Abstract
Diverse management of isolated calf deep venous thrombosis in a university hospital
R Garcia, K Probeck, DM Elitharp, et al.
J Vasc Surg Venous Lymphat Disord 2018; 6: 139–145.
The aim of this study was to describe the management of isolated calf deep venous thrombosis (ICDVT) in a university hospital. All patients had an objective diagnosis of acute ICDVT with duplex ultrasound (DU) and were prospectively entered in a database. A retrospective analysis was performed from July 2015 to June 2016. Patients with proximal DVT were excluded. The management of the patients was assessed for use of different types of anticoagulation, use of sequential compression devices, serial follow-up with ultrasound, or any combination. Patients’ demographic information, risk factors, calf DVT anatomic location, DVT extension into calf deep veins, DVT propagation to proximal deep veins, and pulmonary embolism were collected as well. There were 159 patients diagnosed with ICDVT in one year, of whom 52% were female with a mean age of 59 years. Nearly half of the patients were smokers (48%), 62% had limited or no mobility, 36% had surgery within the past 30 days, and 23% were considered readmissions. Anticoagulation was given to 121 patients who received seven different types of treatment varying from prophylactic dosing to thrombin inhibitors. In the rest of the 38 patients, 28 had a contraindication to anticoagulation and two had an inferior vena cava filter placed. Eighty-six patients had one DU follow-up study, 39 patients had two follow-up studies, and 21 had three follow-up studies. In the 86 patients with one DU study, 7 propagated within the calf (8.1%) and 2 to the proximal veins (2.3%). Two patients developed nonfatal pulmonary embolism (1.2%). Sequential compression devices were applied in 75 patients despite that the majority were receiving anticoagulation and having serial DU examinations. In conclusion, significant variation in the management of ICDVT was found on the basis of the physician’s preference. The type of treatment overall did not follow a plan based on the patient’s risk. Such an approach may increase the cost in the management of these patients without ensuring benefit.
Venous hemodynamics assessed with air plethysmography in legs with lymphedema
K Suehiro, N Morikage, K Ueda, et al.
Vasc Med 2018; Epub ahead of print, doi: 10.1177/1358863X17745372.
The authors investigated whether there would be any hemodynamic differences from air plethysmography in legs with lymphedema. Thirty-one patients with unilateral leg lymphedema were compared with 53 patients with unilateral great saphenous vein reflux and 15 normal subjects. The venous filling index in legs with lymphedema (2.1 ± 1.2 mL/s) was smaller than in legs with great saphenous vein reflux (6.4 ± 4.1 mL/s, p < 0.05) but was not different from that in normal legs (1.9 ± 1.2 mL/s). The ejection fraction was similar in all groups. The residual volume fraction in legs with lymphedema (35 ± 32%) was larger than that in normal subjects (13 ± 23%, p < 0.05) but was not significantly different from that in the contralateral leg of the lymphedema patients (32 ± 27%). The authors concluded that there were no specific differences with air plethysmography findings in uncomplicated lymphedema.
Clinical correlation of success and acute thrombotic complications of lower extremity endovenous thermal ablation
Aurshina A, Ascher E, Victory J, et al.
J Vasc Surg Venous Lymphat Disord 2018; 6: 25–30.
The authors in this study examined the treatment of venous insufficiency with radiofrequency (RFA) and endovenous laser ablation (EVLA) of great saphenous, small saphenous, accessory veins, and perforator veins to identify clinical and demographic predictors of both the early success and thrombotic complications of these treatments. Over a two-year period, 2012–2014, a retrospective analysis was performed to study the efficacy and complications. Of note, perforator veins were treated only with RFA. Obliteration of the target vein was defined as a success. A complication was defined as thrombosis of any vein proximal to the target vein or acute thrombosis of any tributaries. A total of 1811 procedures were included with an average of 2.4 procedures per patient. Excluding the perforator veins, the success rate of RFA was 98.4%, equivalent to EVLA at 98.1% (P = .66). The success rates of thermal ablation for each vein were as follows: GSV, 98.5%; SSV, 98.2%; ASV, 97.2%; and PVs, 82.4%. The overall thrombotic complication rate was 10.5%. The thrombotic complications include endovenous heat-induced thrombosis (EHIT, 5.9; EHIT2-4, 1.16%) and acute superficial venous thrombosis (4.6%). The rate of a thrombotic complication for each vein was as follows: GSV, 11.8%; SSV, 5.5%; ASV, 6.5%; and PVs, 2.4%. The thrombotic complication rate was 7.7% for RFA and 11.4% for EVLA (P = .007). Age, gender, laterality, presenting symptoms (based on clinical, etiology, anatomy, and pathophysiology class), and vein type and diameter have no effect on successful ablation. Increased vein diameter (P < .001) and type of vein (P < .0001) were significant predictors of acute thrombotic complications; however, on multivariable analysis, only vein type was an independent, statistically significant predictor when nested for within-person correlation. The authors concluded that there were no statistical difference in efficacy rates between RFA and EVLA. The type of procedure (EVLA), larger vein diameters, and treatment of the GSV were associated with a greater thrombotic complication rate, but vein type was the most significant independent predictor.
