Clinical results and cost-effectiveness of radiofrequency and cyanoacrylate ablation compared with traditional surgical stripping for treating varicose veins.

BACKGROUND: Disease of the venous system is an underappreciated public health problem. Minimally invasive treatments such as radiofrequency ablation (RFA) or cyanoacrylate adhesive ablation (CAA) have almost entirely replaced surgical stripping (SS) of the great and small saphenous veins. The purpose of the present study was to compare the outcomes at 3 years after SS, RFA, and CAA by assessing the incidence of complications and reinterventions and performing a cost-effectiveness analysis. METHODS: From February 2016 to February 2019, all consecutive patients with symptomatic varicose veins treated at vascular department of two hospitals using SS, RFA, or CAA were included in the present study. The clinical outcomes were measured by quality-adjusted life years (QALYs), complications, and reintervention. A comparison with conservative treatment was also performed. A detailed resource use was recorded for each procedure. All costs were normalized to May 2020 U.S. dollars and euros. Analysis of the data was by the treatment received. All statistical tests were two-sided, and the significance level was set at 5%. Two perspectives of the analysis were considered: the social perspective and that of the Spanish Public Health System. The study period was 3 years. No discount rate was applied. RESULTS: A total of 233 patients were enrolled in the present study: SS, n = 90 (38.6%); RFA, 93 (39.9%); and CAA, n = 50 (21.5%). The number of complications was 11 (12.2%), 3 (3.3%), and 3 (6%) in the SS, RFA, and CAA groups, respectively (P = .06). No patient had required reintervention. The median loss of workdays for the SS, RFA, and CAA group was 15 days (interquartile range [IQR], 10-30 days), 0 days (IQR, 0-6 days), and 0 days (IQR, 0-1 days), respectively (P < .001). The median level of satisfaction for the SS, RFA, and CAA group was 9 (IQR, 8-10), 10 (IQR, 9-10), and 10 (IQR, 9-10), respectively (P < .001). The QALYs was 2.6 years for all three procedures. The median overall cost was €852 (US$926) for SS, €1002 (US$1089) for RFA, and €1228.3 (US$1335) for CAA. The total cost per QALY was €323/QALY (US$351/QALY) for SS, €380/QALY (US$413/QALY) for RFA, and €467/QALY (US$508/QALY) for CAA. The indirect costs were measured by the cost of the workdays lost for each patient and were €1527 (US$1660; IQR, €1018-3054); €0 (IQR, €0-611) for RFA, and €0 (IQR, €0-102) for CAA (P < .001). CONCLUSIONS: All three techniques were cost-effective (procedures with an incremental cost-effectiveness ratio <€30,000/QALY can be recommended). From the Spanish Public Health System perspective, when considering only the health care costs, the most cost-effective technique was SS. From the social perspective, including the opportunity costs of medical leave, CAA was the most cost-effective technique, saving €1600 per patient, a cost that more than compensated for the savings realized from using SS in direct health care costs.

Cost-effectiveness of Carotid Surgery.

BACKGROUND: The purpose of this study is to determinate the cost-effectiveness of carotid endarterectomy (CEA) versus transfemoral stenting (TFS) and transcervical stenting (TCS) in a short- and long-term basis in symptomatic and asymptomatic patients. METHODS: From January 2003 to December 2014, patients from the vascular department, with symptomatic or asymptomatic carotid stenosis, who were clinically and anatomically suitable for TFS, TCS, or CEA, were included. Prospective cost data for each individual procedure and complication during follow-up were obtained from the diagnosis-related group. The quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios were estimated. Analysis of data was by treatment received. All statistical tests were two-sided. The significance level was 5%. RESULTS: A total of 349 patients were enrolled: 61 for CEA (17.5%), 159 for TFS (45.5%), and 129 for TCS (37%). A total of 220 (63%) patients were symptomatic and 129 (37%) were asymptomatic. The median procedural cost and overall cost were lower on CEA (5499€ and 5595€, respectively). However, QALYs, for symptomatic patients, were better on TCS (7.3), whereas for asymptomatic patients, QALYs were better on CEA (9.6). Cost-effectiveness for symptomatic patients was better with TCS (803€/QALY), and for asymptomatic patients, it was with CEA (654€/QALY). CONCLUSIONS: TFS and TCS were associated with clinical outcomes equivalent to CEA on both symptomatic and asymptomatic patients. Cost-effectiveness ratios for symptomatic patients were better on TCS, whereas the CEA showed the best results in asymptomatic patients.

