Editor's Choice - Short Term Cost Effectiveness of Radiofrequency Ablation and High Ligation and Stripping for Great Saphenous Vein Incompetence.

OBJECTIVE: Superficial venous incompetence (SVI) is a common disease that causes significant quality of life (QoL) impairment. There is a need for more health economic evaluations of SVI treatment. The aim of this study was to perform a cost effectiveness analysis in patients with great saphenous vein (GSV) incompetence comparing radiofrequency ablation (RFA), high ligation and stripping (HL/S), and no treatment or conservative treatment with one year follow up. METHODS: Randomised controlled trial economic analysis from an ongoing trial; 143 patients (156 limbs) with GSV incompetence (CEAP clinical class 2 - 6) were included. Treatment was performed with RFA or HL/S. Follow up was performed up to one year using duplex ultrasound, revised venous clinical severity score (r-VCSS), Aberdeen Varicose Vein Questionnaire (AVVQ), and EuroQol-5D-3L (EQ-5D-3L). RESULTS: Seventy-eight limbs were treated with RFA and HL/S respectively. No treatment or conservative treatment was assumed to have zero in treatment cost and no treatment benefit. In the RFA group, one limb had reflux in the GSV after one month and three limbs after one year. In HL/S, two limbs had remaining reflux in the treated area at one month and one year. Both disease severity (r-VCSS, p = .004) and QoL (AVVQ, p = .021 and EQ-5D-3L, p = .028) were significantly improved over time. The QALY gain was 0.21 for RFA and 0.17 for HL/S. The cost per patient was calculated as €1 292 for RFA and €2 303 for HL/S. The cost per QALY (compared with no treatment or conservative treatment) was €6 155 for RFA and €13 549 for HL/S. With added cost for days absent from work the cost per QALY was €7 358 for RFA and €24 197 for HL/S. The cost per QALY for both methods was well below the threshold suggested by Swedish National Board of Health. CONCLUSION: RFA is more cost effective than HL/S and no treatment or conservative treatment at one year follow up.

A Comparison of Venaseal Versus Radiofrequency Ablation Outcomes Within a Managed Care Organization.

BACKGROUND: Chronic venous insufficiency is a common medical condition that afflicts over 30 million adults in the United States. Treatment and management have changed dramatically over the past 20 years with the introduction of various endovenous therapies, including radiofrequency ablation (RFA) and cyanoacrylate closure using the Venaseal system. In this study, we explore a direct comparison of outcomes between RFA and VenaSeal conducted by a single surgeon within a managed care organization. METHODS: Between May 2020 and December 2021, there were 87 patients undergoing 97 total procedures who were treated with either VenaSeal (n = 55) or RFA (n = 42), conducted by a single surgeon within a managed care organization. Primary outcomes included successful greater saphenous vein (GSV) closure, postoperative deep vein thrombosis (DVT), embolization, saphenofemoral junction (SFJ) thrombosis, skin reaction (allergic or thrombophlebitis), or procedure-related emergency room (ER) and urgent care (UC) visits. Retrospective chart review was conducted to describe patient demographics, indications for treatment, treatment details (number of access sites and indication for treatment), as well as follow-up adjunctive vein procedures (sclerotherapy and stab phlebectomy). RESULTS: All patients had postprocedural ultrasound (US) performed within 7 days by the operating surgeon and mean overall patient follow-up from index procedure was 12 months; 2 patients were lost to follow-up due to death. All operations utilized intraoperative US, and SFJ thrombosis was not observed in any patient postprocedure. The average age of VenaSeal and RFA groups was 59.05 and 59.51 years, respectively. The average number of access sites during the procedure for VenaSeal and RFA was 1.56 and 1.20, respectively. Of the 55 VenaSeal treatments, 9.1% of patients reported postoperative skin reactions, and 9.1% of patients underwent subsequent stab phlebectomy (22 stabs on average). Of the 42 RFA treatments, 7.1% of RFA patients reported postoperative skin reactions, and 9.5% underwent subsequent stab phlebectomy (36 stabs on average). The percentage of patients who had postoperative UC or emergency department visits related to the procedure in the VenaSeal and RFA groups was 3.6% and 0%, respectively. CONCLUSIONS: Both VenaSeal and RFA demonstrated effective vein closure of the GSV at 12-month follow-up, with VenaSeal demonstrating continued noninferiority to RFA. Based on our data, postoperative skin reactions do not appear to be significantly higher with VenaSeal treatment, as previously reported.

