Moving forward with elective vascular work: a reflection on the impact of COVID-19 on a regional vascular hub.

INTRODUCTION: Following the initial COVID-19 surge in the UK, there was a national incentive for elective vascular surgery to be restricted to 'clean' sites to reduce perioperative cross-infection and subsequent mortality. We assessed the risk of dying from perioperatively acquired COVID-19 during the peak of the London outbreak. METHODS: Forty-three consecutive patients who had vascular (n=48) procedures in March and April 2020 at a regional hub serving five London hospitals were analysed. The patients were screened for COVID-19 in the 30-day postoperative period and the main outcome measure was mortality from COVID-19. A comparison was then made with patients who underwent minimally invasive procedures in our integrated interventional radiology department. Median follow-up was 41 days (interquartile range 8-58) overall. RESULTS: Three patients (7%) in the vascular group (median age 61 years, all diabetic, two male) died from COVID-19, all of whom tested positive postoperatively. Two others became positive but recovered. In comparison, two patients (2%) in the interventional radiology group died from COVID-19; however, one was positive prior to their procedure. CONCLUSION: Only urgent vascular cases should be performed during a COVID-19 surge. However, with growing waiting lists for elective surgery following the pandemic's second wave, further restrictions may not be a viable long-term solution. When prevalence of the disease is lower and if resources allow, resumption of care at 'hot' sites should be considered, if safety measures can be implemented. The advantages of minimally invasive surgery may also reduce risk.

Aortocaval fistula, a potentially favourable complication of abdominal aortic aneurysm rupture in endovascular repair.

Endovascular aneurysm repair is an established treatment for ruptured abdominal aortic aneurysm. Primary aortocaval fistula is an exceedingly rare finding in ruptured abdominal aortic aneurysm, with a reported incidence of less than 1%. The presence of an aortocaval fistula used to be an unexpected finding in open surgical repair which often resulted in massive haemorrhage and caval injury. We present a case of ruptured abdominal aortic aneurysm with an aortocaval fistula that was successfully treated with percutaneous endovascular aneurysm repair under local anaesthesia. Despite a persistent type 2 endoleak the aneurysm sack shrank from 8.4cm to 4.8cm in 12 months. The presence of an aortocaval fistula may have depressurised the aneurysm, resulting in less bleeding retroperitoneally and may have promoted rapid shrinkage of the sac despite the presence of a persistent type 2 endoleak.

Endovenous laser ablation (EVLA) to treat recurrent varicose veins.

OBJECTIVES: This cohort study assesses the effectiveness and safety of endovenous laser ablation (EVLA) in the management of recurrent varicose veins (RVVS). METHOD: 104 limbs (95 patients) undergoing EVLA for RVVS were grouped according to pattern of reflux. For patients with recurrent SFJ/great saphenous vein (GSV) (Group GR) and SPJ/small saphenous vein (SSV) (Group SR) varicosities ablation rates and QoL (Aberdeen Varicose Vein Severity Scores (AVVSS)) were compared with those for age/sex matched patients undergoing EVLA for primary GSV/SSV dependent varicose veins (Groups GP and SP). RESULTS: In patients with RVVS the axial vein was ablated in 102/104 (98%) limbs whilst 2 GSVs (group GR) partially recanalised by 3 months (GSV ablated in 49/51 (96%) limbs versus 50/51 (98%) limbs in GP [p = 0.2]). Improvements in AVVSS at 3 months (median GR: 14.2 (inter-quartile range (IQR) 10.2-18.9) to 3.2(1.2-6.4), p < 0.001; GP: median 15.9(IQR 11.4-22.7) to 3.8(1.1-5.6), p < 0.001, Mann-Whitney u-test) were similar (78% versus 76%, p = 0.23). The SSV was ablated in 24/24 limbs in groups SR and SP and the % improvement in AVVSS was 83% (median 14.4 (IQR 8.2-19.4) to 2.4 (1.9-4.6), p < 0.001, Mann-Whitney u-test) and 84% (median 13.8 (IQR 6.3-17.5) to 2.2 (1.2-5.1), p < 0.001) respectively (p = 0.33). These improvements persisted at 1 year follow-up. A further 29 limbs with isolated anterior accessory great saphenous vein (AAGSV) or segmental GSV/SSV reflux were successfully ablated. Complication rates for primary and RVVS were similar. CONCLUSIONS: EVLA is a safe and effective option for the treatment of RVVS and could be a preferred option for suitable patients.

