A description of the 'smile sign' and multi-pass technique for endovenous laser ablation of large diameter great saphenous veins.

Aims To report on great saphenous vein diameter distribution of patients undergoing endovenous laser ablation for lower limb varicose veins and the ablation technique for large diameter veins. Methods We collected retrospective data of 1929 (943 left leg and 986 right leg) clinically incompetent great saphenous vein diameters treated with endovenous laser ablation over five years and six months. The technical success of procedure, complications and occlusion rate at short-term follow-up are reported. Upon compression, larger diameter veins may constrict asymmetrically rather than concentrically around the laser fibre (the 'smile sign'), requiring multiple passes of the laser into each dilated segment to achieve complete ablation. Results Of 1929 great saphenous veins, 334 (17.31%) had a diameter equal to or over 15 mm, which has been recommended as the upper limit for endovenous laser ablation by some clinicians. All were successfully treated and occluded upon short-term follow-up. Conclusion We suggest that incompetent great saphenous veins that need treatment can always be treated with endovenous laser ablation, and open surgery should never be recommended on vein diameter alone.

Anatomical abnormalities of the pelvic venous system and their implications for endovascular management of pelvic venous reflux.

Background Pelvic venous reflux is often treated with pelvic vein embolisation; however, atypical pelvic venous anatomy may provide therapeutic challenges. Methods We retrospectively reviewed seven patient files and reported symptoms, diagnostic imaging, aberrant anatomy and means by which the interventional radiologist successfully completed the procedure. Any follow-up data were included if available. Results Four anatomical abnormalities were found: internal iliac veins draining into the contralateral common iliac vein, duplicated inferior vena cava, reverse-angle renal veins with atypical left ovarian vein drainage and direct drainage of the internal iliac vein to the inferior vena cava. All patients were successfully treated with pelvic vein embolisation. Conclusion Abnormal embryologic development may cause variable pelvic venous anatomy. Knowledge of this will enable interventional radiologists to successfully treat such patients.

Strip-tract revascularization as a source of recurrent venous reflux following high saphenous tie and stripping: results at 5-8 years after surgery.

OBJECTIVE: We have previously reported strip-tract revascularization 1 year following high saphenous ligation and inversion stripping. This study reports the 5-8 year results in the same cohort. METHODS: Between 2000 and 2003, 72 patients presented with primary varicose veins and had undergone high saphenous ligation and inversion stripping plus phlebectomies with or without subfascial endoscopic perforator surgery. Of the 64 patients who had attended for follow-up at 1 year, 35 patients (male:female, 16:19; 39 legs) underwent duplex ultrasonography 5-8 years after surgery (response rate 55%). Duplex ultrasonography was performed and all strip-tract revascularization and reflux and groin neovascularization was documented. RESULTS: Eighty-two percent of legs of patients showed some evidence of strip-tract revascularization and reflux. Full and partial strip-tract revascularization and reflux was seen in 12.8% and 59% of limbs of patients, respectively, and 10.2% limbs of patients had neovascularization only at the saphenofemoral junction only. Seven limbs of patients showed no revascularization. CONCLUSION: Five to eight years after high saphenous tie and stripping, 82% of legs of patients showed some strip-tract revascularization and reflux and 12% showed total revascularization and reflux of the stripped great saphenous vein.

Coil protruding into the common femoral vein following pelvic venous embolization.

Pelvic venous embolization is performed for pelvic congestion syndrome and prior to lower limb varicose vein surgery in females with associated pelvic venous insufficiency. The procedure is analogous to varicocele embolization in males, although refluxing internal iliac vein tributaries may also be embolized. We report a case of inadvertent coil placement in the common femoral vein while embolizing the obturator vein, during pelvic vein embolization for recurrent lower limb varicose veins. There were no clinical consequences and the coil was left in situ. We advise caution when embolizing internal iliac vein tributaries where there is clinically significant communication with veins of the lower limb.