Ultrasound assessment is linked to histological vein wall thickness in chronic venous disease.

OBJECTIVES: Few studies compared both ultrasound and histological approaches for the same series of patients with chronic venous disease (CVD). We aimed to assess the diagnostic performances of duplex ultrasound assessment (US) of Vein Wall Thickness (VWT) among patients with CVD. METHODS: 38 adults with primary varicose veins having undergone Great Saphenous Vein thermal ablation with phlebectomy, and agreeing to biopsy of the Posterior Accessory Great Saphenous Vein (PASV) were consecutively included in a two-center prospective study. VWT assessment of the PASV was performed using both US, and microscope examination. High values for microscope-assessed VWT were defined at > 0.5 mm. RESULTS: The mean age was 53.0 ± 13.1 years, 71% were women. Maximization of US performances was obtained with a threshold of 0.6 mm: Sensitivity (Se) = 92.9%, Specificity (Sp) = 91.7%, positive (86.7%) and negative predictive value (NPV) (95.7%), positive (11.1) and negative likelihood ratio (NLR) (0.07). CONCLUSIONS: US assessment of VWT could be a non-invasive tool for diagnosis and follow-up in CVD, and an interesting in vivo parameter complementing diameter and reflux measures, with a view to optimizing treatment. It could help to determine i) the energy level necessary in case of endovenous laser ablation, and ii) the sclerosing agent concentration in case of chemical ablation.

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.

Cell Viability Assessment Using Fluorescence Vital Dyes and Confocal Microscopy in Evaluating Freezing and Thawing Protocols Used in Cryopreservation of Allogeneic Venous Grafts.

The authors present their contribution to the improvement of methods suitable for the detection of the freezing and thawing damage of cells of cryopreserved venous grafts used for lower limb revascularization procedures. They studied the post-thaw viability of cells of the wall of cryopreserved venous grafts (CVG) immediately after thawing and after 24 and 48 h culture at +37 °C in two groups of six CVG selected randomly for slow thawing in the refrigerator and rapid thawing in a water bath at +37 °C. The grafts were collected from multi-organ and tissue brain-dead donors, cryopreserved, and stored in a liquid nitrogen vapor phase for five years. The viability was assessed from tissue slices obtained by perpendicular and longitudinal cuts of the thawed graft samples using in situ staining with fluorescence vital dyes. The mean and median immediate post-thaw viability values above 70% were found in using both thawing protocols and both types of cutting. The statistically significant decline in viability after the 48-h culture was observed only when using the slow thawing protocol and perpendicular cutting. The possible explanation might be the "solution effect damage" during slow thawing, which caused a gentle reduction in the graft cellularity. The possible influence of this phenomenon on the immunogenicity of CVG should be the subject of further investigations.

Saphenous vein valve assessment utilizing upright CT to potentially improve graft assessment for bypass surgery.

Saphenous veins (SVs) are frequently employed as bypass grafts. The SV graft failure is predominantly seen at the valve site. Avoiding valves during vein harvest would help reduce graft failure. We endeavored to detect SV valves, tributaries, and vessel size employing upright computed tomography (CT) for the raw cadaver venous samples and in healthy volunteers. Five cadaver legs were scanned. Anatomical analysis showed 3.0 (IQR: 2.0-3.0) valves and 13.50 (IQR: 10.00-16.25) tributaries. The upright CT completely detected, compared to 2.0 (IQR: 1.5-2.5, p = 0.06) valves and 9.5 (IQR: 7.5-13.0, p = 0.13) tributaries by supine CT. From a total of 190 volunteers, 138 (men:75, women:63) were included. The number of valves from the SF junction to 35 cm were significantly higher in upright CT than in supine CT bilaterally [upright vs. supine, Right: 4 (IQR: 3-5) vs. 2 (IQR:1-2), p < 0.0001, Left: 4 (IQR: 3-5) vs. 2 (IQR: 1-2), p < 0.0001]. The number of tributaries and vessel areas per leg were also higher for upright compared with supine CT. Upright CT enables non-invasive detection of SV valves, tributaries, and vessel size. Although not tested here, it is expected that upright CT may potentially improve graft assessment for bypass surgery.