Influence of warfarin on the success of endovenous laser ablation (EVLA) of the great saphenous vein (GSV).

BACKGROUND: Although warfarin is routinely stopped prior to varicose vein surgery the absence of incisions may make this unnecessary prior to EVLA. Nevertheless continuing therapy may compromise ablation rates resulting in treatment failure. Since EVLA is particularly suitable for older patients with co-morbidities this study investigates whether warfarin influences outcome. METHOD: A prospective observational cohort study was designed to assess ablation rates (1 year, duplex ultrasound), Aberdeen varicose vein symptom severity scores (AVVSS) and patient satisfaction following GSV EVLA in 22 patients ("warfarin group": 12 female, 10 male; 24 limbs) taking warfarin and 24 age/sex and disease-severity matched controls who were not taking anticoagulants ("no-warfarin group"). RESULTS: Complete ablation of the treated-length of GSV was achieved in 20/24 (83%) limbs in the "warfarin group" versus 23/24 (96%) in the "no-warfarin" group (p=0.347, chi squared). Suboptimal energy densities were delivered to 3/4 failures in the "warfarin group". A similar, significant (p<0.001, Wilcoxon) improvement in AVVSS occurred in both groups [warfarin: median 14.6 (inter-quartile range 8.9-19.1) to 3.8 (1.9-6.2), no-warfarin: median 13.9 (IQR 7.6-20.1) to 3.5 (2.2-6.4)]. Patients were equally satisfied with outcomes (warfarin=92%, no-warfarin=90%; p=0.391, Mann-Whitney). No major complications occurred. CONCLUSIONS: EVLA in patients taking warfarin is safe and effective. Since cessation of therapy is unnecessary it should provide a valuable alternative to surgery in these patients.

Neovascularisation and recurrence 2 years after varicose vein treatment for sapheno-femoral and great saphenous vein reflux: a comparison of surgery and endovenous laser ablation.

OBJECTIVE: Neovascularisation is a major cause of recurrent varicosities following surgery. This prospective cohort study compares recurrence rates and the occurrence of neovascularisation following surgery or endovenous laser ablation (EVLA) for great saphenous vein reflux. METHOD: 118 consecutive patients (72 female, 46 male, median age 48 [range 32-68 years]), 129 limbs were reviewed at a median of 24 months (range 18-30) after surgery (n=60 limbs) or EVLA (n=69 limbs) for primary sapheno-femoral and GSV reflux. Varicose vein recurrence, ultrasound detected groin neovascularisation and patient satisfaction (visual analogue scale) were recorded. RESULTS: Recurrence rates at 2 years were: surgery group 4/60 (6.6%; mid-thigh perforator n=2, residual GSV with neovascularisation n=2), EVLA group 5/69 (7%; GSV recanalisation n=3 (all received <50 J/cm laser energy), mid-thigh perforator n=1, new anterior saphenous vein reflux n=1) p=0.631. Neovascularisation was detected in 11/60 (18%) of the surgery group and 1/69 (1%) of the EVLA group, p=0.001. Patient satisfaction rates were 90% and 88% respectively (p=0.37). CONCLUSIONS: Although the frequency of recurrent varicosities 2 years after surgery and EVLA was similar, neovascularisation, a predictor of future recurrence, was less common following EVLA. Further, current recommendations on delivering > or =70 J/cm laser energy should reduce recanalisation rates and recurrence after EVLA.

Arterio-venous fistula following endovenous laser ablation for varicose veins.

Endovenous laser ablation (EVLA) obliterates incompetent truncal veins as an alternative to varicose veins surgery. We describe 3 patients who developed an arterio-venous fistula (AVF) following great (GSV: 1) or small (SSV: 2) saphenous vein EVLA. Two fistulae closed spontaneously with conservative management. Concomitant venous and arterial wall thermal injury or needle trauma during administration of tumescent anaesthesia may cause this rare complication. Haemodynamic effects appear minimal and spontaneous closure is likely, supporting a non-interventional policy.

Endovenous laser ablation (EVLA) of the anterior accessory great saphenous vein (AAGSV): abolition of sapheno-femoral reflux with preservation of the great saphenous vein.