Endovascular recanalization for nonmalignant obstruction of the inferior vena cava
Y Erben, H Bjarnason, GL Oladottir, et al.
J Vasc Surg Venous Lymphat Disord 2018; 6: 173–182.
The aim of this study was to evaluate outcomes of endovascular recanalization of the inferior vena cava (IVC) and iliac veins with long-standing chronic venous obstruction caused by nonmalignant disease. Medical records for 66 patients who underwent endovascular recanalization of the IVC with or without iliac veins from January 2001 to December 2014 at our medical center were retrospectively reviewed. Primary outcomes included morbidity and mortality; secondary outcomes included primary, primary assisted, and secondary patency and resolution of symptoms. Forty-five (68%) patients were male; the mean age was 43 years (range: 17–83 years). All but one patient had chronic symptoms (mean duration: 8 ± 9 years). Clinical, etiology, anatomy, and pathophysiology classes included 3, 4 a, 4 b, 5, and 6 in 41, 2, 1, 2, and 20 patients, respectively. Mean venous clinical severity score was 12.4 ± 6.5). Fifty-nine patients (89%) had history of deep venous thrombosis, and 13 also had pulmonary embolism. Twenty-five patients (38%) had an IVC filter, and 20 (30%) had thrombophilia. The obstruction involved the infrarenal IVC in 44 patients and both the infrarenal and suprarenal IVC in 22 patients. All recanalizations were performed under conscious sedation and local anesthesia and involved sequential angioplasty and stent placement into the IVC, with or without iliac vein stenting. Venous access included bilateral femoral veins and right internal jugular vein. Stents used were Wallstents (Boston Scientific, Marlborough, Mass; n ¼ 70), Protegé stents (ev3, Plymouth, Minn; n ¼ 49), Gianturco (Cook Medical, Bloomington, Ind; n ¼ 44), and Luminexx (Bard, Tempe, Ariz; n ¼ 1). Pressure gradients were 6.7 ± 4.0 mm Hg before and 0.9 ± 1.1 mm Hg after stenting (P < .001). Procedural success was 90% and 100% at first and second attempt at recanalization, respectively. There was no mortality or clinically significant pulmonary embolism. Four patients had five complications: two developed an arteriovenous fistula, one patient developed groin hematoma that required open evacuation, and one had peri-IVC hematoma and femoral vein thrombosis that required repeated angioplasty and stenting; 93% of patients received long-term anticoagulation. Follow-up was 42 ± 36 months. Four patients were lost to follow-up. Primary patency, primary assisted patency, and secondary patency at 36 months were 78%, 87%, and 91%, respectively. Symptoms resolved in 83% of patients. On multivariable regression analysis, hypercoagulable state was the only predictor of reocclusion of the recanalized veins. The investigators concluded that endovascular recanalization for nonmalignant symptomatic IVC and associated iliofemoral venous obstruction with balloon angioplasty and self-expanding stents is technically challenging; however, it is safe and durable. In this retrospective study, estimated patency rates at 36 months were > 85%, and clinical outcomes were excellent. Venous stenting should be attempted for chronic nonmalignant IVC and associated iliac or iliofemoral venous obstructions before open surgical reconstruction is contemplated.
Evaluation of endovenous laser ablation for varicose veins using a computer simulation model
H Hazama, M Yoshimori, N Honda, et al.
Laser Ther 2017; 26: 282–287. doi: 10.5978/islsm.17-RE-03.
The present study was designed to compare endovenous laser ablation (EVLA) delivered through two specific fiber types coupled with a near-IR laser wavelength where water was the major chromophore. A laser diode system at the wavelength of 1470 nm was used as the laser energy source near a peak in the water absorption spectrum. Laser energy was delivered with two specific types of optical fiber, a Radial™ fiber and a Radial 2ring™ fiber (CeramOptec, Germany), and EVLA was evaluated using a computer simulation model taking light transport into account based on the Monte Carlo method and temperature distribution with the heat conduction equation. It was confirmed from both the simulation model and a previously published ex vivo experiment that carbonization and sticking during EVLA caused by excess temperature rise can be minimized by using the Radial 2ring fiber compared with the Radial fiber, coupled with the 1470 nm wavelength. In the future, lasers with different wavelengths or optical fibers with differing irradiation modes may appear as candidate systems for EVLA. It is important to evaluate safety and efficacy carefully using the methods in the present study before moving to in vivo indications in human subjects.
Systematic review and meta-analysis of endovascular and surgical revascularization for patients with chronic lower extremity venous insufficiency and varicose veins
S Vemulapalli, K Parikh, R Coeytaux, et al.
Am Heart J 2018; 196: 131–143.