Short-term assessment of radial artery grafts with multidetector computed tomography.

BACKGROUND: The clinical use of the radial artery (RA) in coronary artery bypass grafting (CABG) is still limited worldwide, although it has been recommended by several guidelines. Multidetector computed tomography (MDCT) is widely used to evaluate graft patency, as invasive coronary angiography could cause potentially serious risks including bleeding, dissection and stroke. This study aims to report the short-term results of the RA in CABG with MDCT. METHODS: The study population consists of 41 consecutive patients undergoing elective CABG with the RA graft between 2017 to 2018, with MDCT performed to evaluate graft patency during follow-up, and target vessels for the RA were non-left anterior descending coronary arteries with > 70% stenosis. RESULTS: A total of 150 grafts were assessed by MDCT during follow-up (mean, 8.9 ± 5.1 months). MDCT could clearly show the structure and patency of grafts, even for complex coronary artery revascularization. Graft patency of the left internal mammary artery was 92.9% (39/42), with the RA patency of 84.4% (38/45) and the patency of the saphenous vein graft of 81.1% (30/37). And the RA anastomosed to the left coronary artery system might have better patency than the RA anastomosed to the right coronary artery system (25/29, 86.2% vs 13/16, 81.3%, p = 0.686). CONCLUSIONS: The short-term patency rate of RA grafts is good, and the RA might be associated with better patency when anastomosed to the left but not the right coronary artery. MDCT could provide excellent visualization of grafts in CABG.

Needs of standardisation in reporting a venous lower limb ultrasound exam for the assessment of varicose veins.

Duplex ultrasound is an important tool in the assessment and management of patients with varicose veins. Over the past two decades several minimally-invasive therapeutic options have become available for the treatment of these patients. Consequently, the ultrasonographic assessment and the parameters to consider have changed accordingly. Ultrasound parameters, such as the diameter of superficial incompetent veins or their depth from the skin surface amongst others, have become of paramount importance for planning a tailored either operative or non-operative treatment. However, in daily practice there is a wide variety of ultrasound parameters described in the report. This variety can be explained by several factors, such as the background of the healthcare professional performing the exam or the available treatments as per the local national healthcare service guidelines or insurance reimbursement plans. The standardisation of the reporting of the ultrasound findings in patients with varicose veins will improve communication between healthcare professionals and the management of these patients.

Effect of endovenous ablation assessment stratified by great saphenous vein size, gender, clinical severity, and patient-reported outcomes.

OBJECTIVE: The policies of insurance carriers have used the truncal vein size as a criterion for coverage. The objective of the present study was to compare the effect of great saphenous vein (GSV) size ≥5 mm vs <5 mm on patient presentation and clinical outcomes. METHODS: Patients in a national cohort were prospectively captured in the Vascular Quality Initiative Varicose Vein Registry. From January 2015 to October 2017, the Vascular Quality Initiative Varicose Vein Registry database was queried for all patients who had undergone varicose vein procedures. The CEAP (clinical, etiologic, anatomic, pathophysiologic) classification, Venous Clinical Severity Score, and patient-reported outcomes were compared by GSV size (<5 mm, group 1; ≥5 mm, group 2) before and after the procedures. A 2-sample Wilcoxon test was performed to assess the differences between the 2 groups stratified by GSV size. To assess for postoperative improvement, a matched-pairs Wilcoxon signed rank test was performed for each group separately. RESULTS: During the study period, 5757 vein ablation procedures had been performed for GSV: 770 for GSV size <5 mm and 4987 for GSV size ≥5 mm. Patients in group 1 were more likely to be women (81.7% vs 68.4%; P = .001) and older (56.8 vs 55.6 years; P = .012). The CEAP clinical class was more advanced in group 2 than in group 1 (P = .001). The maximal GSV diameter in group 2 was significantly greater than in group 1 (8.32 vs 3.86 mm; P = .001); 64% of group 2 and 59.2% of group 1 had undergone radiofrequency thermal ablation (P = .001). No mortalities occurred in either group. Group 2 had more complications postoperatively (0.6% vs 0%; P = .027), required postoperative anticoagulation (8.8% vs 5%, P = .001), developed partial recanalization (0.8% vs 0.3%; P = .001), and missed more work days (2.32 vs 1.6 days) compared with group 1. A similar rate of hematoma developed in both groups, but group 1 had a higher rate of paresthesia. Both groups had improvement in the Venous Clinical Severity Score and HASTI (heaviness, achiness, swelling, throbbing, itching) score. The degree of symptomatic improvement between the 2 groups was similar. CONCLUSIONS: All patients demonstrated improvement in both clinical outcomes and patient-reported outcomes after endovenous ablation, regardless of GSV size. Patients with a preoperative GSV size ≥5 mm experienced similar improvement in symptoms but an increased complication rate. Patients with a smaller vein size should not be denied intervention or coverage by vein size.

