Search

Purpose To evaluate the use of inframalleolar access for endovenous ablation when treating advanced venous disease with nonthermal nontumescent (NTNT) techniques. Methods This single-center retrospective study included 109 patients with advanced venous disease, treated using inframalleolar access between May 2018 and March 2020. NTNT techniques included ClariVein (Merit Medical Systems, South Jordan, Utah) and ScleroSafe (VVT Medical, Kefar Sava, Israel). Outcomes measured were postprocedure pain, leg edema, ulcer healing and recurrence rates, and venous insufficiency recurrence. Results Seventy-seven patients (70%) were treated with ClariVein and 32 (30%) with ScleroSafe. Postprocedure pain score (range, 0-10) after 1 week decreased from a preprocedure median of 5 (interquartile range, 3-6) to 1 ((interqartiel range, 0-2) (P = .0001). Complete wound healing was achieved in 38 patients (43.7%) after 30 days and in 71 patients (81.6%) after 90 days. One patient developed an ulcer recurrence and six developed venous insufficiency recurrence. There was no reported nerve or skin injuries. Conclusions NTNT ablation techniques using inframalleolar access are effective and safe without risk of nerve damage. Their use facilitates ulcer healing and limits pain in patients with advanced disease.

Objective The growth of endovenous ablation in the United States over the last few years has raised concerns of overuse by many vascular societies and payers. Reasons for such growth are unclear (ie, increased awareness, less invasive procedure, or inappropriate overuse). The Medicare Provider Utilization and Payment database was analyzed to define metrics of current practice trends in Medicare patients by providers. Methods The Medicare Provider Utilization and Payment database was queried for endothermal ablation Current Procedural Terminology codes (36475, 36476, 36478, and 36479) from 2012 through 2015. These results were imported into a relational database program. Queries were designed to ascertain the practice trends of all providers, inclusive of all specialties, and the data were exported to a spreadsheet program for analysis. Analysis for ablations per patient was calculated by assessing the number of beneficiaries who underwent at least one ablation by a provider in relation to the total number of ablations performed by that provider. Results Most saphenous vein ablations were done by vascular surgeons (29%), cardiologists (21%), or general surgeons (14%). The remaining one-third was performed by 33 other provider specialties ranging from nuclear medicine specialists to ophthalmologists. Regional variation was significant with 51% of ablations being performed in the south (Florida, 15.7% and Texas, 11.4%). The Western region had the greatest percentage growth of 62% with the addition of 14,788 cases added between 2012 and 2015. Ablations per patient averaged 1.8 in the aggregate dataset. Over the 4-year period, there was a steady increase seen in the number of patients undergoing ablation, number of ablations performed, number of providers performing ablation, average amount of ablations being performed as well as the number and proportion of providers performing more than ablations per patient. The number of ablations per patient was higher than average in specialties without any formal vascular training. Conclusions Endovenous ablation is performed by a wide variety of subspecialists with different levels of formal training for the management of chronic venous disease. This data analysis can help to establish better guidelines and governance over the use of endovenous ablation, but care should be taken to realize this is only an average and many patients will require more than two ablations for appropriate care. As our health care system shifts from a fee-for-service to a value-based system, and taxpayer-funded resources in Medicare patients become less available, it is important that practice trends be scrutinized using data-driven initiatives so that the appropriate physician treats the appropriate patient for the appropriate reasons.

Objective Management of chronic deep vein disease focuses on the alleviation of reflux and obstruction. For the suprainguinal veins, the main underlying pathologic process is obstruction, which has been recognized as a significant contributor to chronic venous insufficiency. This is currently being addressed with venous stenting and the development of dedicated stents designed for this segment of the venous system. Treatment of the femoropopliteal vein (FPV) is far more challenging because of the idiosyncratic anatomy, the hemodynamic physiology, and the technical aspects of size mismatch and valve flow dynamics in managing deep venous reflux. This review article discusses traditional and emerging technologies to treat infrainguinal disease. Methods Previous and current articles addressing this issue were reviewed. Emphasis was placed on emerging techniques and technologies. Results Significant bench work, in vitro and in vivo studies, have been conducted over the last 40 years addressing the issue of infrainguinal reflux and obstruction. Historically, open procedures to address FPV reflux and obstruction have had variable success in a few centers around the world. The significant increase of emerging endovascular therapies may allow more appropriate, reproducible, widespread treatment of infrainguinal deep venous disease. Conclusions Adequate and durable therapies for infrainguinal venous disease represent one of the greatest challenges for a vein specialist. Recently, a cluster of interest and techniques/technologies have been developed. The endovascular management of arterial disease is mature. The endovenous management of infrainguinal disease is on the cusp of meaningful innovation. The purpose of this evidence summary is to describe the options for the management of chronic FPV disease, with emphasis on emerging technologies and techniques.

