Comparative effectiveness of non-compounded polidocanol 1% endovenous microfoam (Varithena) ablation versus endovenous thermal ablation utilizing a systematic review and network meta-analysis.

OBJECTIVE: We compared the effectiveness and safety of polidocanol 1% endovenous microfoam ablation vs endovenous thermal ablation with radiofrequency or laser energy for treatment of venous insufficiency caused by lower extremity truncal vein incompetence via network meta-analysis of published comparative evidence. METHODS: We conducted a systematic literature review following best practices, including a prospective protocol. We screened studies published in English from 2000 to 2023 for randomized and nonrandomized studies reporting direct or indirect comparisons between polidocanol 1% endovenous microfoam and endovenous thermal ablation. Thirteen studies met our eligibility criteria for the network meta-analysis. The co-primary effectiveness outcomes were the closure rate ≥3 months after procedure and the average change in the Venous Clinical Severity Score. For the subgroup of venous ulcer patients, the ulcer healing rate was the primary effectiveness outcome. The secondary outcomes included safety and patient-reported outcomes. Network meta-analyses were conducted on outcomes having sufficient data. Categorical outcomes were summarized using odds ratios (ORs) with 95% confidence intervals (CIs). Sensitivity tests and estimates of network inconsistency were used to investigate the robustness of our meta-analysis. RESULTS: We found that polidocanol 1% endovenous microfoam was not significantly different statistically from endovenous thermal ablation for venous closure (OR, 0.65; 95% CI, 0.36-1.18; P = .16). Although not the primary aim of the study, the network meta-analysis also provided evidence to confirm our supposition that polidocanol 1% endovenous microfoam was significantly differentiated statistically from physician-compounded foam, with higher odds for vein closure (OR, 2.91; 95% CI, 1.58-5.37; P < .01). A sensitivity analysis using the longest available time point for closure in each study, with a minimum of 12 months of follow-up (median, 48 months; range, 12-72 months), showed results similar to those of the main analysis. No association was found between the risk of deep vein thrombosis and the treatment received. The available data were insufficient for a network meta-analysis of Venous Clinical Severity Score improvement and ulcer healing rates. CONCLUSIONS: Polidocanol 1% endovenous microfoam was not significantly different statistically from endovenous thermal ablation for venous closure and deep vein thrombosis risk for chronic venous insufficiency treatment, based on a network meta-analysis of published evidence. Polidocanol 1% endovenous microfoam was significantly differentiated statistically from physician-compounded foam, with higher odds of vein closure. A sensitivity analysis found venous closure findings were robust at follow-up intervals of 12 months or greater and for up to 6 years. New evidence meeting the inclusion criteria for this review will be incorporated at regular intervals into a living network meta-analysis.

Relationship between iliofemoral venous stenting and femoropopliteal deep venous reflux.