Leiomyosarcoma of the deep femoral vein. A rare cause of venous obstruction in lower limbs and an alternative diagnosis to chronic venous thrombus.

Primary venous leiomyosarcoma of the extremities is an uncommon, but aggressive, tumoral entity with a high rate of local recurrence and early hematogenous metastasis. In the present article, we report a case of leiomyosarcoma of the vena profunda femoris. This pathology causes deep venous thrombosis-like symptoms. No improvement in lower limb status and a significant and progressive increase in the diameter of the vein as seen using ultrasonography could indicate tumor disease. Particular care must be taken to avoid biopsies due to the possible dissemination. We must complete the medical study with imaging techniques, and the tumor must be removed as soon as possible for histopathological diagnosis. After a follow-up of 12 months, there was no evidence of local or metastatic recurrence in our patient.

Renal embolization and nephrectomy in a single surgical act in high-risk renal tumor pathology.

BACKGROUND: Renal artery embolization is a procedure that has been shown to be useful as a concomitant treatment for the resection of large renal tumors. Over the years, preoperative renal artery embolization concomitant with nephrectomy as a treatment option has proved to be useful in reducing morbi-mortality rates; however this procedure is not exempt from significant iatrogenia. Performing this technique in conjunction with nephrectomy in a single surgical act helps to maintain the advantages of this treatment, which in turn considerably reduces the associated morbi-mortality rates. METHODS: This study presents seven patients selected by the Urology Service in a nonconsecutive manner who underwent renal artery embolization concomitant with nephrectomy in a single surgical procedure for large renal tumors, thus presenting a variation to the usual techniques to improve and simplify the procedure. RESULTS: General data were obtained from all patients including age, gender, characteristics of the tumor, and symptomatology at the time of diagnosis. For all the cases, use of resources was analyzed in terms of duration of surgery, the amount of iodinated contrast medium used during the embolization procedure, and the mean duration of hospital and intensive care unit stay. Complications were evaluated with respect to general morbi-mortality associated with the complete procedure, hematic losses during the procedure, transfusion requirements, and renal function (calculated by measuring preoperative and 48-hour postoperative serum creatinine levels). All patients reported having symptoms at the time of diagnosis, all of them had tumors measuring >13 cm in diameter (major). In all the cases, 100% technical success was obtained with the embolization and nephrectomy. The mean duration of surgery in the case of embolization with coils was 45 minutes, and 25 minutes in the case of embolization with Amplatzer. A mean volume of 115 mL of contrast medium was used in the case of embolization with coils, whereas for the other cases, a mean volume of 71 mL of iodinated contrast was used. Among all the patients, only two of them required to be cared at the intensive care unit during 24 hours. On an average, reported blood loss was 380 mL. During the procedure, two patients (28.6%) required a transfusion of two units of red cells. No cases of perioperative or postoperative mortality were reported. With respect to morbidity, only one patient (14.3%) experienced a complication in the form of a superficial infection of the surgical wound, which was later resolved by antibiotic therapy. One patient (14.3%) presented a slightly higher preintervention level of creatinine (1.42). Two patients (28.6%), both of whom underwent embolization by using coils, experienced deterioration of postoperative renal function. CONCLUSION: Preoperative embolization of the renal artery as a coadjuvant treatment option in high-risk renal neoplasia has clear technical benefits for the subsequent nephrectomy and also medical benefits for the patients. Performing both the procedures concomitantly as a single surgical act seems to retain the advantages of the embolization procedure, by reducing mortality rates and producing little associated morbidity. Technically, embolization with Amplatzer plugs seems to be faster and easier as compared with embolization with coils.

