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1.
Ann Surg ; 2019 Dec 16.
Artigo em Inglês | MEDLINE | ID: mdl-31850976

RESUMO

BACKGROUND: The 21st century has witnessed a rise in the use of endovenous thermal ablation. Being highly clinically and cost-effective and improving the quality of life of patients, they are now considered to be the "gold-standard" treatment for varicose veins. Post-intervention management, especially in terms of postoperative compression, however, remains unclear. As a result, a randomized study was undertaken to investigate the effects of wearing compression stockings after varicose vein treatment. METHOD: Patients with saphenous vein reflux undergoing treatment with endothermal ablation (with or without concurrent phlebectomies) were randomized to receive either 7 days of compression stockings or no stockings. The primary outcome measure for this study was the pain score over the first 10 postoperative days. The pain scores, clinical score, time to return to normal activities, and ecchymosis were assessed. Patients were followed-up at 2 weeks and 6 months post-ablation. RESULTS: In total, 206 patients were randomized, 49% of them to the compression group. The mean age was 49.7 (±16) years and approximately 51% of the population was male. The median pain score in the compression group using a visual analog scale was significantly lower on days 2-5, compared to the no compression group. Those having concurrent phlebectomies and compression stockings also had significantly better pain scores on days 1-3, day 5, and day 7. Improvement in the median venous clinical severity score was noted at 6-month follow-up, but this was not significant. No difference in the generic- or disease-specific quality of life was observed and the time to return to activities was similar. There were no differences in the degree of ecchymosis between the 2 groups and both groups had similar occlusion rates. CONCLUSIONS: These results indicate that wearing compression stockings after endothermal ablation is advantageous in the first few days after treatment and is especially beneficial for those having concurrent phlebectomies.

2.
Trials ; 20(1): 392, 2019 Jul 03.
Artigo em Inglês | MEDLINE | ID: mdl-31269978

RESUMO

BACKGROUND: Ambulatory phlebectomies and foam sclerotherapy are two of the most common treatments for varicose vein tributaries. Many studies have been published on these treatments, but few comparative studies have attempted to determine their relative effectiveness. METHODS/DESIGN: This is a prospective single-centre randomised clinical trial. Patients with primary truncal vein incompetence and varicose vein tributaries requiring treatment will be assigned randomly to either ambulatory phlebectomies or foam sclerotherapy. The primary outcome measure is the re-intervention rate for the varicose vein tributaries during the study period. The secondary outcomes include the degree of pain during the first two post-operative weeks and the time to return to usual activities or work. Improvements in clinical scores, quality of life scores, occlusion rates and cost-effectiveness for each intervention are other secondary outcomes. The re-intervention rate will be considered from the third month. DISCUSSION: This study compares ambulatory phlebectomies and foam sclerotherapy in the treatment of varicose vein tributaries. The re-intervention rates, safety, patient experience and the cost-effectiveness of each intervention will be assessed. This study aims to recruit 160 patients and is expected to be completed by the end of 2019. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03416413 . Registered on 31 January 2018.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/métodos , Veia Safena/cirurgia , Soluções Esclerosantes/administração & dosagem , Escleroterapia , Varizes/terapia , Procedimentos Cirúrgicos Vasculares/métodos , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Humanos , Londres , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto , Retratamento , Veia Safena/diagnóstico por imagem , Soluções Esclerosantes/efeitos adversos , Escleroterapia/efeitos adversos , Fatores de Tempo , Resultado do Tratamento , Varizes/diagnóstico por imagem , Procedimentos Cirúrgicos Vasculares/efeitos adversos
3.
Phlebology ; 34(3): 179-190, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29860923

RESUMO

OBJECTIVES: The aim was to assess the effectiveness and safety of catheter-directed thrombolysis in children with deep venous thrombosis and to evaluate its long-term effect. METHOD AND RESULTS: EMBASE, Medline and Cochrane databases were searched to identify studies in which paediatric acute deep venous thrombosis patients received thrombolysis. Following title and abstract screening, seven cohort studies with a total of 183 patients were identified. Technical success was 82% and superior in regional rather than systemic thrombolysis (p < 0.00001). One cohort study identified significant difference in thrombus resolution at one year between thrombolytic and anticoagulant groups (p = 0.01). The complication rate was low, with incidence rates of major bleeding, pulmonary embolism and others at 2.8%, 1.8% and 8.4%, respectively. The overall post-thrombotic syndrome rate was 12.7%. The incidence of re-thrombosis ranged from 12.3% to 27%. CONCLUSION: Thrombolysis for paediatric deep venous thrombosis is an effective and relatively safe therapeutic option, lowering the incidence of post-thrombotic syndrome and deep venous thrombosis recurrence.