Comparison of hand-held acoustic Doppler with point-of-care portable color Doppler ultrasound in the assessment of venous reflux disease.

OBJECTIVE: Diagnostic-quality portable color Doppler ultrasound (PCD) offers convenient point-of-care venous reflux disease (VRD) diagnosis. Philips Lumify (Philips N.V., Best, The Netherlands), a high-fidelity broadband linear array transducer (4-12 MHz frequency), connects through a web-enabled smartphone or tablet to cloud software and offers B-mode and color Doppler imaging without pulsed wave Doppler capability. The aims of the study were to compare hand-held acoustic Doppler (HHD) vs PCD diagnostic performance using conventional duplex ultrasound (DUP) as the "gold standard" for VRD assessment, to assess effects of body mass index (BMI) and disease severity on diagnostic performance of HHD and PCD, and to determine whether PCD offers any diagnostic improvement over HHD in VRD assessment. METHODS: There were 241 patients (65 male, 176 female; mean age, 55.5 ± 15.5 years; mean BMI, 32.2 ± 7.9 kg/m2). DUP (447 legs), PCD (262 legs), and HHD (217 legs) studied the great saphenous vein at above-knee (AK) and below-knee (BK) levels. A phlebologist performed HHD, whereas PCD and DUP were performed sequentially (PCD first) by an experienced technologist and interpreted independently. PCD was done blinded to DUP results. DUP findings were analyzed blinded to HHD and PCD results. Venous reflux was dichotomously assessed as <2 seconds and >2 seconds. RESULTS: HHD improves from moderate to good sensitivity from AK level (68%) to BK level (94%) but suffers poor specificity that declines significantly from AK level (50%) to BK level (12%; P < .05). HHD positive predictive value exceeds its negative predictive value (NPV) and remains unchanged from AK level (71%) to BK level (72%). HHD NPV remains consistently poor at AK (48%) and BK (42%) levels. PCD has similar sensitivity from AK level (69%) to BK level (74%), better AK level (79%) vs BK level (58%) specificity (P < .05), similar positive predictive value for AK (76%) and BK levels (78%), and better NPV for AK level (72%) vs BK level (53%; P < .05). BMI range (<30 kg/m2 vs ≥ 30 kg/m2) did not influence diagnostic performance of HHD and PCD significantly. HHD and PCD specificity was higher for Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) class <4 compared with CEAP class ≥4 (P < .05). CONCLUSIONS: The relative diagnostic performance of HHD and PCD is highly dependent on insonation level. PCD advantages compared with HHD are marginally greater specificity at AK and BK levels and better NPV at AK level. Compared with HHD, PCD's disadvantage is lower sensitivity at BK level. Both HHD and PCD have higher specificity at AK level than at BK level. Overall, PCD offers only moderate sensitivity and specificity, making it inadequate for exclusion of significant venous reflux. Neither obesity nor CEAP class significantly influenced the general diagnostic performance of PCD or HHD.

Computed Tomography Angiography in the Assessment of Great Saphenous Vein as Conduit for Infrainguinal Bypass Surgery.