Reliability of preoperative duplex scanning in designing a therapeutic strategy for chronic lower limb ischemia.

The objective of this study was to compare the treatment plan designed on the basis of preoperative duplex scanning evaluation of the critical limb ischemia with the treatment plan finally carried out, after assessing the findings obtained during surgical or endovascular treatment. Over a period of 51 months a preoperative duplex scanning study was carried out in 335 consecutive patients with chronic critical ischemia, to design the best therapeutic strategy. Agreement between both plans were as follows: 80%, 82,7% and 59% in the examinations of the iliac arteries, femoropopliteal or tibial arteries respectively. The operation plan was more frequently modified due to a duplex scanning failure in procedures involving the the distal vessels(10 of 44 [22.7%], p < 0.01). In conclusion, duplex scanning evaluation of patients with occlusive arterial disease of the lower limbs permits the design of both a medical and a surgical or endovascular treatment plan with a high level of agreement with the findings obtained during the revascularization procedure.

Transcervical carotid stenting with carotid artery flow reversal: 3-year follow-up of 103 stents.

OBJECTIVE: This study evaluated the perioperative and 3-year follow-up results of 103 consecutive carotid artery stenting (CAS) procedures done with a transcervical approach using carotid flow reversal for cerebral protection that were performed over a 28-month period in 97 patients. METHODS: The mean age of these patients was 72 years, and 82 (80%) were men. Mean preoperative internal carotid artery (ICA) peak systolic velocity was 314 cm/s, 36% of treated hemispheres were symptomatic, and 42% of patients had neurologic symptoms for >6 months. Ten patients (10%) had contralateral ICA occlusion, six (6%) had recurrent carotid stenosis, and two (2%) had previous neck radiation. Local anesthesia was used in 72 (70%) cases and general in 31 (30%). Predilatation was used in 34 cases (33%), and closed-cell self-expanding stents were deployed and postdilated in all cases. RESULTS: Technical success was achieved in 100 cases (97%). No major strokes or deaths occurred. One ipsilateral transient ischemic attack (1%), one contralateral transient ischemic attack (1%), and two minor strokes (2%) occurred. There were two wound complications (2%) and one major arterial complication (1%). Mean operative time was 69 minutes, and mean carotid flow reversal time was 21 minutes. Three awake patients (4%) did not tolerate carotid flow reversal. Hypotension/bradycardia occurred in 24 cases (23%). No electrocardiographic myocardial infarctions were diagnosed. At 40 months of follow-up, the stent patency rate on an intention-to-treat basis was 95%, and the stroke-free survival was 91%. CONCLUSIONS: Transcervical CAS with carotid flow reversal can be done with a high rate of technical success, a negligible rate of major adverse events, and an excellent 3-year stroke-free survival and stent patency rate. These results compare favorably with those of recently published prospective studies using distal filter protection during CAS.

Screening algorithm for aortoiliac occlusive disease using duplex ultrasonography-acquired velocity spectra from the distal external iliac artery.

Aortoiliac duplex scanning can be difficult to perform owing to the deep location of these vessels. We propose a new method to indirectly screen for aortoiliac disease by performing duplex examination of the distal external iliac artery (DEIA). After performing a preliminary study on 21 patients, the parameters of the Doppler waveform that best distinguish normal from diseased arteries were the presence or absence of reverse flow, peak systolic velocity, and resistance index. These values were used in a derived equation, with the value Y > or = 0.78 predicting normal proximal inflow. We then studied 118 aortoiliac segments in 81 consecutive patients with arteriography and DEIA duplex ultrasonography. To predict moderate to severe stenosis, duplex ultrasonography had a sensitivity of 95.7%, a specificity of 84.1%, a positive predictive value of 80%, and a negative predictive value of 96.8%. Our formula thus predicted significant disease in 55 of the 118 aortoiliac segments (47%), with these segments needing further arteriographic evaluation. The other 63 limbs can be safely considered as having normal aortoiliac inflow. Our method accurately screens for aortoiliac disease and is excellent for predicting normal inflow. This information can be used to better plan the intraoperative diagnostic study and intervention.