Assuntos
Anticoagulantes/uso terapêutico , Terapia Trombolítica/métodos , Trombose Venosa/tratamento farmacológico , Anticoagulantes/efeitos adversos , Criança , Feminino , Humanos , Masculino , Terapia Trombolítica/efeitos adversos , Trombose Venosa/sangue , Trombose Venosa/patologia
4.
Phlebology ; 34(2): 115-127, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29788818

RESUMO

OBJECTIVES: The aim is to evaluate venous stent patency, the development of post-thrombotic syndrome, recurrence, quality of life and the optimal post-procedural anticoagulation regimen in the treatment of iliofemoral deep venous thrombosis. METHOD AND RESULTS: EMBASE and Medline databases were interrogated to identify studies in which acute deep venous thrombosis patients were stented. Twenty-seven studies and 542 patients were identified. Primary, assisted primary and secondary patency rates 12 months after stent placement ranged from 74 to 95, 90 to 95 and 84 to 100%, respectively. The observed post-thrombotic syndrome rate was 14.6%. The incidence of stent re-thrombosis was 8%. In 26% of studies, patients received additional antiplatelet therapy. Quality of life questionnaires employed in 11% of studies, demonstrating an improvement in the chronic venous insufficiency questionnaire (22.67 ± 3.01 versus 39.34 ± 6.66). CONCLUSION: Venous stenting appears to be an effective adjunct to early thrombus removal; however, further studies are needed to identify optimal anticoagulant regimen and effect on quality of life.


Assuntos
Extremidade Inferior/irrigação sanguínea , Trombólise Mecânica , Stents , Insuficiência Venosa/cirurgia , Trombose Venosa/cirurgia , Doença Aguda , Doença Crônica , Feminino , Humanos , Extremidade Inferior/cirurgia , Masculino , Insuficiência Venosa/fisiopatologia , Trombose Venosa/fisiopatologia
5.
Angiology ; 70(5): 388-396, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-29874921

RESUMO

Varicose veins are a very common condition and have been the subject of a recent proliferation of treatment modalities. The advent of the endovenous treatment era has led to a confusing array of different techniques that can be daunting when making the transition from traditional surgery. All modalities offer excellent results in the right situation, and each has its own treatment profile. Thermal ablation techniques have matured and have a reassuring and reliable outcome, but the arrival of nonthermal techniques has delivered further options for both patient and surgeon. This article provides an overview of the different treatment devices and modalities available to the modern superficial vein surgeon and details the currently available evidence and summation analysis to help surgeons to make an appropriate treatment choice for their patients.


Assuntos
Técnicas de Ablação , Cianoacrilatos/administração & dosagem , Embolização Terapêutica , Procedimentos Endovasculares , Soluções Esclerosantes/administração & dosagem , Escleroterapia , Varizes/terapia , Técnicas de Ablação/efeitos adversos , Tomada de Decisão Clínica , Cianoacrilatos/efeitos adversos , Embolização Terapêutica/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Humanos , Seleção de Pacientes , Soluções Esclerosantes/efeitos adversos , Escleroterapia/efeitos adversos , Resultado do Tratamento , Varizes/diagnóstico , Varizes/fisiopatologia
6.
Value Health ; 21(8): 911-920, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-30098668