INTRODUCTION: The great saphenous vein (GSV) is commonly used as a conduit during infrainguinal bypass (IIB) and is usually well seen on computed tomography angiography (CTA) which is frequently performed for preoperative planning. In this study, we asked whether CTA could replace ultrasonography (US) as the primary mode of conduit assessment, by comparing GSV measurements for patients who underwent both CTA and US vein mapping prior to IIB. METHODS: All IIB that were completed in the six-and-a-half-year period from January 1, 2012, to July 31, 2018, at the authors' institution were examined. Great saphenous vein measurements were analyzed for patients who had undergone both CTA and US vein mapping. Correlation between the measurements was calculated with the Pearson correlation coefficient. Data were then examined using Bland-Altman plots. Then categorical analysis was used to determine the adequacy of GSV for use as a bypass conduit. RESULTS: There were 302 patients who underwent IIB, with 73 legs, in 47 patients, examined with CTA and US. Computed tomography angiography and US measurements were moderately correlated (r = 0.531) across all measurement locations. Correlation progressively reduced distally (proximal thigh r = 0.534, midthigh r = 0.536, knee r = 0.35, midcalf r = 0.185, P = .074, ankle r = 0.078, P = .485). Bland-Altman plots of the pooled location data demonstrated no systematic bias. However, the upper and lower limits of agreement were wide, between -2.02 and +2.37 mm, demonstrating a lack of agreement between CTA and US. Analysis of each location revealed similar findings. A receiver operator characteristic curve was constructed based on a minimum US GSV diameter for adequate bypass conduit of 3 mm. The CTA value that maximized the Youden index was 3.8 mm. CONCLUSION: The level of error between CTA and US measurements, demonstrated by the large limits of agreement on Bland-Altman plots, would not be clinically acceptable. However, if a larger threshold is accepted, CTA has the potential to replace preoperative US vein mapping of GSV.

Intravascular Ultrasound Assessment of In-Stent Restenosis in Saphenous Vein Grafts.

Outcomes after percutaneous coronary interventions (PCI) in saphenous vein grafts (SVG) are inferior compared with native coronary arteries, but the mechanisms of SVG in-stent restenosis (ISR) have not been well-described. Thus, we aimed to evaluate the patterns of SVG ISR using intravascular ultrasound (IVUS) in 54 SVG ISR lesions. Stent underexpansion was defined as minimum stent area (MSA) <5 mm2. The time from stent implantation to presentation with ISR (9 BMS, 18 first-generation DES, and 27 second-generation DES) was 3.7 ± 3.0 years. IVUS-defined ISR patterns were categorized as mechanical (33%) or biological (67%). Mechanical patterns comprised 10 cases of stent underexpansion (MSA = 4.2 ± 0.9 mm2), 6 stent fractures or deformations, and 2 uncovered aorto-anastomotic lesions. Biological patterns comprised 19 cases of neoatherosclerosis, 13 excessive neointimal hyperplasia (NIH, 65 ± 11%), and 4 thrombi. Compared with biological patterns of ISR, mechanical patterns were more frequently located at the SVG anastomosis (72% vs 39%, p = 0.04) and at the SVG hinge motion site (55% vs 21%, p = 0.02). Although patients with mechanical patterns of ISR presented earlier than those with biological patterns (2.3 vs 4.4 years, p = 0.009), 61% of them were diagnosed >1 year after stent implantation. In conclusion, SVG ISR is dominated by biological patterns including neoatherosclerosis. Mechanical patterns of SVG ISR are associated with earlier presentation and location at graft anastomosis or hinge motion site.

[Functional assessment of primary lesion of the great saphenous vein when deciding upon stripping]. / Funktsional'naia otsenka pervichnogo porazheniia bol'shoi podkozhnoi veny pri reshenii voprosa o stripinge.

The purpose of the study was to examine a possibility of functional assessment of the great saphenous vein (GSV) with the help of a day orthostatic loading test for prognosis of restoration of the function of the GSV afterremoving its varicose tributaries in patients with primary varicose veins. Our prospective study included a total of sixty-five 29-to-53-year-old patients (15 men and 50 women, mean age - 36.7 years). The total number of the lower limb examined amounted to 87. All patients underwent ultrasonographic examination (duplex scanning) prior to operation, 1 and 12 months thereafter. The study was carried out using a day orthostatic loading test consisting in duplex scanning performed twice during 24 hours: in the evening after 18:00 hours and in the morning before 10:00 hours after a good night's rest. It was demonstrated that the day orthostatic loading test characterized the degree of preservation of the muscular-tonic properties of the GSV, making it possible to predict reversibility of reflux along it after removing the varicose tributaries, hence it may be used as a criterion for individualization of the choice of the scope of surgical intervention. A high orthostatic gradient prior to operation suggests preservation of the potential of the muscular-tonic function of the GSV; its decrease after surgery demonstrates reduction of the volemic loading on the GSV.