OBJECTIVE: Severe presentations of chronic venous insufficiency can result from reflux or obstruction at the deep venous, perforator, or superficial venous levels. Iliofemoral venous stenting can be used to address central venous obstruction; however, its effects on deep venous reflux (DVR) have remained unclear. The purpose of the present study was to evaluate the effects of iliac vein stenting on femoropopliteal DVR with the hypothesis that ultrasound evidence of DVR would remain absent or would have improved after iliac vein stenting. METHODS: The present study was a retrospective review of patients who had undergone iliofemoral venous stenting from 2013 to 2018. The patients were divided into two cohorts according to the preprocedural presence (group A) or absence (group B) of femoropopliteal DVR. Baseline patient variables were collected, including age, gender, CEAP (clinical, etiologic, anatomic, pathophysiologic) class, presence of concomitant superficial or perforator reflux, deep vein thrombosis history, and additional venous interventions. The primary outcome evaluated was the persistent absence or resolution of DVR on the latest venous duplex ultrasound at follow-up. Other outcomes included the follow-up CEAP classification and the need for secondary deep venous interventions. RESULTS: A total of 275 consecutive patients had undergone iliofemoral venous stenting. Of the 275 patients, 58 had presented with DVR (group A). A comparison of groups A and B revealed that group A had had a greater likelihood of prior deep vein thrombosis (P = .0001) and a higher frequency of superficial venous ablation. The remaining demographic variables did not differ significantly between the two groups. Of the 58 patients in group A, DVR had resolved at follow-up in 17 (P = .0001). When stratified by level, 7 of these 17 patients had had isolated popliteal reflux. In group B, DVR had developed at follow-up in 6 of the 217 patients. The CEAP class had improved from before intervention (C0, 1.1%; C1, 0.4%; C2, 1.8%; C3, 41.4%; C4, 24.9%; C5, 5.9%; C6, 24.5%) to the latest follow up (C0, 4.9%; C1, 1.9%; C2, 5.7%; C3, 34.2%; C4, 22.8%; C5, 17.1%; C6, 13.3%). Significant improvement had occurred in C6 disease within both groups (group A, 16 of 58 [27.6%; P = .0078]; group B, 19 of 217 [8.8%; P = .0203]). CONCLUSIONS: For patients who undergo iliofemoral venous stenting, DVR could improve if present initially and is unlikely to develop if not present before stenting. A cohort of patients had experienced persistent DVR and warranted further evaluation. Prospective studies are required to corroborate the safety, efficacy, and durability of iliofemoral venous stenting for patients with DVR.

The presence of a pathologic perforator may be predictive of central venous pathology and multilevel disease in severe chronic venous insufficiency.

OBJECTIVES: The treatment of a refluxing perforator is indicated in the setting of severe chronic venous insufficiency, but there are limited data on the presence of multilevel disease in these patients. This study sought to evaluate whether the presence of a pathologic perforator is predictive of the presence of central venous pathology. METHODS: This study was a retrospective review of the institutional Vascular Quality Initiative database. Consecutive patient limbs were identified that underwent intervention of refluxing perforators. The patients who underwent imaging, including magnetic resonance imaging or computed tomography (group A), were compared with those who did not undergo imaging (group B). The treated limbs in group A were also compared with the contralateral limbs as an internal control. Anatomical findings on imaging were analyzed by two independent investigators. The primary outcome was the presence and degree of central venous stenosis as measured by an orthogonal diameter reduction of >50% by axial imaging. Secondary outcomes included demographic and clinical differences between the two groups, frequency of central venous intervention, and duration of ulcer healing. Standard statistical analysis was performed. RESULTS: Ninety-three patient limbs underwent treatment of a pathologic perforator, with 30 in group A and 63 in group B. The following demographic and clinical variables were higher in group A compared with group B: male sex, body mass index, deep venous thrombosis history, recent or active anticoagulation use, perforator diameter, Clinical Etiology Anatomy Pathophysiology class 4, 5, or 6, and Venous Clinical Severity Score. Radiographic analysis of group A revealed concordance of a treated pathologic perforator with an ipsilateral central venous stenosis in 53.3% of patients, and a higher frequency of common iliac vein stenosis (50% vs 21.4%, P = .024) and external iliac vein stenosis (20% vs 0%, P = .012) compared with the contralateral limbs. When separated by the left or right limb, the left limbs exhibited a greater degree of common iliac vein stenosis as compared with the contralateral limbs (50.7% ± 20.9% vs 16.3% ± 16.5%, P < .001) as well as a greater frequency of >50% common iliac vein stenosis (46.7% vs 13.3%, P = .046). The right limbs exhibited a greater frequency of >50% external iliac vein stenosis as compared with the contralateral limbs (33.3% vs 0%, P = .022). CONCLUSIONS: This study suggests that patients with severe chronic venous insufficiency who undergo treatment for a pathologic perforator may have additional ipsilateral central venous pathology, supporting the presence of multilevel disease. Additional axial imaging might unmask central venous pathology and provide another option for treatment.

Current status of endothermal heat induced thrombosis.