RESUMO

OBJECTIVES: To analyze the cost-effectiveness of current technologies (conservative care [CONS], high-ligation surgery [HL/S], ultrasound-guided foam sclerotherapy [UGFS], endovenous laser ablation [EVLA], and radiofrequency ablation [RFA]) and emerging technologies (mechanochemical ablation [MOCA] and cyanoacrylate glue occlusion [CAE]) for treatment of varicose veins over 5 years. METHODS: A Markov decision model was constructed. Effectiveness was measured by re-intervention on the truncal vein, re-treatment of residual varicosities, and quality-adjusted life-years (QALYs) over 5 years. Model inputs were estimated from systematic review, the UK National Health Service unit costs, and manufacturers' list prices. Univariate and probabilistic sensitivity analyses were undertaken. RESULTS: CONS has the lowest overall cost and quality of life per person over 5 years; HL/S, EVLA, RFA, and MOCA have on average similar costs and effectiveness; and CAE has the highest overall cost but is no more effective than other therapies. The incremental cost per QALY of RFA versus CONS was £5,148/QALY. Time to return to work or normal activities was significantly longer after HL/S than after other procedures. CONCLUSIONS: At a threshold of £20,000/QALY, RFA was the treatment with highest median rank for net benefit, with MOCA second, EVLA third, HL/S fourth, CAE fifth, and CONS and UGFS sixth. Further evidence on effectiveness and health-related quality of life for MOCA and CAE is needed. At current prices, CAE is not a cost-effective option because it is costlier but has not been shown to be more effective than other options.


Assuntos
Procedimentos Cirúrgicos Eletivos/economia , Varizes/complicações , Técnicas de Ablação/economia , Tratamento Conservador/economia , Análise Custo-Benefício , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Humanos , Terapia a Laser/economia , Cadeias de Markov , Escleroterapia/economia , Varizes/economia , Varizes/cirurgia
7.
Trials ; 19(1): 428, 2018 Aug 07.
Artigo em Inglês | MEDLINE | ID: mdl-30086774

RESUMO

BACKGROUND: Thermal ablation techniques have become the first-line treatment of truncal veins in the management of chronic venous disease (CVD). Despite excellent outcomes, these methods are often associated with pain; generally due to their use of heat and the necessity of fluid infiltration around the vein. More recently, novel non-thermal techniques, such as mechanochemical ablation (MOCA) and cyanoacrylate adhesive (CAE) have been developed to overcome these unwelcome effects. So far, the novel techniques have been found to have similar efficacy to thermal methods, yet no direct comparisons between the non-thermal treatment techniques have been conducted to date, giving rise to this study. METHODS/DESIGN: This is a prospective, multicentre, randomised clinical trial, recruiting patients with truncal saphenous incompetence. Patients will be randomised to undergo either MOCA or CAE truncal ablation, followed by treatment of any varicosities. All patients will be required to wear compression stockings for 4 days post intervention. The primary outcome measure is the pain score immediately following completion of truncal ablation, measured by a 100-mm Visual Analogue Scale (VAS). The secondary outcomes are entire treatment pain scores, clinical scores, quality of life scores, occlusion rates, time to return to usual activities/work at 2 weeks, 3, 6 and 12 months. Re-intervention rate will be considered from the third month. Cost-effectiveness will be assessed for each intervention at 12 months. The study is powered to detect a mean 10-mm difference in maximum pain score. Allowing for loss to follow-up, the total target recruitment is 180 patients. DISCUSSION: The study will be the first study to compare MOCA against CAE and is designed to determine which method causes less pain. Completion of this study is expected to be the end of 2019. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT03392753 . Registered on 17 November 2017.


Assuntos
Técnicas de Ablação , Cianoacrilatos/administração & dosagem , Adesivos Teciduais/administração & dosagem , Varizes/terapia , Técnicas de Ablação/efeitos adversos , Cianoacrilatos/efeitos adversos , Humanos , Londres , Estudos Multicêntricos como Assunto , Medição da Dor , Estudos Prospectivos , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Recuperação de Função Fisiológica , Retorno ao Trabalho , Singapura , Meias de Compressão , Fatores de Tempo , Adesivos Teciduais/efeitos adversos , Resultado do Tratamento , Varizes/diagnóstico por imagem , Varizes/fisiopatologia , Varizes/psicologia
9.
Phlebology ; 32(2): 89-98, 2017 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-27221810

