Objective: A randomized clinical trial assessing the difference in quality of life and clinical outcomes between delayed and simultaneous phlebectomies in the context of endovenous truncal vein ablation.Background: Endovenous ablation has replaced open surgery as the treatment of choice for truncal varicose veins. Timing of varicosity treatment is controversial with delayed and simultaneous pathways having studies advocating their benefits. A previous small randomized study has shown improved outcomes for simultaneous treatment.Methods: Patients undergoing local anesthetic endovenous thermal ablation were randomized to either simultaneous phlebectomy or delayed varicosity treatment. Patients were reviewed at 6 weeks, 6 months, and 1 year with clinical and quality of life scores completed, and were assessed at 6 weeks for need for further varicosity intervention, which was completed with either ultrasound-guided foam sclerotherapy or local anesthetic phlebectomy. Duplex ultrasound assessment of the treated trunk was completed at 6 months.Results: 101 patients were successfully recruited and treated out of 221 suitable patients from a screened population of 393. Patients in the simultaneous group (n = 51) showed a significantly improved Venous Clinical Severity Score at all time points, 36% of the delayed group required further treatment compared with 2% of the simultaneous group (P < 0.001). There were no deep vein thromboses, with 1 superfificial venous thrombosis in each group.Conclusions: Combined endovenous ablation and phlebectomy delivers improved clinical outcomes and a reduced need for further procedures, as well as early quality of life improvements.

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OBJECTIVES:Although the clinical benefits of endovenous thermal ablation are widely recognized, few studies have evaluated the health economic implications of different treatments. This study compares 6-month clinical outcomes and cost-effectiveness of endovenous laser ablation (EVLA) compared with radiofrequency ablation (RFA) in the setting of a randomized clinical trial.METHODS:Patients with symptomatic primary varicose veins were randomized to EVLA or RFA and followed up for 6 months to evaluate clinical improvements, health related quality of life (HRQOL) and cost-effectiveness.RESULTS:A total of 131 patients were randomized, of which 110 attended 6-month follow-up (EVLA n = 54; RFA n = 56). Improvements in quality of life (AVVQ and SF-12v2) and Venous Clinical Severity Scores (VCSS) achieved at 6 weeks were maintained at 6 months, with no significant difference detected between treatment groups. There were no differences in treatment failure rates. There were small differences in favor of EVLA in terms of costs and 6-month HRQOL but these were not statistically significant. However, RFA is associated with less pain at up to 10 days.CONCLUSIONS:EVLA and RFA result in comparable and significant gains in quality of life and clinical improvements at 6 months, compared with baseline values. EVLA is more likely to be cost-effective than RFA but absolute differences in costs and HRQOL are small.

The objective of the study was to review the literature reporting visual disturbance (VD) following sclerotherapy for varicose veins. Underlying mechanisms will be discussed. A literature search of the databases Medline and Google Scholar was performed. Original articles including randomized trials, case series and case reports reporting VD in humans following sclerotherapy for varicose veins were included. Additional references were also obtained if they had been referenced in related publications. The search yielded 4948 results of which 25 reports were found to meet the inclusion criteria. In larger series with at least 500 included patients the prevalence of VD following sclerotherapy ranges from 0.09% to 2%. In most reports foam sclerotherapy was associated with VD (19); exclusive use of liquid sclerosant was reported in two cases, some reports included foam and liquid sclerosant (4). There were no persistent visual disorders reported. VD occurred with polidocanol and sodium tetradecyl sulphate in different concentrations (0.25–3%). Various forms of foam preparation including various ways of foam production and the liquid – air ratio (1 or 2 parts of liquid mixed with 3, 4 or 5 parts of air) were reported in association with the occurrence of VD. VDs following sclerotherapy for varicose veins are rare and all reported events were transient. Bubble embolism or any kind of embolism seems unlikely to be the only underlying mechanism. A systemic inflammatory response following sclerotherapy has been suggested. Further research to clarify the mechanism of action of sclerosants is required.