AIM: During surgery for sapheno-femoral junction (SFJ) and anterior accessory great saphenous vein (AAGSV) reflux, many surgeons also strip the great saphenous vein (GSV). This study assesses the short-term efficacy (abolition of reflux on Duplex ultrasound) of endovenous laser ablation (EVLA) of the AAGSV with preservation of a competent GSV in the treatment of varicose veins occurring due to isolated AAGSV incompetence. METHOD: Thirty-three patients (21 women and 12 men) undergoing AAGSV EVLA alone (group A) and 33 age/sex-matched controls undergoing GSV EVLA (Group B) were studied. Comparisons included ultrasound assessment of SFJ competence, successful axial vein ablation, Aberdeen Varicose Vein Symptom Severity Scores (AVVSS) and a visual analogue patient-satisfaction scale. RESULTS: At the 1-year follow-up, EVLA had successfully abolished the target vein reflux (AAGSV: median length 19 cm (inter-quartile range, IQR: 14-24 cm) vs. GSV: 32 cm (IQR 24-42 cm)) and had restored SFJ competence in all patients. Twenty of the 33 patients (61%) in group A and 14 of the 33 (42%) in group B (p=0.218) required post-ablation sclerotherapy at 6 weeks post-procedure for residual varicosities. The AVVSS at 12 months follow-up had improved from the pre-treatment scores in both the groups (group A: median score 4.1 (IQR 2.1-5.2) vs. 11.6 (IQR: 6.9-15.1) p<0.001; group B: median score 3.3 (IQR 1.1-4.5) vs. 14.5 (IQR 7.6-20.2), p<0.001), with no significant difference between the groups. Patient-satisfaction scores were similar (group A: 84% and group B: 90%). Previous intervention in group A included GSV EVLA (n=3) or stripping (n=9). Thus, the GSV was preserved in 21 patients. The AVVSS also improved in this subgroup (4.4 (2.0-5.4) vs. 11.4 (6.0-14.1), p<0.001) and SFJ/GSV competence was found to be restored at the 1-year follow-up. CONCLUSIONS: AAGSV EVLA abolishes SFJ reflux, improves symptom scores and is, therefore, suitable for treating varicose veins associated with AAGSV reflux.

The clinical significance of below-knee great saphenous vein reflux following endovenous laser ablation of above-knee great saphenous vein.

AIMS: The standard technique for endovenous laser ablation (EVLA) for varicose veins due to great saphenous vein (GSV) reflux involves obliteration of the above-knee (AK) GSV. This study assesses the significance of persistent below-knee (BK) GSV reflux following such therapy. METHODS: Sixty-nine limbs (64 patients) with varicosities and GSV reflux underwent AK-EVLA. Post treatment, GSV reflux (ultrasound: six, 12 weeks) and Aberdeen varicose vein severity scores (AVVSS, 12 weeks) were assessed, and residual varicosities treated with foam sclerotherapy (six weeks). RESULTS: The untreated BK-GSV remained patent in all limbs. Ultrasound showed normal antegrade flow in 34/69 (49%, Group A), flash reflux<1 s in 7/69 (10%, Group B) and >1 s reflux in 28/69 (41%, Group C). Although AVVSS improved in all groups (P<0.001): A: 14.6 (8.4-19.3) versus 2.8 (0.5-4.4), B: 13.9 (7.5-20.1) versus 3.7 (2.1-6.8), C: 15.1 (8.9-22.5) versus 8.1 (5.3-12.6) the improvement was less in Group C (P<0.001 versus A and B) and was associated with a greater requirement (A: 4/34 [12%]; B: 1/7 [14%]; C: 25/28 [89%]) for sclerotherapy (persisting varicosities) (P<0.001). CONCLUSION: Although AK-GSV EVLA improves symptoms regardless of persisting BK reflux, the latter appears responsible for residual symptoms and a greater need for sclerotherapy for residual varicosities.

Fate of the great saphenous vein following endovenous laser ablation: does re-canalisation mean recurrence?

OBJECTIVE: To assess changes in great saphenous vein (GSV) diameter and the significance of re-canalisation following endovenous laser ablation (EVLA). DESIGN: Prospective cohort study. METHODS: Two groups were studied. Group A: 73 consecutive patients (84 GSVs) underwent EVLA followed by duplex ultrasound at 6, 12 and 52 weeks. Vein diameter and patency were recorded. Group B: From a prospectively maintained database 27 patients with a GSV that was found to have recanalised 6-12 weeks post-EVLA were identified and rescanned at 52 weeks. Pre- and post-treatment Aberdeen varicose vein severity scores (AVVSS) were measured. RESULTS: Group A: 81/84 (96%) GSVs were ablated and 3/84 (4%) had re-canalised (flash reflux <1s). GSV diameter diminished with time: pre-EVLA: mean diameter 7.7 S.D .2.0mm; 6 weeks: 5.1 S.D. 1.3mm; 12 weeks: 3.2 S.D. 1.2; 52 weeks: 85% non-visible (p<0.001). Group B: 3/27 (11%) with reflux >1s underwent repeat EVLA. 16/27 (59%) remained competent at 52 weeks and 8/27 (30%) showed trickle reflux. Vein diameter decreased in both subgroups (mean diameter 7.3 S.D. 2.5mm to 3.1 S.D. 0.8mm (p=0.006) and 7.2 S.D. 2.3mm to 3.0 S.D. 0.7mm (p=0.009) respectively) as did the AVVSS (p<0.001). CONCLUSIONS: Successful EVLA causes GSV shrinkage with transition from a non-compressible "thrombosed" vein to a non-visible vein by 1 year. A re-canalised GSV usually remains small with no/minimal reflux and persisting clinical benefit.