RESUMO

Background Endovenous thermal ablation has revolutionised varicose vein treatment. New non-thermal techniques such as mechanical occlusion chemically assisted endovenous ablation (MOCA) allow treatment of entire trunks with single anaesthetic injections. Previous non-randomised work has shown reduced pain post-operatively with MOCA. This study presents a multi-centre randomised controlled trial assessing the difference in pain during truncal ablation using MOCA and radiofrequency endovenous ablation (RFA) with six months' follow-up. Methods Patients undergoing local anaesthetic endovenous ablation for primary varicose veins were randomised to either MOCA or RFA. Pain scores using Visual Analogue Scale and number scale (0-10) during truncal ablation were recorded. Adjunctive procedures were completed subsequently. Pain after phlebectomy was not assessed. Patients were reviewed at one and six months with clinical scores, quality of life scores and duplex ultrasound assessment of the treated leg. Results A total of 170 patients were recruited over a 21-month period from 240 screened. Patients in the MOCA group experienced significantly less maximum pain during the procedure by Visual Analogue Scale (MOCA median 15 mm (interquartile range 7-36 mm) versus RFA 34 mm (interquartile range 16-53 mm), p = 0.003) and number scale (MOCA median 3 (interquartile range 1-5) versus RFA 4 mm (interquartile range 3-6.5), p = 0.002). ' Average' pain scores were also significantly less in the MOCA group; 74% underwent simultaneous phlebectomy. Occlusion rates, clinical severity scores, disease specific and generic quality of life scores were similar between groups at one and six months. There were two deep vein thromboses, one in each group. Conclusion Pain secondary to truncal ablation is less painful with MOCA than RFA with similar short-term technical, quality of life and safety outcomes.


Assuntos
Ablação por Cateter/métodos , Procedimentos Endovasculares/métodos , Varizes/cirurgia , Adulto , Ablação por Cateter/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Dor/etiologia , Dor/fisiopatologia , Varizes/fisiopatologia
10.
Phlebology ; 31(1 Suppl): 125-9, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-26916779

RESUMO

Management of varicose vein disease has changed drastically over the past decades. Since its introduction in vein practice, surgery has gone through several stages of evolution until the method of ligation with stripping eventually became and remained the standard for a long time. It was found to be effective at treating the condition and, indications of its beneficial impact on patients' quality of life soon also became evident. However, being associated with significant morbidity, surgery gradually fell out of favour, especially, once the newer endovenous techniques were launched around the turn of the century. These endothermal methods allowed procedures to be carried out under local anaesthetic as day case interventions, often with a similar or even better effect on occlusion rates and quality of life. In addition, there is mounting evidence that these newer techniques might be more cost-effective. This review evaluates surgical treatment of varicose veins compared to endovenous methods and also assesses its place in current phlebological practice.


Assuntos
Hipertermia Induzida/métodos , Qualidade de Vida , Varizes/terapia , Seguimentos , Humanos , Fatores de Tempo , Varizes/fisiopatologia
11.
Phlebology ; 31(1): 5-14, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-26130051

RESUMO

Varicose veins are common and their management has undergone a number of changes over the years. Surgery has been the traditional treatment option, but towards the 21st century, new endovenous thermal ablation techniques, namely, radiofrequency ablation and endovenous laser ablation, were introduced which have revolutionised the way varicose veins are treated. These minimally invasive techniques are associated with earlier return to normal activity and less pain, as well as enabling procedures to be carried out as day cases. They are, however, also known to cause a number of side-effects and involve infiltration of tumescent fluid which can cause discomfort. Non-thermal, non-tumescent methods are believed to be the answer to these unwelcome effects. Ultrasound-guided foam sclerotherapy is one such non-thermal, non-tumescent method and, despite a possible lower occlusion, has been shown to improve the quality of life of patients. The early results of two recently launched non-thermal, non-tumescent methods, mechanochemical ablation and cyanoacrylate glue, are promising and are discussed.


Assuntos
Escleroterapia/métodos , Varizes/terapia , Feminino , Humanos , Masculino , Varizes/patologia
13.
Int Wound J ; 10(1): 98-104, 2013 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-22364410

RESUMO

Immunosuppressive therapy is increasingly being used in clinical practice and has been shown to affect wound healing to varying degrees. This article looks at the effects of the newer immunosuppressive agents on wound healing. It is shown that wound healing is impaired via different mechanisms. Some of the animal and human studies are reviewed in more detail. It is shown that some of the newer agents affect wound healing to such an extent that reduction or avoidance of these drugs until complete wound healing is achieved is advocated. More research is required for these newer agents to determine the most appropriate time to introduce them.


Assuntos
Imunossupressores/farmacologia , Cicatrização/efeitos dos fármacos , Ferimentos e Lesões/tratamento farmacológico , Animais , Azatioprina/farmacologia , Ciclosporina/farmacologia , Everolimo , Humanos , Ácido Micofenólico/análogos & derivados , Ácido Micofenólico/farmacologia , Ratos , Sirolimo/análogos & derivados , Suínos , Tacrolimo/farmacologia
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