Economic implications of endovenous great saphenous ablation in a public health care system.

BACKGROUND: In mid-2007, endovenous ablation (EVA) of the great saphenous vein was introduced into the publicly funded health care system in Saskatchewan, Canada. We hypothesize that the introduction of EVA resulted in a decrease in use of high ligation and stripping (HL/S), decreased costs to the health care system, and increased demand of patients for great saphenous vein ablative procedures. METHODS: We retrospectively reviewed administrative data to capture cases of HL/S between 2003 and 2014 and cases of EVA of the great saphenous vein (endovenous laser treatment and radiofrequency ablation) between 2007 and 2014. Accounting for the change in practice pattern that occurred slowly between 2007 and 2009, we divided our patients into the pre-EVA era (2003-2006) and the post-EVA era (2010-2014). Procedure costs were determined with models used by our health region for this purpose. RESULTS: Utilization rates for great saphenous vein intervention remained similar in the pre-EVA (90 procedures per year) and post-EVA (92 procedures per year; P = .83) eras. Case costs of HL/S ($1965.12/case) were higher than those of EVA (endovenous laser treatment, $1295.08/case; radiofrequency ablation, $1410.54/case). The total annual costs of great saphenous vein intervention decreased from $176,861 in the pre-EVA era to $134,525 (P = .02). CONCLUSIONS: Introduction of publicly funded EVA has reduced rates of HL/S and reduced costs to our health system by approximately $42,000 per year, without increasing great saphenous vein intervention rates.

An Artificial Cadaveric Leg Blood Flow System for Endoscopic Vein Harvesting Simulation.

Despite being the most common training model for endoscopic vein harvesting, cadaveric legs are limited by their absence of blood flow, resulting in a faded vascular appearance. Because the saphenous vein and the surrounding tissue seem less distinguishable, dissection of the saphenous vein and bipolar coagulation of its branches becomes increasingly inefficient and difficult. An inexpensive artificial blood flow system was developed to overcome this limitation. A cadaveric leg was thawed to a soft and yielding degree, and the saphenous vein was dissected medial and proximal to the medial malleolus. An artificial blood solution was prepared by dissolving 4% protein powder, red dye, and a contrast agent-for x-ray visualization-in saline. The solution was perfused through the saphenous vein and artery. The open ends of the vessels were temporarily clamped after the perfusion had been completed. Blood flow within the vessels was confirmed via angiography and endoscopic visualization of the leg's vessels. A bleeding effect was observed when the saphenous vein was perforated or when a vascular branch was transected. Conversely, a tight seal indicated successful bipolar coagulation of a branch, providing an objective, quantifiable assessment parameter. The artificial blood flow system helps overcome the limitations of the cadaveric leg, creating a more realistic and inexpensive model for endoscopic vein harvesting simulation training.

Clinical presentation of women with pelvic source varicose veins in the perineum as a first step in the development of a disease-specific patient assessment tool.