There remain many questions regarding the pathophysiology and risk factors for endothermal heat induced thrombosis formation. Moreover, there are a paucity of data on the timing of its occurrence, and there has been no consensus regarding for its treatment. The purpose of this review was to summarize the current knowledge on the pathophysiology, risk factors and treatment strategies for endothermal heat induced thrombosis. The PubMed database was searched from 2001 to present for endothermal heat induced thrombosis, EHIT, deep vein thrombosis, chronic venous insufficiency, varicose veins, endovenous laser and radiofrequency ablation (treatment). All relevant articles identified by the authors mentioning endothermal heat induced thrombosis were included in this review. A multitude of risk factors, several pathophysiological hypotheses and different treatment strategies are described in the literature. Endothermal heat induced thrombosis is marginally understood. There remains a theoretical risk for significant venous thromboembolic complications. With the new uniform classification of EHIT (American Venous Forum), healthcare providers should continue to investigate the nature of this event.

Classification and treatment of endothermal heat-induced thrombosis: Recommendations from the American Venous Forum and the Society for Vascular Surgery This Practice Guidelines document has been co-published in Phlebology [DOI: 10.1177/0268355520953759] and Journal of Vascular Surgery: Venous and Lymphatic Disorders [DOI: 10.1016/j.jvsv.2020.06.008]. The publications are identical except for minor stylistic and spelling differences in keeping with each journal's style. The contribution has been published under a Attribution-Non Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0), (https://creativecommons.org/licenses/by-nc-nd/4.0/).

The American Venous Forum (AVF) and the Society for Vascular Surgery set forth these guidelines for the management of endothermal heat-induced thrombosis (EHIT). The guidelines serve to compile the body of literature on EHIT and to put forth evidence-based recommendations. The guidelines are divided into the following categories: classification of EHIT, risk factors and prevention, and treatment of EHIT.One major feature is to standardize the reporting under one classification system. The Kabnick and Lawrence classification systems are now combined into the AVF EHIT classification system. The novel classification system affords standardization in reporting but also allows continued combined evaluation with the current body of literature. Recommendations codify the use of duplex ultrasound for the diagnosis of EHIT. Risk factor assessments and methods of prevention including mechanical prophylaxis, chemical prophylaxis, and ablation distance are discussed.Treatment guidelines are tailored to the AVF EHIT class (ie, I, II, III, IV). Reference is made to the use of surveillance, antiplatelet therapy, and anticoagulants as deemed indicated, and the recommendations incorporate the use of the novel direct oral anticoagulants. Last, EHIT management as it relates to the great and small saphenous veins is discussed.

Classification and treatment of endothermal heat-induced thrombosis: Recommendations from the American Venous Forum and the Society for Vascular Surgery.

The American Venous Forum (AVF) and the Society for Vascular Surgery set forth these guidelines for the management of endothermal heat-induced thrombosis (EHIT). The guidelines serve to compile the body of literature on EHIT and to put forth evidence-based recommendations. The guidelines are divided into the following categories: classification of EHIT, risk factors and prevention, and treatment of EHIT. One major feature is to standardize the reporting under one classification system. The Kabnick and Lawrence classification systems are now combined into the AVF EHIT classification system. The novel classification system affords standardization in reporting but also allows continued combined evaluation with the current body of literature. Recommendations codify the use of duplex ultrasound for the diagnosis of EHIT. Risk factor assessments and methods of prevention including mechanical prophylaxis, chemical prophylaxis, and ablation distance are discussed. Treatment guidelines are tailored to the AVF EHIT class (ie, I, II, III, IV). Reference is made to the use of surveillance, antiplatelet therapy, and anticoagulants as deemed indicated, and the recommendations incorporate the use of the novel direct oral anticoagulants. Last, EHIT management as it relates to the great and small saphenous veins is discussed.

In Well-Selected Patients With a Femoral Deep Vein Thrombosis Central Venous Imaging May Identify Additional Iliocaval Disease.