Transcervical carotid stenting with internal carotid artery flow reversal: feasibility and preliminary results.

OBJECTIVE: Transfemoral carotid artery stenting (CAS), with or without distal protection, is associated with risk for cerebral and peripheral embolism and access site complications. To establish cerebral protection before crossing the carotid lesion and to avert transfemoral access complications, the present study was undertaken to evaluate a transcervical approach for CAS with carotid flow reversal for cerebral protection. METHODS: Fifty patients underwent CAS through a transcervical approach. All patients with symptoms had greater than 60% internal carotid artery (ICA) stenosis, and all patients without symptoms had greater than 80% ICA stenosis. Twenty-one patients (42%) had symptomatic disease or ipsilateral stroke, and 8 patients (16%) had contralateral stroke. Four patients (8%) had recurrent stenosis, 7 patients (14%) had contralateral ICA occlusion, and 1 patient (2%) had undergone previous neck radiation. Twenty-seven procedures (54%) were performed with local anesthesia, and 23 (46%) with general anesthesia. Using a cervical cutdown, flow was reversed in the ICA by occluding the common carotid artery and establishing a carotid-jugular vein fistula. Pre-dilation was selective, and 8-mm to 10-mm self-expanding stents were deployed and post-dilated with 5-mm to 6-mm balloons in all cases. RESULTS: The procedure was technically successful in all patients, without significant residual stenoses. No strokes or deaths occurred. There was 1 wound complication (2%). All patients were discharged within 2 days of surgery. Mean flow reversal time was 21.4 minutes (range, 9-50 minutes). Carotid flow reversal was not tolerated in 2 patients (4%). Early in the experience, carotid flow reversal was not possible in 1 patient, and there were 1 major and 3 minor common carotid artery dissections, which resolved after stent placement. One intraoperative transient ischemic attack (2%) occurred in 1 patient in whom carotid flow was not reversed, and 1 patient with a contralateral ICA occlusion had a contralateral transient ischemic attack. At 1 to 12 months of follow-up, all patients remained asymptomatic, and all but 1 stent remained patent. CONCLUSION: Transcervical CAS with carotid flow reversal is feasible and safe. It can be done with the patient under local anesthesia, averts the complications of the transfemoral approach, and eliminates the increased complexity and cost of cerebral protection devices. Transcervical CAS is feasible when the transfemoral route is impossible or contraindicated, and may be the procedure of choice in a subset of patients in whom carotid stenting is indicated.

Transcervical carotid artery angioplasty and stenting with carotid flow reversal: surgical technique.

We have performed this technique in 40 patients with carotid artery stenosis. No deaths or strokes have occured. During the initial experience, one patient in whom flow reversal was not properly established sutained an hemispheric transient ischemic attack. Transcervical carotid artery balloon dilatation and stenting is feasible and safe. It establishes reliable cerebral protection before the carotid lesion is instrumented by reversing flow in the internal and external carotid arteries. It can be done under local anesthesia, and it avoids the potential limitations, complications, and additional cost of the transfemoral approach with protection devices.

Carotid angioplasty with internal carotid artery flow reversal is well tolerated in the awake patient.