OBJECTIVE: Pelvic venous incompetence can cause symptomatic varicose veins in the perineum, buttock, and thigh. Presentation, symptom severity, and response to treatment of pelvic source varicose veins are not well defined. Currently available tools to measure the severity of lower extremity venous disease and its effects on quality of life may be inadequate to assess disease severity in these patients. The purpose of this study was to evaluate the histories, demographics, and clinical presentations of women with pelvic source varicose veins and to compare these data to a population of women with nonpelvic source varicose veins. METHODS: A total of 72 female patients with symptomatic pelvic source varicose veins were prospectively followed up. Age, weight, height, parity, and birth weights of offspring were recorded. Both pelvic source varicose veins and saphenous incompetence were identified by duplex ultrasound. Patients were queried as to their primary symptoms, activities that made their symptoms worse, and time when their symptoms were most prominent. Severity of disease was objectively evaluated using the revised Venous Clinical Severity Score (rVCSS) and 10-point numeric pain rating scale (NPRS). RESULTS: Compared with women without a pelvic source of varicose veins (N = 1163), patients with pelvic source varicose veins were younger (mean, 44.6 ± 8.6 vs 52.6 ± 12.9 years; P < .001), had lower body mass index (mean, 21.9 ± 2.8 vs 25.8 ± 6.2; P < .001), and had larger babies than the U.S. population mean (mean, 3656 ± 450 g vs 3389 ± 466 g; P < .001). The most common symptoms were aching (68%), throbbing (47%), and heaviness (35%). In premenopausal patients, 70% noted that symptoms were worst during menses. NPRS score varied from 0 to 8 (mean, 4.9). The correlation between rVCSS (mean 5.6 ± 1.9) and NPRS was small (r = 0.26; P = .03). There was a modest correlation between older age and lower NPRS scores (r = -0.39; P < .001). CONCLUSIONS: Women with pelvic source varicose veins are a unique subset of patients. They are younger and thinner than those with nonpelvic source varicose veins, have larger infants than the general U.S. population, and have an inverse correlation between age and pain. As the majority of premenopausal patients have increased symptoms during menses, this may be due to hormonal influence. As it is poorly associated with patient-reported discomfort, the rVCSS is a poor tool for evaluating pelvic source varicose veins. A disease-specific tool for the evaluation of pelvic source varicose veins is critically needed, and this study is a first step in that endeavor.

Quantitative assessment technique of HyperEye medical system angiography for coronary artery bypass grafting.

PURPOSE: The HyperEye Medical System (HEMS) uses indocyanine green (ICG) to visualize blood vessels in coronary artery bypass grafting (CABG). We performed quantitative HEMS assessment to detect grafts at risk of occlusion. METHODS: We assessed the HEMS angiograms of 177 grafts from 69 patients who underwent CABG and compared the results with those of fluoroscopic coronary angiography, by measuring the increasing rate of ICG intensity, average acceleration value, and time to peak luminance intensity. RESULTS: Grafts in the patent and failed groups showed significant differences in their increasing rate of intensity and average acceleration value. The average accelerations value of ICG intensity of internal thoracic artery (ITA) and saphenous vein (SV) grafts were 112.3 and 144.9 intensity/s2 in the patent group, and 71.0 and 91.8 intensity/s2 in the failed group. The time to peak luminance intensity was 1.7 and 1.4 s in the patent group and 2.3 and 1.9 s in the failed group; these values were not significantly different. CONCLUSION: Significant reductions in the ICG intensity rate and average acceleration value can occur in failed grafts. Therefore, quantifiable changes in ICG intensity may help detect minute changes in blood flow.

Gender-specific Differences in Great Saphenous Vein Conduit. A Link to Lower Extremity Bypass Outcomes Disparities?

BACKGROUND: Inferior lower extremity bypass (LEB) outcomes have been reported among women with peripheral arterial disease (PAD), but the mechanisms responsible for this disparity are unknown. Great saphenous vein (GSV) is considered the conduit of choice for LEB; GSV diameter is associated with graft patency and therefore is often used as a criterion for suitability for use as bypass conduit. We hypothesized that gender-based differences in GSV may contribute to LEB outcomes disparities. To explore this hypothesis, we performed a gender-based analysis of GSV anatomic characteristics among patients with PAD who were studied with duplex ultrasound vein mapping during evaluation for LEB. METHODS: Consecutive patients undergoing ultrasound vein mapping for planned LEB were analyzed. Minimum above- and below-knee GSV diameters were obtained in addition to demographic, procedural, and clinical data. Associations between gender and GSV diameter were evaluated using multivariate mixed models adjusting for anatomic location and within-patient correlation. RESULTS: One hundred five patients were analyzed. Mean patient age was 65 ± 11 years, 25% were women, and 78% were white. Mixed model estimates of minimum GSV diameters were 3.14 ± 0.09 mm above knee and 2.74 ± 0.09 below knee for men versus 3.23 ± 0.14 above-knee and 2.49 ± 0.14 below knee for women. A gender-based interaction between anatomic location and GSV diameter was identified, with women having a greater difference between above- and below-knee GSV diameters (or taper; mean difference of 0.73 ± 0.12 vs. 0.41 ± 0.17 mm; P = 0.017). CONCLUSIONS: GSV taper (difference between above- and below-knee diameters) is greater in women and may contribute to inferior patency after LEB with vein conduit, particularly for below-knee target vessels. Further research is necessary to evaluate specific hemodynamic effects of graft taper and links with other clinical endpoints. In addition to minimum diameter, vein graft taper may warrant consideration when planning LEB.

