Sandip Nandhra

Systematic review of compression following treatment for varicose veins

Consensus regarding compression following treatment of varicose veins has yet to be reached. This systematic review aims to establish the optimal compression regimen after venous treatment.

A randomized clinical trial of endovenous laser ablation versus conventional surgery for small saphenous varicose veins

BACKGROUND This randomized clinical trial compared endovenous laser ablation (EVLA) and surgical ligation with attempted stripping in the treatment of small saphenous vein (SSV) insufficiency. The early results demonstrated that EVLA was more likely to eradicate axial reflux and was also associated with a faster recovery, lower periprocedural pain, and fewer sensory complications. The aim of this 2-year follow-up was to establish whether these benefits remained stable over time and whether these improved technical outcomes were associated with less clinical recurrence. METHODS Patients with primary saphenopopliteal junction and SSV reflux were randomized to EVLA or saphenopopliteal junction ligation and attempted stripping/excision. Outcomes assessed at 2 years included the presence of residual or recurrent reflux, clinical recurrence, sensory complications, the need for secondary intervention, and patient-reported quality of life on the Aberdeen Varicose Veins Questionnaire, SF-36, and EuroQol. RESULTS Of 106 patients who were equally randomized and successfully treated according to the protocol, 88 (83%) were successfully assessed at 2 years. The groups were comparable at baseline. At 2 years, EVLA remained superior to surgery in eradicating axial reflux in 36 patients (81.2%) compared with 29 (65.9%) in the surgery group (P = .002). There was no significant difference in clinical recurrence (EVLA: seven of 44 [16%] vs surgery: 10 of 44 [23%]; P = .736), sensory disturbance (EVLA: one [2.4%] vs surgery vs three [6.8%]; P = 1.000) or any quality of life domain. CONCLUSIONS The results of treatment of SSV insufficiency with EVLA appear durable up until 2 years. The study does not appear to suggest that the improved abolition of reflux after EVLA compared with surgery is associated with superior outcomes than those seen after surgery by this time point, because equal effect was shown in both groups. The sensory disturbance associated with surgery appears to settle over this time frame. EVLA is therefore superior in the short-term and not inferior by 2 years.

Compression regimes after endovenous ablation for superficial venous insufficiency--A survey of members of the Vascular Society of Great Britain and Ireland.

Introduction The optimal compression regime following ultrasound guided foam sclerotherapy (UGFS), radiofrequency ablation (RFA) and endovenous laser ablation (EVLA) for varicose veins is not known. The aim of this study was to document current practice. Methods Postal questionnaire sent to 348 consultant members of the Vascular Society of Great Britain and Ireland. Results Valid replies were received from 41% (n = 141) surgeons representing at least 68 (61%) vascular units. UGFS was used by 74% surgeons, RFA by 70% and EVLA by 32%, but fewer patients received UGFS (median 30) annually, than endothermal treatment (median 50) – P = 0.019. All surgeons prescribed compression: following UGFS for median seven days (range two days to three months) and after endothermal ablation for 10 days (range two days to six weeks) – P = 0.298. Seven different combinations of bandages, pads and compression stockings were reported following UGFS and four after endothermal ablation. Some surgeons advised changing from bandages to stockings from five days (range 1–14) after UGFS. Following endothermal ablation, 71% used bandages only, followed by compression stockings after two days (range 1–14). The majority of surgeons (87%) also treated varicose tributaries: 65% used phlebectomy, the majority (65%) synchronously with endothermal ablation. Concordance of compression regimes between surgeons within vascular units was uncommon. Only seven units using UGFS and six units using endothermal ablation had consistent compression regimes. Conclusion Compression regimes after treatments for varicose veins vary significantly: more evidence is needed to guide practice.

Defining the optimum tumescent anaesthesia solution in endovenous laser ablation.

Objectives To produce a tumescent anaesthesia solution with physiological pH for endovenous thermal ablation and evaluate its influence on peri- and postoperative pain, clinical and quality of life outcomes, and technical success. Methods Tumescent anaesthetic solution (0.1% lidocaine with 1:2,000,000 epinephrine) was titrated to physiological pH by buffering with 2 ml incremental aliquots of 8.4% sodium bicarbonate. Patients undergoing great saphenous vein endovenous laser ablation and ambulatory phlebectomy were studied before and after introduction of buffered tumescent anaesthetic. Primary outcome was perioperative pain measured on a 10 cm visual analogue scale. Secondary outcomes were daily pain scores during the first postoperative week, complications, time to return to normal activity, patient satisfaction, generic and disease-specific quality of life, and technical success. Patients were assessed at baseline, and at 1, 6 and 12 weeks following the procedure. Results A physiological pH was achieved with the addition of 10 ml of 8.4% sodium bicarbonate to 1 l of standard tumescent anaesthetic solution. Sixty-two patients undergoing great saphenous vein endovenous laser ablation with phlebectomy were recruited before and after the introduction of buffered tumescent anaesthetic solution. Baseline and operative characteristics were well matched. The buffered solution was associated with significantly lower (median (interquartile range)) periprocedural pain scores (1 (0.25–2.25) versus 4 (3–6), p < 0.001) and postoperative pain score at the end of the treatment day (1.8 (0.3–2.8) versus 3.0 (1.2–5.2), p = 0.033). There were no significant differences in postoperative pain scores between the groups at any other time. There were no significant differences in other clinical outcomes between the groups. Both groups demonstrated significant improvements in generic and disease-specific quality of life, with no intergroup differences. Both groups demonstrated 100% ultrasonographic technical success at all time points. Conclusions Buffering of tumescent anaesthetic solution during endovenous thermal ablation is a simple, safe, inexpensive and effective means of reducing perioperative and early postoperative pain.