OBJECTIVE: The purpose of this study was to evaluate the neurologic tolerance and changes in ipsilateral hemispheric oxygen saturation during transcervical carotid artery stenting with internal carotid artery (ICA) flow reversal for embolic protection. PATIENTS AND METHODS: This was a prospective study of 10 patients (mean age 68 years) undergoing transcervical carotid angioplasty and stenting. All ICA stenoses were greater that 70%. Seven patients had an ipsilateral hemispheric stroke (3) or transient ischemic attack (4), two patients had a contralateral stroke, and one patient was asymptomatic. Nine procedures were done under local anesthesia. Cerebral protection was established through a cervical common carotid (CCA) cutdown to create an external fistula between the ICA and the internal jugular vein with temporally CCA occlusion. Venous oxygen saturation (SVO(2)) was continuously monitored through a catheter placed in the distal internal jugular vein. Mental status and motor-sensory changes were categorized and assessed throughout and after the procedure. RESULTS: All procedures were technically successful without significant residual stenosis. Mean ICA flow reversal time was 22 minutes (range, 15 to 32). Common carotid artery (CCA) occlusion produced a slight (SVO(2) = 72.6%+/-9.4) but significant decrease (P =.012) in SVO(2), compared with baseline (SVO(2) = 77% +/-10.5). During ICA flow reversal (SVO(2) = 72.4% +/-10.1) cerebral oxygen saturation did not change compared with CCA occlusion alone (P =.85). Transient balloon occlusion during angioplasty of the ICA (SVO(2) = 64.6%+/-12.9) produced a significant decrease in cerebral SVO(2) compared with CCA occlusion (P =.015) and compared with CCA occlusion with ICA flow reversal (P =.018). No mental status changes or ipsilateral hemispheric focal symptoms occurred during CCA occlusion with ICA flow reversal. One patient with contralateral ICA occlusion sustained brief upper extremity weakness related to the contralateral hemisphere. Five patients sustained a vasovagal response during balloon dilatation, four did not require treatment, and one had asystole requiring atropine injection. Mean SVO(2) saturation was not different in these five patients compared with the five who did not sustain a vasovagal response. No deaths or neurologic deficits occurred within 30 days after the procedure. CONCLUSIONS: Our data suggest that transcervical carotid angioplasty and stenting with ICA flow reversal is well tolerated in the awake patient, even in the presence of symptomatic carotid artery disease. Cerebral oxygenation during ICA flow reversal is comparable to that during CCA occlusion. ICA angioplasty balloon inflation produces a decrease in cerebral SVO(2) significantly greater than that occurring during ICA flow reversal.

Thoracodorsal sympathectomy for severe hyperhydrosis: posterior bilateral versus unilateral staged sympathectomy.

The aim of this study was to compare the results of simultaneous bilateral thoracodorsal sympathectomy in the prone position with those of anterolateral sympathectomy performed in two staged, separate procedures for the treatment of bilateral excessive sweating of the hands and axillae, and to describe our technique for bilateral, simultaneous thoracodorsal sympathectomy. From July 1995 to March 2001, 202 thoracodorsal sympathectomies were done in 101 patients for severe hyperhydrosis. There were 79 females (age range 20-46) and 22 males (age range 19-65). In 52 patients, anterolateral sympathectomies were performed in the supine position, using unilateral lung collapse, with both sides operated on in two separate, staged procedures. In 49 patients, bilateral sympathectomy was conducted during a single procedure, in the prone position, without using unilateral lung collapse. In comparing the results from these two methods, we concluded that simultaneous bilateral thoracodorsal posterior sympathectomy, has comparable safety, may improve outcome, decreases in half the number of hospital admissions, and produces a significant overall reduction in cost when compared with staged anterolateral sympathectomy for the treatment of severe hyperhydrosis.

Conservative hemodynamic surgery for varicose veins.

Conservative hemodynamic surgery for varicose veins is a minimally invasive, nonablative technique that preserves the saphenous vein and helps avoid excision of varicosities. It represents a physiologic approach to the surgical treatment of varicose veins based on knowledge of the underlying venous pathophysiology gained through detailed duplex scanning. A change in venous hemodynamics is attained through fragmentation of the blood column by interruption of the refluxing saphenous trunks, closure of the origin of the refluxing varicose branches, and preservation of the communicating veins that drain the incompetent varicose veins into the deep venous system. After surgery, varicose veins regress through a reduction in hydrostatic pressure and efficient emptying of the superficial system by the musculo-venous pump. Obvious advantages of this technique are that it is done in an ambulatory setting, minimizes the risk of surgical complications, and permits a rapid return to full activity. The long-term hemodynamic improvement and recurrence rate of this technique remain to be established.