Nonthermal nontumescent (NTNT) technologies for saphenous vein ablation encompass mechanicochemical (MOCA) ablation, cyanoacrylate adhesive embolization (CAE), and polidocanol endovenous microfoam (PEM), with others emerging. The NTNT segment is the fastest growing due to some inherent advantages: minimal nerve or skin injury; safety when treating disease to the ankle; decreased patient discomfort due to the decreased needle sticks by avoiding tumescence; and the elimination of any capital equipment (generator). There are two components to the MOCA device/technique: (1) mechanical damage to the endothelium by a rotating wire, and (2) chemical installation of a detergent liquid sclerosant simultaneously. Regarding the use of CAE, a proprietary formulated cyanoacrylate adhesive is delivered into the target vein utilizing a catheter that does not allow solidification of the glue within it. Once in the vasculature, the glue sets and causes immediate occlusion. A foreign body reaction incites an inflammatory response in the vessel, ultimately leading to fibrotic occlusion. PEM is a low-nitrogen (

Pathologic perforating veins have become an interest to the venous specialist caring for patients with CEAP 4 to 6 disease. Historically, open perforator ligation and then subdermal endoscopic perforator ligation was described. These methods had clear shortcomings. More recently, thermal ablation techniques, including radiofrequency ablation and laser ablation, have been described. Ultrasound-guided sclerotherapy has also been used as a possible means to treat pathologic perforator veins. This report describes and summarizes the updated techniques to treat perforating veins in a challenging patient population.

Background and Purpose This study was designed to determine a safe target distance (TD) from the saphenopopliteal junction (SPJ) to initiate endovenous laser therapy (EVLT). Methods A retrospective chart review was performed. Thirty-six limbs in 33 patients were treated with EVLT for small saphenous vein (SSV) incompetence. An 810-nm diode laser at 12W in the continuous mode was used. Clinical assessment was performed 1 week postoperatively and duplex scanning within 30 days. Results Mean vein diameter was 7.1 mm (max, 11 mm). The distance between the EVLT starting point and the SPJ ranged from 1.5 to 3.5 cm (mean, 2.19cm). Closure of the SSV was confirmed by completion ultrasonography in all cases. Twenty of 33 patients had 1 month follow-up scanning. None had SSV recanalization, deep venous thrombosis, adverse reactions to the laser, or clinical signs of nerve injury. Closure was noted 0.5–1 cm proximal to the initial target distance fiber location at the onset of EVLT ranging from 1 to 1.5 cm from the SPJ. Conclusion We propose a minimal 2 cm distance from the SPJ and a 2 cm radius of tumescent solution to counteract the perivenous effects of the laser energy. Anatomic morphology and these calculated distances determined by intraoperative ultrasound guidance are critical to the safe outcome of EVLT of the SSV.

Perforating veins are valved venous conduits that, with rare exception, direct blood to travel from the superficial to the deep venous system. There are 100–150 perforating veins in the lower extremities. Direct perforators connect to the deep axial veins and are more predictable in their locations. Indirect perforating veins that connect with intramuscular veins are more variable in location.

Publisher Summary TriVex is a mechanical method to remove tributary varicosities. As with any procedure, it has its unique qualities and quirks. The TriVex system consists of a transilluminator/irrigator and a powered resector. The transilluminator/irrigator is placed subcutaneously to provide for visualization of the varicose veins and instillation of the tumescent fluid. The advantages of the TriVex technique compared to traditional open surgery are speed, efficiency, decreased number of incisions, and better removal due to direct visualization of the target veins. In this technique, full duplex imaging is obtained, and all abnormal vein segments are identified and marked. The markings are placed around the veins and not directly on the varices themselves. The reason for not placing markings directly over the veins is that these may be misinterpreted under transillumination as residual unresected veins. Saphenous incompetence is managed by surgeon's choice, laser (EVLT), radiofrequency (VNUS), or by traditional stripping. The operation is done using general, spinal, or laryngeal mask airway anesthesia with the patient positioned in Trendelenburg position. An initial 3 mm incision is made just outside the marked area of varicosities. The transilluminator/irrigator is placed subcutaneously and distal to the level of the veins, and the room lights are dimmed for better transillumination.

• The diagnosis of venous insufficiency and hypertension was established in 53 patients using standard diagnostic methods including ascending and descending venography, venous pressure measurements, and photoplethysmography. Autogenous vein valve transplant, which is gaining acceptance as a treatment for this condition, was employed in this group of patients to relieve venous valvular insufficiency. Biopsy specimens of the gastrocnemius muscle were obtained before surgery in all 53 patients and studied pathologically. Three types of morphologic injury were encountered, suggesting that disuse, denervation, and ischemia may each be partially responsible for damage in skeletal muscle subjected to venous insufficiency and hypertension. Skeletal muscle injury probably explains the preoperative elevations of serum creatine kinase levels in many of our patients and may account for the failure of venous pressures to return to normal levels following surgery. ( Arch Surg 1984;119:929-931)