Background: Recurrent varicose veins (RVV) occur in 13% to 65% of patients following treatment, and remain a debilitating and costly problem. RVV were initially thought largely to be due to inadequate intervention, however, more recently neovascularization and other factors have been implicated. This review aims to provide an overview of the current understanding of the etiology and pathogenesis of RVV.Methods: A systematic search of the PubMed database was performed using the search terms including "recurrent," " varicose veins," and "neovascularization."Results: Three types of RVV have been reported, namely residual veins, true RVV, and new varicose veins, although the definitions varied between studies. RVV are attributable to causes including inadequate treatment, disease progression, and neovascularization. Using duplex ultrasonography, neovascularization has been observed in 25% to 94% of RVV. These new vessels appear in various size, number, and tortuosity, and they reconnect previously treated diseased veins to the lower limb venous circulation. Histologically, these vessels appear primitive with incomplete vein wall formation, decreased elastic component, and lack of valves and accompanying nerves. Although the rate of RVV following open surgery and endovenous treatment appears similar, neovascularization seems less common following endothermal ablation. Other causes of RVV following endovenous treatment include recanalization and opening of collaterals.Conclusions: Recurrence remains poorly understood following treatment of varicose veins. Neovascularization is an established and common cause of RVV, although other factors may contribute. (J Vasc Surg 2013;57:860-8.)

Chronic venous disorders remain a common problem worldwide; however, despite increasing research into novel endovenous therapies for the treatment of superficial venous disease, the natural history of primary venous disorders remains poorly understood. The following article provides a review of the longitudinal studies evaluating the progression of chronic venous disorders in the published literature. This includes a summary of the rate of development of venous disease in asymptomatic limbs and the rate of progression of venous disease in terms of hemodynamic, anatomical, and clinical progression including the development of skin changes and venous ulceration.Venous disorders, including varicose veins and superficial venous insufficiency, are a common pathology, thought to affect between 15% and 40% of the adult population. 1-2 They have plagued mankind for thousands of years and there is documentation of their existence from as early as 3500 BC. 3 In the last decade, the development of endovenous techniques has led to a rapid increase in the popularity of many novel therapies including thermal and chemical ablation techniques. 4-7 Yet, despite the large number of research studies supporting the use of new devices, the etiology and natural history of the progression of venous disease remains poorly understood. Evidence from clinical ultrasonographic and histological studies supports a multicentric theory for the development of venous disorders due to abnormalities in the composition of the vein wall leading to functional changes. 8-9 However, the investigation of the progression of venous disease is complex and can be measured in a number of different ways. In recent years, there has been a move away from the use of surrogate end points to grade disease severity, such as the presence or absence of reflux, or the use of hemodynamic parameters such as venous refill times. A greater emphasis is now placed on the clinical assessment of disease severity and its functional impact on the individual patient. The association between the presence of superficial reflux and venous hemodynamic measurements with clinical and functional outcomes has been shown to be weak, 2,10,11 and the relationship between these parameters remains poorly understood.To date, there have been few studies that have investigated the natural history of the progression of primary venous disease. Much of the current information is based on patients self-reporting their symptoms, many of whom subsequently undergo treatment, and the natural history of the condition is infrequently documented. In the current financial climate, the natural history of patients presenting with mild or moderate venous disease becomes increasingly important in order to justify the allocation of scarce resources. The overall societal burden of venous disease is unknown; however, chronic venous ulceration is debilitating for patients and costly for society and therefore preventative treatments are likely to be cost effective. 12,13 This article includes a review of the available information from longitudinal studies to date.

Objective: The wide variety of outcome measures to evaluate patients with varicose veins poses significant difficulties when comparing clinical trials. In addition, the relationship between different outcome measures is poorly understood. The aim of this study was to compare anatomical, hemodynamic, and clinical outcomes with disease-specific quality-of-life tools in patients undergoing treatment for varicose veins.Methods: Patients undergoing treatment for symptomatic veins in a single unit were studied. Assessments included duplex ultrasonography, digital photoplethysmography, evaluation of Venous Clinical Severity Scores and CEAP scores, generic (Short Form 12 [SF12]) and disease-specific (Aberdeen Varicose Vein Questionnaire [AVVQ], and Specific Quality-of-life and Outcome Response-Venous [SQOR-V]) questionnaires. Patients were reviewed at 6 weeks when hemodynamic, clinical, and quality-of-life assessments were repeated. The relationships between these outcomes were assessed.Results: The AVVQ showed a strong positive correlation with the SQOR-V (Spearman coefficient 0.702; P < .001) and weaker, but significant correlations with the SF12 physical and mental component scores and the Venous Clinical Severity Score (VCSS) (P < .001, P = .019, and P < .001, respectively, Spearman correlation). No correlations were observed between the AVVQ and photoplethysmography results (Spearman coefficient -0.042; P = .606), and weak correlations were observed with the AVVQ and anatomical reflux. At 6 weeks, functional, clinical, and hemodynamic measurements were all responsive to changes following interventions; however, correlations observed between changes in disease-specific quality-of-life and generic, clinical, and hemodynamic outcomes were weak.Conclusions: Both the AVVQ and SQOR-V questionnaire are sensitive and responsive disease-specific questionnaires, which correlate with generic and clinical outcomes to some extent. Anatomical and hemodynamic measurements correlated poorly with functional outcomes both preoperatively and following interventions. (J Vasc Surg 2011;53: 374-82.)