A systematic review of the compression regimes used in randomised clinical trials following endovenous ablation

Objectives There is insufficient evidence to inform guidelines on the optimal compression strategy following ablation for varicose veins. This study aimed to identify the practice of key opinion leaders performing randomised clinical trials involving endovenous ablation. Method A systematic review of MEDLINE/EMBASE/CENTRAL was performed identifying the compression strategies used in randomised clinical trials where at least one comparator arm underwent endovenous ablation. Results Thirty-four randomised clinical trials were identified. At least 14 different compression products were used, with at least 6 different pressures in 7 different regimes with durations from 2 to 84 days. There was no evidence of any convergence of practice over time. Conclusions A lack of evidence as to the optimal strategy for compression has resulted in a marked variation in clinical practice. There is no suggestion that this variation is becoming less over time indicating that experience is not helping to form a consensus and, therefore, further research is required.

The classic saphenofemoral junction and its anatomical variations

Background The intraoperative anatomy of the saphenofemoral junction can vary from the ‘textbook’ description of six independent proximal tributaries: three medial – superficial external pudendal, deep external pudendal and the posteromedial thigh branch – and three lateral – superficial epigastric, superficial circumflex iliac and the anterolateral thigh branch. Varicose veins can recur following inadequate initial open surgery with failure to identify, ligate and divide these tributaries. An appreciation of common anatomical variations could minimise recurrence rates following surgery. This study aimed to identify common anatomical variations within our patient cohort. Methods This prospective observational study documented diagrammatically the anatomy of saphenofemoral junction in a consecutive series of 172 patients undergoing unilateral, primary saphenofemoral junction ligation for symptomatic superficial venous insufficiency. Diagrams recorded the number of tributaries and their relationship to the saphenofemoral junction, the existence of bifid systems and the relationship of the external pudendal artery to the saphenofemoral junction. Results In sum, 110 women and 62 men with a mean age of 47.2 (IQR 21–77) years were studied. The median number of saphenofemoral junction tributaries was 4 (IQR 0–7). In 74 cases (43.0%), at least one tributary drained directly into the common femoral vein (IQR 0–4), commonly the deep external pudendal (91.9%). The anterolateral thigh branch was identified in 62 cases (35.8%) and the posteromedial thigh branch in 93 cases (53.8%). The external pudendal artery was identified in 150 cases (87.2%) and was superficial to the great saphenous vein in 36 cases (20.9%). Conclusions Significant variations exist in the saphenofemoral junction anatomy. Familiarity with anatomical saphenofemoral junction variations is imperative to ensure operative success and reduce recurrence. Thorough dissection of the common femoral vein is necessary not only to ensure all proximal tributaries are identified and ligated but also as a safety mechanism in preventing avulsion trauma of direct common femoral vein tributaries.

Long-term outcomes of endovenous laser ablation and conventional surgery for great saphenous varicose veins: Endovenous laser ablation versus conventional surgery for great saphenous varicose veins

Clinical guidelines recommend endovenous laser ablation (EVLA) over surgery based on short‐term evidence, yet there are few studies reporting mid‐ to long‐term outcomes. The aim of this study was to report the 5‐year outcomes from an RCT of surgery versus EVLA for treatment of symptomatic great saphenous varicose veins.

Midterm Results of a Randomized Controlled Trial Comparing Endovenous Laser Ablation and Surgery for the Treatment of Small Saphenous Insufficiency

anesthesia. Two studies were conducted to evaluate the feasibility of a novel biodegradable implant, polyglycolic acid (PGA), to occlude incompetent great saphenous veins (GSV) without tumescent anesthesia. Methods: TAHOE I and TAHOE II were prospective, single-arm studies using the same PGA implant. Slight modifications were made to the TAHOE II protocol (eg, removed mandate for heparin use and postprocedure compression). TAHOE I was conducted at three sites in Europe and enrolled 51 patients; TAHOE II was conducted at one site in the Dominican Republic and enrolled 30 patients. After treatment patients returned at 1 day, 1, 2, and 6 weeks, and 3 and 6 months. Vein occlusion, reflux, postprocedure pain (0-10), quality-of-life (CIVIQ2), Venous Clinical Severity Score (VCSS), and adverse events were assessed at each visit. Results: Occlusion and reflux-free rates are summarized in Table I. Initial occlusion and reflux-free rates were >90% in both studies. Change in CIVIQ2 scores and VCSS scores to 6 months are summarized in Table II. CIVIQ2 scores were elevated at 1 day but showed improvement at 6 weeks that was sustained through 6 months. VCSS improved after day 1 and through to 6 months. Pain (median [IQR]) at day 1 was 2.0 (0,3) in the TAHOE I study and 2.5 (0,5) in the TAHOE II study but decreased to 0 (0,0) from 2 weeks to 6 months for both groups. The most commonly reported adverse events were induration (20% TAHOE I, 41.4% TAHOE II), erythema (12% TAHOE I, 48.3% TAHOE II), fever (34.5% TAHOE II), nausea (34.5% TAHOE II), and phlebitis (8% TAHOE I); all resolved by 6 weeks. No patient experienced neuropraxia. Conclusions: Tumescent-free PGA implantation resulted in high initial GSV occlusion with recanalization appearing in some patients at 3 months postprocedure. PGA is promising, but requires modification to achieve higher long-term occlusion and reflux-free rates.