were calculated using Kaplan and Meier analysis. The mean follow-up was 26 months. Results: Technical success was 97.4%. Thirty-day mortality was 2.7%. The primary patency rate was 94%, 89% and 77% at 1, 3 and 5 years respectively. Three re-occlusions (8.1%) and one restenosis (2.7%) were observed during follow-up. The secondary patency (SP) rate was 100%, 94% and 94% after 1, 2 and 3 years. Fifteen patients underwent an associated procedure. A kissing stent procedure in three patients, a contralateral PTA of an iliac stenosis in 8, a femoro-femoral bypass in 2, a femoropopliteal bypass in 1 and an femoral endarterectomy in 2. The procedure related complication rate was 5.4%. Conclusion: Long-term results of iliac recanalization are excellent without major complications if the procedure is technically successful. The endovascular procedure can be an alternative to an iliofemoral or aortobifemoral bypass in a high risk population.

Randomized clinical trial of endovenous laser ablation versus steam ablation (LAST trial) for great saphenous varicose veins

The aim was to compare endovenous laser ablation (EVLA) and endovenous steam ablation (EVSA) for great saphenous varicose veins in a non‐inferiority study.

Paravertebral schwannoma with high uptake of fluorodeoxyglucose on positron emission tomography.

Abstract A paravertebral mass was discovered in a 27-year-old woman, while investigating a painful shoulder and arm. CT, MRI and fine needle aspiration cytology (FNAC) pointed in the direction of a benign mass, but positron emission tomography (PET) showed a high uptake of [18F]fluorodeoxyglucose (FDG), which was indicative of a malignant lesion. Pathological analysis of the thoracoscopically resected tumour gave us the final diagnosis of a benign schwannoma. This report demonstrates that a high uptake of FDG in a non-malignant mediastinal tumour is possible.

The endovenous revolution

More than 25 per cent of the general population suffers from varicose veins or more advanced stages of chronic venous disease (Fig. 1). Although often underestimated, chronic venous disease has a considerable impact on quality of life. Worsening clinical grade corresponds strongly with deterioration of disease-specific as well as generic quality of life1. For most of the 20th century, varicose veins were treated predominantly by surgery. This was challenged in the 1990s with the introduction of catheter-based systems of endovenous heating of the great saphenous vein (GSV) with radiofrequency (RF) energy. Early reports established the efficacy of this procedure, showing that venous ablation could be achieved without high ligation of the saphenofemoral junction2. Endovenous RF ablation was quickly followed by endovenous laser ablation (EVLA), initially using an 810nm diode laser. Many other laser devices appeared subsequently, using different wavelengths, varying power settings, pulsed or continuous withdrawal, and a variety of laser-tip designs. In the past few years, userfriendly RF technologies and endovenous steam have been added to the therapeutic repertoire. Requirements for the introduction of a new device are far less stringent than for the introduction of a new drug. Moreover, if a new device is similar to ones that have already been approved, companies can use a fast-track system to introduce it into clinical practice, with relatively little evidence of effectiveness3. The introduction of many endovenous thermal ablation (EVTA) devices provides good examples of this behaviour, resulting in widespread use based on small numbers of inadequately powered studies. It was not until 2007 that the first randomized clinical trial comparing EVLA and stripping was published4. It must also be acknowledged that research in EVTA is often sponsored by manufacturers, influencing the dissemination of information in scientific papers and at

Ulcer recurrence after in‐hospital treatment for recalcitrant venous leg ulceration

Background  Leg ulceration caused by chronic venous disease occurs in 1% of the adult Western population. A majority of these patients is successfully treated in the outpatient setting. A minority of patients is hospitalized, most frequently because of the lack of healing tendency. The literature provides recurrence rates for ulcer disease, but lacks specific data on recurrence rates after in‐hospital treatment of recalcitrant venous leg ulcers.

Diagnosis of deep vein thrombosis: How many tests do we need?

Abstract The requirement for a safe diagnostic strategy should be based on an overall post-test incidence of venous thromboembolism (VTE) of less than 1% during 3 month follow-up. Compression ultrasonography (CUS) has a negative predictive value (NPV) of 97 to 98% indicating a post-CUS incidence of deep vein thrombosis (DVT) of 2 to 3%. A post-CUS DVT incidence of 3% implicates that 90 to 120 DVTs per 1 million inhabitants will be overlooked each year indicating the need to improve the diagnostic work-up of DVT as much as possible. The qualitative D-dimer test (SimpliRed) has a sensitivity of 82 to 89% and a negative predictive value of 94 to 95% indicating a 5 to 6% post-test incidence of DVT, which is not sensitive enough for venous thrombosis exclusion. The post-test DVT incidence could be reduced from 3.2% to 0.6% in one study and from 11% to 2% in another study by the combination of a normal CUS and low clinical score and from 4,5% to 1.6% by the combination of low clinical score and a negative SimpliRed test in one study. The combination of a negative CUS and a negative SimpliRed test reduced the post-test incidence of DVT from 2.6% to < 1% or even < 1%o in two management studies without the need of a repeated CUS on the basis of which anticoagulant therapy can safely be withheld. The rapid quantitative turbidimetric D-dimer assay (Tinaquant) has a sensitivity and a negative predictive value (NPV) of 97.7% with a 2.3% post-test incidence of DVT. The combination of a normal Tinaquant D-Dimer test result plus a low to moderate clinical score reduces the post-test incidence of DVT from 2.3 to 0,6% without the need of CUS testing in 29% of patients with suspected DVT. The rapid ELISA VIDAS D-dimer assay has a sensitivity and NPV of 98,6 and 99.5% in two management studies for the exclusion of DVT irrespective of clinical score. The combination of a normal ELISA VIDAS D-Dimer test with clinical score assessment will reduce the post-test DVT incidence of less than 0.5% and the need for CUS testing by 40 to 50%. It is concluded that the sequential use of a rapid quantitative D-dimer test, clinical score and CUS appears to be safe and the most cost-effective diagnostic work-up of DVT.

Anatomical patterns of the above knee great saphenous vein and its tributaries: implications for endovenous treatment strategy.

Abstract Objective: The aim of the present study was to analyse the anatomical patterns of the above knee great saphenous vein (GSV) and its tributaries in limbs with varicose veins in view of potential suitability for endovenous treatment. Methods: Limbs of a consecutive series of new patients with varicose veins presenting at the phlebologic clinic during a 4 month period were studied. In 73 limbs of 56 patients with varicose veins and both saphenofemoral junction and GSV reflux, anatomical patterns of the above knee GSV were defined as : -‘complete’ GSV: main trunk visualised within the saphenous compartment from the groin to the knee -‘incomplete’ GSV: main trunk partially visualised from the groin to mid thigh with a non-refluxing mostly hypoplastic distal GSV and a superficial tributary vein (STV) parallel to the GSV. Results: 51 limbs (70 %) had a ‘complete’ GSV. In 4 of these 51 limbs reflux passed from the main GSV trunk to a STV at mid thigh level leaving a non-refluxing part of the GSV from mid thigh to the knee. Conclusion: In only 64% of limbs with varicose veins the entire above knee GSV was involved in the disease. This may have implications for endovenous treatment strategy.

Randomized clinical trial of 940- versus 1470-nm endovenous laser ablation for great saphenous vein incompetence

The independent effect of wavelength used for endovenous laser ablation (EVLA) on patient‐reported outcomes, health‐related quality of life (HRQoL), treatment success and complications has not yet been established in a randomized clinical trial. The aim was to compare two different wavelengths, with identical energy level and laser fibres, in patients undergoing EVLA.