Hypoxia-inducible factor-1 (HIF-1) is a nuclear transcription factor that is upregulated in hypoxia and co-ordinates the adaptive response to hypoxia by driving the expression of over 100 genes. In facilitating tissues to adapt to hypoxia, HIF-1 may have a role in reducing the cellular damage induced by ischaemia, such as that seen in peripheral arterial disease (PAD), or following acute ischaemic insults such as stroke and myocardial infarction. This therefore raises the possibility of HIF-1 modulation in such contexts to reduce the consequences of ischaemic injury. HIF1 has further been implicated in the pathogenesis of atherosclerosis, abdominal aortic aneurysm (AAA) formation, pulmonary hypertension and systemic hypertension associated with obstructive sleep apnoea. Through a better understanding of the role of HIF-1 in these disease processes, novel treatments which target HIF-1 pathway may be considered. This review summarises the role of HIF-1 in arterial disease, specifically its role in atherosclerosis, ischaemic heart disease, in-stent restenosis following coronary revascularisation, stroke, PAD, AAA formation, pulmonary artery hypertension and systemic hypertension. The potential for exploiting the HIF-1 signalling pathway in developing therapeutics for these conditions is discussed, including progress made so far, with attention given to studies looking into the use of prolyl-hydroxylase inhibitors.

Background: Sclerotherapy has been shown to be an effective and increasingly popular therapeutic strategy for the treatment of varicose veins. However, recent reports of serious side effects, including cerebrovascular accidents (CVA) and transient ischemic attacks (TIA), as well as speech and visual disturbances, have caused serious concern regarding its use. This review evaluated the reported incidences of neurological side effects associated with the use of sclerotherapy.Methods: A systematic search of the data bases MEDLINE, OVID Embase, and Google Scholar was undertaken by two independent reviewers. Articles reporting neurological side effects in humans following foam and liquid sclerotherapy were included; animal studies, laboratory studies, and review articles were excluded. Additional references were also obtained using the related articles function.Results: The search yielded 1023 articles, of which 41 studies were found to meet the inclusion criteria. A total of 10,819 patients undergoing sclerotherapy were reviewed. There were 12 case reports of CVA with confirmatory brain imaging and nine reports of TIA. There were 97(0.90%) reports of neurological events overall, including TIA, visual and speech disturbances, and 29 cases of reported migraine (0.27%). Symptoms occurred at times ranging from minutes to several days following sclerotherapy. Eleven patients with TIA or CVA were found to have a right to left cardiac shunt, usually a patent foramen ovale.Conclusions: Neurological side effects following sclerotherapy are a rare occurrence; however, CVA associated with the use of sclerotherapy is clearly documented. The pathologic mechanisms resulting in CVA are likely to be different to those leading to migraine and visual disturbances; however, care should be exercised in patient selection, particularly in those with known cardiac defects. (J Vasc Surg 2012;55:243-51.)

INTRODUCTION:This paper aims to summarize the scientific rationale and future perspectives in the development of effective matrix metalloproteinase (MMP) modulators in the management of patients with arterial and venous disease.METHODS:Pubmed, Embase and Cinahl databases were searched using the search terms 'MMP', 'matrix metalloproteinase', 'arterial disease', 'venous disease', 'aneurysm', 'vascular disease', 'atherosclerosis' and 'varicose veins'. Articles focussing on aneurysm disease, peripheral arterial disease, carotid stenosis and venous disorders were included.RESULTS:Animal studies assessing MMP expression have demonstrated that MMP-2 and MMP-9 may contribute to arterial aneurysm formation and in atherosclerosis. Human studies and animal models have shown that MMP-3 and MMP-9 may have a protective role against plaque development and destabilization whereas MMP-12 might promote these changes. In venous disease, increased expression of MMP-1, MMP-9 and MMP-13 have been shown in human varicose veins. MMP-2 and MMP-9 were also shown to be upregulated in experimentally induced venous hypertension and higher concentrations of MMP-2 in wound exudate and biopsies have been shown to correlate with impaired venous ulcer healing. The use of statins has become widespread in patients with arterial disease and MMP inhibition is likely to contribute to the mechanism of action. More selective MMP modulators are currently being developed, although clinical studies are currently lacking.CONCLUSIONS:MMPs have been directly implicated in the pathophysiology of many arterial and venous disorders and remain an important potential therapeutic target. Studies are needed to further develop and demonstrate the clinical benefits of MMP modulating agents.