OBJECTIVE: Patients who present acutely with a femoral deep vein thrombosis (DVT) diagnosed by ultrasound are often treated with anticoagulation and instructed to follow-up electively. This study sought to assess whether obtaining axial imaging of the central venous system results in the identification of additional iliocaval pathology warranting treatment. METHODS: This study was a retrospective review of a prospectively maintained registry from November 2014 through April 2017 with follow-up through March 2020. Consecutive patients with a diagnosis of femoral DVT diagnosed by ultrasound were evaluated; those who underwent axial imaging of the iliocaval system (Group A) were compared to those who did not undergo imaging of the central veins (Group B). The primary outcome was the performance of any percutaneous central venous intervention. Secondary outcomes included the extent of DVT identified on duplex and after axial imaging, follow-up duplex patency and persistence of severe symptoms. RESULTS: Eighty patients presented with an ultrasound diagnosis of a femoral vein DVT. Mean follow-up was 551 ± 502 days. Group A comprised 24 patients (30%) and Group B comprised 56 patients (70%). Baseline demographics did not differ significantly between the 2 groups. After duplex imaging, Group A exhibited an increased prevalence of DVT in the common femoral vein. After central imaging, Group A exhibited an increased prevalence of DVT in the iliocaval veins. The number of patients who underwent invasive treatment differed significantly between the 2 groups, Group A 16/24 (67%) vs. Group B 9/56 (16%), P < 0.0001. The number of patients that demonstrated duplex patency and had persistent symptoms on follow-up did not differ significantly. CONCLUSIONS: Patients with an ultrasound diagnosis of femoral DVT may have additional iliocaval pathology warranting intervention. Well-selected imaging of the central veins may reveal a more complete picture, potentially altering management.

Endovenous laser ablation: A comprehensive review.

OBJECTIVE: To provide an evidence-based overview of endovenous laser ablation and describe its role as an effective and durable technique for the management of superficial venous insufficiency. METHODS: The published literature on the treatment of varicose veins using endovenous laser ablation was reviewed. The literature search focused on the history of endovenous laser ablation, its safety and durability, known complications, and differences in outcomes based on the iterations of fiber type and laser wavelength. RESULTS: Treatment safety and efficacy of endovenous laser ablation appear to be based on the amount of energy administered over a defined distance, or the linear endovenous energy density. The ideal linear endovenous energy density varies with the laser wavelength and fiber-type. Post-operative pain and bruising may be reduced by the use of higher wavelength fibers or the use of radial or jacket-tip fibers as compared to bare-tip fibers. The incidence of endothermal heat-induced thrombosis remains low and has declined with increasing experience. Reports have demonstrated a greater than 90% technical success rate with saphenous endovenous laser ablation, long-term durability of ablation, and commensurate improvement in quality of life. CONCLUSIONS: Endovenous laser ablation is a safe and durable treatment option for the management of incompetent superficial and perforator veins of the lower extremities. As an endothermal technology, it remains a key component of the standard of care for the treatment of chronic venous insufficiency.

A prospective safety and effectiveness study using endovenous laser ablation with a 400-µm optical fiber for the treatment of pathologic perforator veins in patients with advanced venous disease (SeCure trial).

BACKGROUND: Treatment of pathologic perforator veins (PPVs) can shorten time to healing and reduce recurrence of ulcers in patients with advanced venous disease. Because of limited clinical evidence and device options, widespread adoption of PPV treatment is controversial. The objective of this study was to evaluate the safety and efficacy of endovenous laser therapy using a 400-µm optical fiber to treat PPVs. METHODS: This study was a single-arm, prospective, seven-center, nonblinded clinical study examining patients with advanced skin changes or healed or active ulceration (Clinical, Etiology, Anatomy, and Pathophysiology clinical class C4b, C5, and C6). Patients received treatment with a 1470-nm laser. Procedural technical success and 10-day primary closure were evaluated. All device-related adverse events were reported. Follow-up of patients was continued for 12 months after initial ablation. RESULTS: The primary PPV closure (at 10-day visit) rate was 76.9% (95% confidence interval, 70.3%-82.4%). Successful primary closure rates of 75.7%, 70.3%, 62.1%, 68.8%, and 71.3% of PPVs were achieved at 1 month, 3 months, 6 months, 9 months, and 12 months, respectively. Statistically significant improvements (P < .05) were seen in patients' quality of life at 1 month, 3 months, 6 months, 9 months, and 12 months compared with screening. The percentage of patients with ulcers (22.9% at screening, 14.1% at 1 month, 13.7% at 3 months, 10.1% at 6 months, 12.3% at 9 months, and 11.1% at 12 months) displayed improvement during the course of the study. Tibial deep venous thrombosis and procedural pain were the only device-related adverse events observed. CONCLUSIONS: Endovenous laser therapy for PPV using the 400-µm optical fiber with the 1470-nm laser yielded safe and effective outcomes with no major adverse sequelae.