Chronic venous disease (CVD) is twice as prevalent as coronary heart disease. In 2015, invasive therapies accounted for an estimated $290 million in Medicare expenditures. The authors conducted a systematic review to see if they could determine the comparative effectiveness for treatments in patients (symptomatic and asymptomatic) with lower extremity varicosities and/or lower extremity chronic venous insufficiency. The authors searched PubMed, Embase, and the Cochrane Database of Systematic Reviews for pertinent English-language studies published from January 2000 to July 2016. Included were comparative randomized controlled trials (RCTs) with > 20 patients and observational studies with > 500 patients. Short, intermediate, and long-term outcomes of placebo, mechanical compression therapy, and invasive therapies (surgical and endovascular) were included. Quality ratings and evidence grading were performed. Random-effects models were used to compute summary estimates of effects. Fifty-seven studies were identified representing 105,878 enrolled patients, including 53 RCTs comprising 10,034 patients. Among the RCTs, 16 were good quality, 28 were fair quality, and 9 were poor quality. Allocation concealment, double blinding, and reporting bias were inadequately addressed in 25 of 53 (47%), 46 of 53 (87%), and 15 of 53 (28.3%), respectively. Heterogeneity in therapies, populations, and/or outcomes prohibited meta-analysis of comparisons between different endovascular therapies and between endovascular intervention and placebo/compression. Meta-analysis evaluating venous stripping plus ligation compared with radiofrequency ablation revealed no difference in short-term bleeding (P = .43) or reflux recurrence at one to two years (P = .44). Meta-analysis evaluating high ligation/stripping versus endovascular laser ablation revealed no difference in long-term symptom score (P = .84) or quality of life at two years (P = .50). The authors concluded that the lack of high-quality comparative effectiveness and safety data in CVD is concerning given the overall rise in endovascular procedures. More high-quality studies are needed to determine comparative effectiveness and guide policy and practice.
Day surgery versus outpatient setting for endovenous laser ablation treatment. A prospective cohort study
G Varetto, L Gibello, E Frola, et al.
Int J Surg 2018; 51: 180–183.
The authors, in this study, evaluated the day surgery activity vs. the outpatient surgery activity of a single center. Of 112 consecutive patients who underwent endovenous laser ablation for great saphenous venous ablation, 57 operations (51%) were performed in day surgery, while 55 (49%) were performed in outpatient setting according to endovascular laser ablation's criteria. Post-operative results (success and complication rates, patient’s functional and aesthetic satisfaction) were evaluated at 7 and 30 days after intervention. CIVIQ score was obtained 30 days after the event. There was no statistically significant difference between the two groups regarding efficacy or complications. However, the quality of life assessment was better for patients over the age of 65 in the outpatient setting (p = .05). The authors concluded that venous laser ablation technique is safe and effective in the outpatient setting, thus reducing costs of treatment.
Systematic review and meta-analysis of endovascular and surgical revascularization for patients with chronic lower extremity venous insufficiency and varicose veins
S Vemulapalli, K Parikh, R Coeytaux, et al.
Am Heart J 2018; 196: 131–143. doi: 10.1016/j.ahj.2017.09.017.
The authors conducted a systematic review and meta-analysis of treatments for patients (symptomatic and asymptomatic) with lower extremity varicosities and/or lower extremity chronic venous insufficiency/incompetence/reflux. They searched PubMed, Embase, and the Cochrane Database of Systematic Reviews for relevant English-language studies published from January 2000 to July 2016. They included comparative randomized controlled trials (RCTs) with > 20 patients and observational studies with > 500 patients. Short-, intermediate-, and long-term outcomes of placebo, mechanical compression therapy, and invasive therapies (surgical and endovascular) were included. Quality ratings and evidence grading was performed. Random-effects models were used to compute summary estimates of effects. They identified a total of 57 studies representing 105,878 enrolled patients, including 53 RCTs comprising 10,034 patients. Among the RCTs, 16 were good quality, 28 were fair quality, and 9 were poor quality. Allocation concealment, double blinding, and reporting bias were inadequately addressed in 25 of 53 (47%), 46 of 53 (87%), and 15 of 53 (28.3%), respectively. Heterogeneity in therapies, populations, and/or outcomes prohibited meta-analysis of comparisons between different endovascular therapies and between endovascular intervention and placebo/compression. Meta-analysis evaluating venous stripping plus ligation (high ligation/stripping) compared with radiofrequency ablation revealed no difference in short-term bleeding (odds ratio (OR) = 0.30, 95% CI−0.16 to 5.38, P = .43) or reflux recurrence at 1–2 years (OR = 0.76, 95% CI 0.37–1.55, P = .44). Meta-analysis evaluating high ligation/stripping versus endovascular laser ablation revealed no difference in long-term symptom score (OR 0.02, 95% CI −0.19 to 0.23, P = .84) or quality of life at two years (OR 0.06, 95% CI −0.12 to 0.25, P = .50). The paucity of high-quality comparative effectiveness and safety data in chronic venous disease is concerning given the overall rise in endovascular procedures. More high-quality studies are needed to determine comparative effectiveness and guide policy and practice.