Prospective Randomized Study of Ultrasound-Guided Foam Sclerotherapy Combined with Great Saphenous Vein High Ligation in the Treatment of Severe Lower Extremity Varicosis.

BACKGROUND: To evaluate the effect of ultrasound-guided foam sclerotherapy (UGFS) in a single session combined with great saphenous vein (GSV) high ligation for severe lower extremity varicosis classified as C4-C6, compared with GSV stripping plus multistab avulsion or transilluminated powered phlebectomy (TIPP). METHODS: From January 2012 to December 2014, 177 patients with primary GSV insufficiency, classified as C4-C6, were randomized into the UGFS group or the control group. The UGFS group was managed by GSV high ligation and foam sclerotherapy in one session under the surveillance of ultrasonography, whereas the control group received GSV high ligation and stripping combined with multistab avulsion or TIPP. The patients were followed up at 1, 6, and 12 months after treatment. Outcome assessments included reflux recurrence rate, procedure-related adverse events, hemodynamic parameters, revised Venous Clinical Severity Score (VCSS), and Aberdeen Varicose Vein Questionnaire (AVVQ) score. The medical cost and operating time of the 2 groups were also compared. RESULTS: In total, 73 patients received UGFS, whereas 90 patients underwent traditional surgery. Sixty-five patients in the UGFS group (89.0%) and 74 patients in the control group (82.2%) completed the follow-up. At the end of 12 months, the cumulative reflux recurrence rate was 13.8% in the UGFS group and 13.5% in the control group (P = 0.955). In the UGFS and control groups, minor complications (27.7% vs. 21.6%, P = 0.406) and major complications (3.1% vs. 2.7%, P = 0.895) were not significantly different. Compared with baseline values, obvious improvements of the venous filling index, VCSS, and AVVQ scores after treatment were confirmed in both groups (P < 0.001). The average operating and recovery times were much shorter (38.3 vs. 81.2 min, 5.4 vs. 9.6 days, P < 0.001, respectively), and the average hospital cost was much lower ($853 vs. $1,575, P < 0.001) in the UGFS group than in the control group. The patient satisfaction rate reached 92.3% in the UGFS group and 89.2% in the control group 12 months after operation (P = 0.270). CONCLUSIONS: Our outcomes indicated that UGFS combined with GSV high ligation was safe and effective for severe lower extremity varicosis.

Validation of a Decision Tree to Streamline Infrainguinal Vein Graft Surveillance.

BACKGROUND: Duplex ultrasound (DU)-based graft surveillance remains controversial. The aim of this study was to assess the ability of a recently proposed decision tree in identifying high-risk grafts which would benefit from DU-based surveillance. MATERIALS AND METHODS: Consecutive patients undergoing infrainguinal vein graft bypass from January 2008 to December 2015 were identified from the National Vascular registry and enrolled in a duplex surveillance program. An early postoperative DU was performed at a median of 6 weeks (range: 4-9 weeks). Grafts were classified into high risk or low risk based on the findings of the earliest postoperative scan and 4 established risk factors for graft failure (diabetes, smoking, infragenicular distal anastomosis, and revision bypass surgery) using a classification and regression tree (CRT). The accuracy of the CRT model was evaluated using area under receiver operator characteristic (AROC) curve. RESULTS: About 278 vein graft bypasses were performed; 29 grafts had occluded by the first surveillance visit; 249 vein grafts were entered into surveillance. Sixty-four (23%) developed critical stenosis. Overall 30-month primary patency, primary-assisted patency, and secondary patency rates were 71.2%, 77.2%, and 80.1%, respectively. AROC for prediction of graft stenosis or occlusion was 83% (95% confidence interval [CI]: 78-87%). The sensitivity and specificity of the CRT model for prediction of graft stenosis or occlusion were 95% (95% CI: 88-98%) and 52.2% (95% CI: 45-60%). CONCLUSIONS: A prediction model based on commonly recorded clinical variables and early postoperative DU scan is accurate at identifying grafts which are at high risk of failure. These high-risk grafts may benefit from DU-based surveillance.