Radiofrequency and laser vein ablation for patients receiving warfarin anticoagulation is safe, effective, and durable.

OBJECTIVE: The objective of this study was to evaluate the efficacy, durability, and safety of radiofrequency ablation (RFA) and endovenous laser ablation (EVLA) of the great saphenous vein (GSV) and small saphenous vein (SSV) to treat symptomatic venous reflux in patients receiving therapeutic anticoagulation. METHODS: Patients treated at a single institution with RFA or EVLA while receiving warfarin (Coumadin) anticoagulation were identified retrospectively along with a consecutive sample of patients not receiving anticoagulation who were similarly treated. Patients' demographics, comorbidities, procedural details, and follow-up data were obtained from electronic medical records. Outcomes of interest included the rates of persistent vein ablation, bleeding, deep venous thrombosis (DVT), and endothermal heat-induced thrombosis. Groups were compared using χ2 tests, Fisher exact test, Kaplan-Meier curves, and Cox proportional hazard modeling. RESULTS: There were 100 procedures performed in 65 patients receiving anticoagulation and 127 procedures in 89 control patients. Mean follow-up time was 467 days. The most common indications for anticoagulation were atrial fibrillation (52%), remote DVT (29%), and mechanical heart valves (8%). Patients receiving anticoagulation were on average older (67 years vs 52 years), were more likely to be male (51% vs 27%), and had higher rates of coronary disease (9% vs 0%) and hypertension (55% vs 20%), although they were more likely to have never smoked (86% vs 69%). There were 127 RFA procedures (56%) and 100 EVLA procedures (44%); 189 procedures treated the GSV or its tributaries (83%), and 38 treated the SSV (17%). At 1 year, the target vessel remained ablated after 96% of procedures performed with anticoagulation and in 99% of controls; at 18 months, rates were 92% vs 95% (P = .96). Rates of persistent ablation did not differ significantly by vessel treated (P = .28), EVLA vs RFA (P = .36), or use of antiplatelet therapy (P = .92). One patient had bleeding from a phlebectomy site 2 days postprocedurally when supratherapeutic on warfarin; this was controlled with pressure. DVT in the ipsilateral leg occurred within 90 days after 1 of 100 (1%) procedures in patients receiving anticoagulation and 2 of 127 (1.6%) procedures in control patients; endothermal heat-induced thrombosis rates were similarly 1 of 100 (1%) procedures in patients receiving anticoagulation and 1 of 127 (0.8%) in control patients. CONCLUSIONS: This is the largest series to date reporting >30-day follow-up for patients undergoing venous ablation procedures while receiving anticoagulation and the longest follow-up reported of any series. Durability, safety, and efficacy of vein ablation in patients receiving anticoagulation are comparable to those in control patients. Anticoagulation should not be considered a contraindication to endothermal ablation of the GSV or SSV for symptomatic venous reflux.

Age is not a barrier to good outcomes after varicose vein procedures.