Randomized clinical trial comparing endovenous laser ablation with surgery for the treatment of primary great saphenous varicose veins.

BACKGROUND: Endovenous laser ablation (EVLA) is a minimally invasive technique for treating varicose veins due to truncal vein incompetence. This randomized trial compared EVLA with conventional surgery in patients with primary saphenofemoral and great saphenous vein (GSV) reflux. METHODS: Consecutive consenting patients with symptomatic varicose veins were randomized to EVLA 1 (stepwise laser withdrawal), EVLA 2 (continuous laser withdrawal) or surgery (saphenofemoral ligation, GSV stripping, multiple phlebectomies). Principal outcome measures were abolition of GSV reflux and improvement in Aberdeen Varicose Vein Symptom Score (AVVSS) 3 months after treatment. RESULTS: GSV reflux was abolished in 41 of 42 legs treated with EVLA 1, 26 of 29 following EVLA 2 and 28 of 32 after surgery (P = 0.227). The median (interquartile range, i.q.r.) AVVSS improvement was similar: 9.38 (4.54-14.93) with EVLA 1, 10.26 (5.03-15.03) after EVLA 2 and 8.36 (4.54-13.21) following surgery (P = 0.694). Return to normal activity (median (i.q.r.) 2 (0-7) versus 7 (2-26) days; P = 0.001) and work (4 (2-7) versus 17 (7.25-33.25) days; P = 0.005) was quicker after EVLA by either method. CONCLUSION: Abolition of reflux and improvement in disease-specific quality of life was comparable following both EVLA and surgery. The earlier return to normal activity following EVLA may confer important socioeconomic advantages. REGISTRATION NUMBER: ISRCTN99270116 (http://www.controlled-trials.com).

Factors influencing the effectiveness of endovenous laser ablation (EVLA) in the treatment of great saphenous vein reflux.

OBJECTIVE: Endovenous laser ablation (EVLA) is an alternative to surgery for treating sapheno-femoral and great saphenous vein (GSV) reflux. This study assesses factors that might influence its effectiveness. DESIGN: Prospective, observational study. METHOD: EVLA was used to treat the great saphenous vein in 644 limbs as part of the management of varicose veins. Body mass index (BMI), maximum GSV diameter, length of vein treated, total laser energy (TLE) and energy density (ED: Joules/cm) delivered were recorded prospectively. Data from limbs with ultrasound confirmed GSV occlusion at 3-months were compared with those where the GSV was partially occluded or patent. Complications were recorded prospectively. RESULTS: GSV occlusion was achieved in 599/644 (93%) limbs (group A). In 45 limbs (group B) the vein was partially occluded (n=19) or patent (n=26). Neither BMI [group A: 25.2 (23.0-28.5); group B: 25.1 (24.3-26.2)], nor GSV diameter [A: 7.2mm (5.6-9.2); B: 6.9 mm (5.5-7.7)] influenced success. TLE and ED were greater p<0.01) in group A (median [inter-quartile range]: 1877J (997-2350), 48 (37-59)J/cm) compared to group B (1191J (1032-1406), 37 (30-46)J/cm). Although TLE reflects the greater length of GSV ablated in Group A (33 cm v 29 cm, p=0.06) this does not influence ED. GSV occlusion always occurred when ED>/=60 J/cm with no increase in complications. CONCLUSIONS: ED (J/cm) of laser delivery is the main determinant of successful GSV ablation following EVLA.

Angioleiomyoma of the small intestine - a rare cause of gastrointestinal bleeding.