BACKGROUND: The Vascular Quality Initiative (VQI) Varicose Vein Registry (VVR) represents a patient-centered database launched in January 2015. Previous work describing overall trends and outcomes of varicose vein procedures across the United States demonstrates a benefit from these procedures. The existing gaps in evidence to support current and future Medicare coverage of varicose vein procedures necessitate further description of clinical outcomes in patients ≥65 years old compared with the population <65 years old. METHODS: This study analyzed prospectively captured anatomic, procedural, and outcome data for all patients in a national cohort of all VQI VVR-participating centers. The VQI VVR database was queried for all patients undergoing varicose vein procedures between January 2015 and July 2016. Preprocedural and postprocedural Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) classification, Venous Clinical Severity Score (VCSS), and patient-reported outcomes (PROs) were compared between patients <65 years and ≥65 years old. Univariate descriptive statistics of demographic and procedural data were performed. Student t-tests were then performed on change in CEAP classification, VCSS score, and PROs (heaviness, achiness, throbbing, swelling, itching, appearance, and impact on work) for each group. RESULTS: There were 4841 varicose vein procedures performed from January 2015 to May 2016. There were 3441 procedures performed in 2691 patients (3631 limbs) in the group <65 years old and 1400 procedures performed in 1068 patients (1467 limbs) in the group ≥65 years old. Truncal veins alone were the most common veins treated in both groups. The majority of patients were white and female in both groups. Most of the demographic characteristics were clinically similar (although statistically different) in both groups with the exception of a higher body mass index in the group <65 years old and a history of bilateral varicose vein treatment, and anticoagulation was more common among patients ≥65 years old. Patients in both groups experienced statistically significant improvement in VCSS, PROs, and CEAP class. There was no difference in overall complications between age groups. CONCLUSIONS: All patients demonstrated an associated improvement in both clinical outcomes (CEAP class, VCSS) and PROs. There was no significant difference in the improvement in CEAP class and VCSS between patients younger and older than 65 years, although the younger population reported greater improvement in PROs. Given these findings, patients older than 65 years appear to benefit from varicose vein procedures and should not be denied interventions on their varicose veins and venous insufficiency on the basis of their age only.

Fiber type as compared to wavelength may contribute more to improving postoperative recovery following endovenous laser ablation.

OBJECTIVE: To define the relative importance of fiber type as compared to laser wavelength on tissue injury depth, postoperative pain, and bruising during endovenous laser ablation. METHODS: This study included 213 limbs that were treated with an 810-, 980-, or 1470-nm laser, with bare-tip (BT) or jacket-tip (JT) fibers. Pain scores (10-point scale) and bruising scores (5-point scale) were recorded. Tissue thermal injury depth (mm) was evaluated in vitro for the 810- and 1470-nm wavelengths with BT and JT fibers. RESULTS: The JT fibers had lower pain scores as compared to the BT fibers at 810 nm (1.69 ± 1.77 vs 3.70 ± 1.34; P < .0005) and at 980 nm (1.14 ± 1.06 vs 2.71 ± 1.80; P < .0005). The JT fibers had lower bruising scores as compared to the BT fibers at 980 nm (0.89 ± 1.06 vs 2.00 ± 1.44; P < .0005). The in vitro study showed lower thermal injury depths for the JT as compared to the BT fibers at 810 nm (0.36 mm ± 0.26 mm vs 1.05 mm ± 0.34 mm; P < .0005) and at 1470 nm (0.20 ± 0.16 mm vs 0.71 ± 0.31 mm; P < .0005). With regard to wavelength, 980-nm laser had lower pain scores as compared to 810-nm laser with BT fibers (2.71 ± 1.80 vs 3.70 ± 1.34; P = .015), and with JT fibers, a similar result trended toward significance (1.14 ± 1.06 vs 1.69 ± 1.77; P = .057). The 980-nm JT fiber showed less bruising as compared to the 810-nm JT fiber (0.89 ± 1.06 vs 1.42 ± 1.19; P = .019). Similarly, the 1470-nm JT fiber showed less bruising as compared to the 810-nm JT fiber (0.94 ± 1.02 vs 1.42 ± 1.19; P = .038). The in vitro study showed thermal injury depths that were less for 1470 nm as compared to 810 nm, with JT fibers (0.20 ± 0.16 mm vs 0.36 ± 0.26 mm; P = .013) or with BT fibers (0.71 ± 0.31 mm vs 1.05 ± 0.34 mm; P =.001). All mean differences between JT and BT fibers were greater than between differing wavelengths. The multivariate analysis for the in vitro study showed a mean difference between 1470 nm and 810 nm of 0.26 mm, P < .0005 favoring 1470 nm and a mean difference between JT and BT fibers of 0.61 mm, P < .0005 favoring the JT fibers. CONCLUSIONS: The use of a JT fiber appeared to be more significant in reducing pain and bruising as compared to a longer wavelength. Moreover, the results appeared additive, and the cohort using 1470 nm with a JT fiber produced the best treatment outcomes. Additional study is required to confirm the efficacy and durability of the various iterations evaluated; however, these data should be taken into consideration when undertaking treatment with endovenous laser ablation.

Exploring the value of vein center accreditation to the venous specialist.

Whereas advancements in medicine offer potential alternatives for better treatment outcomes, these additional therapeutic options can make health care decision-making more difficult for patients, referring physicians, payers, and policy makers. In a complex and ever-changing medical world, quantifying quality care is a challenge, while the need to promote higher quality care is even more important. Many of the key developments in the field have come into common use without the opportunity for formal training for physicians already in practice, regardless of specialty background. These techniques are often learned through postgraduate educational experiences. As a result, it is likely that there is a wide range of knowledge, skill, and experience among physicians offering vein services. Given that many of these services are provided in the office, there is no hospital or institutional supervision or accreditation. In an effort to improve quality of venous care, the Intersocietal Accreditation Commission (IAC) established accreditation standards for superficial vein centers. This review discusses the process used to create the IAC Vein Center guidelines; summarizes important requirements for accreditation and their impact on quality of care; and examines the potential impact of IAC accreditation on patients, providers, and payers.

Treatment of superficial venous incompetence.

Superficial venous incompetence is a common lower limb vascular condition, with venous ulceration representing the most severe sequela of the disease. The treatment of superficial venous incompetence can aid in ulcer healing, and a variety of modalities are available. Successful treatment requires attention to appropriate patient selection and procedural technique.

Use of the Clinical, Etiologic, Anatomic, and Pathophysiologic classification and Venous Clinical Severity Score to establish a treatment plan for chronic venous disorders.

To be useful in clinical practice and in the evaluation of clinical therapies for chronic venous disorders, a measurement instrument should be objective, inclusive of all severities of venous disease, and rapidly performed by clinicians. The Clinical, Etiologic, Anatomic, and Pathophysiologic classification helps us identify the etiology, whether it is congenital, nonthrombotic, or post-thrombotic; anatomic segments involved, whether deep, superficial, or perforators; and pathophysiologic data, such as reflux or obstruction. The Venous Clinical Severity Score can be used to observe patients longitudinally, especially after interventions, although the total score is biased with regard to advanced disease, such as C4 through C6. To be able to predict progression of disease, more patient-validated instruments are needed. Physician-reported outcomes (the Venous Clinical Severity Score and the Clinical, Etiologic, Anatomic, and Pathophysiologic classification) in association with a patient-reported outcome may be the solution for the development of an ideal treatment plan.

Perioperative duplex ultrasound following endothermal ablation of the saphenous vein: is it worthless?

Fifteen years ago, radiofrequency ablation of the saphenous vein was introduced as a new and minimally invasive modality for the treatment of superficial venous insufficiency. Three years later, it was followed by endovenous laser ablation. These procedures have revolutionized the treatment of superficial venous insufficiency and have caused a dramatic shift from a highly invasive and morbid inpatient procedure, to a minimally invasive and ambulatory office procedure. Soon after their introduction, a new clinical entity was identified: endothermal heat-induced thrombosis (EHIT). This terminology, a classification system, and treatment strategies were introduced by Kabnick in 2005. Subsequently, advances in technique, along with the discovery of associated risk factors and a better understanding of the pathophysiologic process of endothermal coagulum formation, have reduced the current incidence of EHIT classes 2-4 to between 1%-2%. Still, a paucity of data exists regarding the true incidence of clinically significant pulmonary embolism secondary to EHIT. The authors believe that the rate is less than 0.01%. Furthermore, successful thermal saphenous ablation efficacy in the perioperative period approaches 99%. Despite these excellent numbers, the standard of care is to obtain a duplex ultrasound to evaluate for the presence of EHIT within the first 1-2 weeks post endovenous thermal ablation. Given this information, the authors believe that performing duplex ultrasound in the perioperative period is wasteful and an inefficacious use of limited health-care resources. Thus, the authors advocate against routine duplex to evaluate treatment efficacy and EHIT presence during the perioperative period in asymptomatic patients.