BACKGROUND: Benign tumors are a rare cause of gastrointestinal hemorrhage of which angioleiomyomas constitute a very small minority. They have been reported in literature to present with volvulus, bleeding or intussusceptions. CASE PRESENTATION: An interesting case of a patient presenting with gastrointestinal bleeding from an underlying angioleiomyoma is discussed along with its management options. CONCLUSION: Angioleiomyoma though rare can be managed successfully by surgical and/or minimally invasive endovascular procedures.

Fate and clinical significance of saphenofemoral junction tributaries following endovenous laser ablation of great saphenous vein.

BACKGROUND: Unlike surgery, endovenous laser ablation (EVLA) abolishes great saphenous vein (GSV) reflux but does not specifically interrupt the GSV tributaries at the groin. The fate and clinical significance of these tributaries were assessed in a prospective study. METHODS: Eight-one legs (70 patients) underwent colour flow duplex ultrasonography 12 months after GSV ablation for primary varicose veins. Saphenofemoral junction (SFJ) reflux, tributary patency, and recurrent or residual varicosities were recorded, and Aberdeen Varicose Vein Severity Scores (AVVSS) were compared with pretreatment values. RESULTS: The GSV had recanalized without evidence of reflux in two patients. None of the 81 legs showed SFJ reflux although one or more patent tributaries were visible in 48 (59 per cent); all were competent. In 32 legs (40 per cent) there was flush GSV occlusion with the SFJ and no tributaries were detectable. One leg showed evidence of neovascularization in the groin. AVVSS values were similar in groups with or without visible tributaries, both before and after EVLA: median (interquartile range) 13.9 (7.6-19.2) before EVLA and 2.9 (0.6-4.8) at follow-up in patients with visible tributaries, and 14.9 (9.2-20.2) and 3.1 (0.8-5.1) respectively in those without. Recurrent varicosities were present in one leg only, due to an incompetent mid-thigh perforating vein. CONCLUSION: Persistent non-refluxing GSV tributaries at the SFJ did not appear to have an adverse impact on clinical outcome 1 year after successful EVLA of the GSV.

Endovenous laser ablation (EVLA) of great saphenous vein to abolish "paradoxical reflux" in the Giacomini vein: a short report.

INTRODUCTION: Reflux in the GSV due to sapheno-popliteal incompetence associated with ascending (paradoxical) reflux in the Giacomini vein is a rare but well described pattern of reflux. Treatment of this type of reflux is controversial and only surgical treatment has been described. REPORT: We describe 2 patients in whom this type of reflux was successfully abolished following endovenous laser ablation (EVLA) of the GSV with the SPJ and Giacomini vein regaining competency. DISCUSSION: Paradoxical reflux in the Giacomini vein and SPJ is secondary to GSV incompetence which exerts a syphon effect. EVLA of the refluxing segment of GSV interrupts this effect and prevents the paradoxical reflux at the SPJ.

Initial experience in endovenous laser ablation (EVLA) of varicose veins due to small saphenous vein reflux.

OBJECTIVE: Conventional surgery for varicose veins due to small saphenous reflux is associated with high recurrence rates (up to 50%), many resulting from inadequate surgery. This prospective audit examines the safety and efficacy of EVLA in the treatment of this. METHOD: 65 patients (68 limbs) with varicosities due to primary or recurrent sapheno-popliteal junction (SPJ) and small saphenous vein (SSV) reflux underwent out-patient EVLA (810 nm diode laser). The SSV was ablated from mid-calf to the SPJ. Symptomatic improvement (Aberdeen Varicose Vein Severity Score [AVVSS]), time to return to normal activity, post-EVLA analgesic requirements, and complications were recorded. RESULTS: Duplex ultrasound follow-up (median 6-months) confirmed abolition of SPJ/SSV reflux in all limbs following a median total laser energy delivery of 1131J (IQR 928-1364) at an energy density of 66.3 Joules/cm (IQR 54.2-71.6). AVVSS improved from 15.4 (IQR 11.8-19.7) to 4.6 (IQR 3.2-6.7) at three months (p<0.001). Median analgesia requirement was 3 days (23% [15/65] patients required none) and the median time to normal activity was 0 (0-4) days (65% [42/65] returning to normal daily activity immediately). There were no instances of skin burns or DVT but 3 patients (4.4%) developed transient cutaneous numbness (sural nerve). 98% (64/65) patients would undergo EVLT again. CONCLUSIONS: EVLA abolished SPJ/SSV reflux in all limbs. This is likely to be more effective than conventional surgery, although long-term follow up is required. Data from a randomised control trial would be desirable.