Increasing ablation distance peripheral to the saphenofemoral junction may result in a diminished rate of endothermal heat-induced thrombosis.

OBJECTIVE: The treatment of venous insufficiency using endovenous laser ablation or radiofrequency ablation may result in endothermal heat-induced thrombosis (EHIT), a form of deep venous thrombosis. This study sought to assess whether increasing the ablation distance peripheral to the deep venous junction would result in a reduction in the incidence of EHIT II. METHODS: This study was a retrospective review of a prospectively maintained database from April 2007 to December 2011. Consecutive patients undergoing great saphenous vein (GSV) or small saphenous vein (SSV) ablation were evaluated. Previous to February 2011, all venous ablations were performed 2 cm peripheral to the saphenofemoral or saphenopopliteal junction (group I). Subsequent to February 2011, ablations were performed greater than or equal to 2.5 cm peripheral to the respective deep system junction (group II). The primary outcome was the development of EHIT II or greater (ie, thrombus protruding into the deep venous system but comprising less than 50% of the deep vein lumen). Secondary outcomes included procedure-site complications such as thrombophlebitis and hematomas. χ(2) tests were performed for all discrete variables, and unpaired Student's t-tests were performed for all continuous variables. P < .05 was considered statistically significant. RESULTS: A total of 4223 procedures were performed among group I (n = 3239) and group II (n = 984). Patient demographics were similar between the two groups; however, the CEAP classification was higher by a small margin in group II, and the result was significant (group I: 2.6% ± 0.9% vs group II: 2.8% ± 1.0%; P = .006). The incidence of EHIT II was 76 in group I and 13 in group II. This represented a trend toward diminished frequency in group II as compared with group I (group I: 2.3% vs group II: 1.3%; P = .066). There were no reported cases of EHIT III or IV in this patient cohort. Patients who developed an EHIT II in group I were treated using anticoagulation 54% of the time, and patients who developed an EHIT II in group II were treated using anticoagulation 100% of the time. CONCLUSIONS: This study suggests that changing the treatment distance from 2 cm to greater than or equal to 2.5 cm peripheral to the deep venous junction may result in a diminished incidence of EHIT II. Ongoing evaluation is required to validate these results and to affirm the long-term durability of this technique.

Arteriovenous fistula after endovenous ablation for varicose veins.

Endovenous ablation, using radiofrequency or laser, is becoming the mainstay of treatment for symptomatic varicose veins in the setting of saphenous vein incompetency. Both procedures have been shown to produce high rates of truncal vein occlusion with few complications. This article presents three patients who developed arteriovenous fistula (AVF) following great saphenous vein treatment: two following radiofrequency ablation (RFA) and one following laser ablation. This is the first published report of AVF following RFA for which operative details are known. We review the literature and discuss possible causes and management of this rare complication.

Update on endovenous laser ablation: 2011.

In 2001, the use of endovenous laser ablation (EVLA) was introduced to the United States to treat superficial venous insufficiency. EVLA has subsequently undergone a rapid rise in popularity and usage with a concomitant decrease in traditional operative saphenectomy. Since its inception, the use of EVLA to treat superficial venous insufficiency has advanced significantly. The efficacy of treatment has been validated using both hemoglobin-specific laser wavelength and water-specific laser wavelength lasers. Currently, laser optimization is focusing on reducing postprocedural sequelae. The clinical parameters that correlate best with improved postoperative recovery use lower power/energy settings, water-specific laser wavelength lasers, and jacket or radial-emitting tips. Future study is still required to assess the durability of treatment at lower power and energy settings coupled with jacket or radial-emitting tip fibers. Long-term follow-up using duplex imaging is recommended to ensure persistent treatment success.