Objectives: The aim of this study was to evaluate postoperative pain following endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) and identify risk factors for increased pain. Methods: Patients undergoing either segmental RFA (VNUS Closure Fast TM , VNUS Medical Technologies, San Jose, California) or EVLA (980 nm) for varicose veins completed a preoperative disease-specific quality-of-life questionnaire (Aberdeen Varicose Vein Questionnaire [AVVQ]) and a diary card recording postoperative pain, return to normal activities, and return to work. Median 3- and 10-day pain scores were calculated. Results: In all, 81 patients returned diary cards (RFA = 45, EVLA = 36). Patients receiving RFA reported less postoperative pain than those receiving EVLA at 3 days (14.5 vs 25.8 mm, P = .053, Mann-Whitney U test) and 10 days (13 vs 23.3 mm, P = .014, Mann-Whitney U test) and returned to work earlier than those receiving EVLA (median 5 vs 9 days, P = .022). Conclusions: Patients treated with segmental RFA had less postoperative pain and returned to work quicker than those treated with EVLA.

Purpose: To report a salvage maneuver for accidental coverage of both renal arteries during endovascular aneurysm repair (EVAR) of an infrarenal aortic aneurysm (AAA) and survey our surgical colleagues in the UK for their use of this bypass procedure. Methods: A 74-year-old woman who had an EVAR complicated by renal failure secondary to malposition of the stent-graft underwent successful delayed renal revascularization with hepatorenal and splenorenal bypasses. This case prompted a literature review and preparation of an online 6-part questionnaire regarding the incidence and management of renal impairment following EVAR. The survey invitation was sent to all listed members of the Vascular Society of Great Britain and Ireland. Results: Responses from 68 (10.5%) of the 650 vascular surgeons invited to participate in the survey were analyzed. The combined experience of those who completed the survey was >1500 EVAR procedures per annum. Forty percent (27/68) of the respondents had experienced a case of bilateral renal artery occlusion during EVAR. Two thirds (67%, 18/27) of these surgeons stated a preference for revascularizing the kidneys endovascularly, 7 surgeons would convert to open repair, 1 surgeon favored iliorenal bypass, and another suggested splenorenal bypass. Following intervention, 15 (56%) of 27 surgeons achieved revascularization that resulted in a return to baseline serum creatinine, 7 (26%) achieved partial recovery of the patient's serum creatinine, 3 (11%) had a patient on permanent dialysis, and 2 (7%) had patients who died (after open repair and endovascular procedure, respectively). Conclusion: Bilateral renal artery occlusion caused by malposition of a stent-graft is probably underreported. If revascularization of the kidneys by endovascular techniques fails, there is no consensus as to the optimal approach. Delayed revascularization should be considered if the kidneys show concentration of imaging contrast. Hepato-spleno-renal bypass, which has not heretofore been indicated for renal salvage post EVAR, can provide a good functional result in this situation.

Objective: To evaluate patient satisfaction following endothermal ablation for varicose veins (VVs). Methods: A 12-question survey was sent to consecutive patients treated with endothermal ablation—questions related to preprocedure symptoms, recurrence, further treatments, and patient satisfaction. Results: Questionnaires sent a median 12 (range 6-22) months postintervention were returned by 177 (60.0%) of 295 patients; 63 (35.6%) of 177 received treatment for recurrent VVs. Preintervention symptoms included aching (141 [79.7%] of 177), swelling (86 [48.6%] of 177), and heaviness (72 [40.7%] of 177). Improvements in preoperative symptoms were reported by 82.5% (146 of 177). Postintervention recurrence was reported by 87 (49.4%) of 177; 61 (70.1%) of 87 reported a few recurrent varicosities only. Further treatment was required by 11 (6.2%) of 177; 79 (44.6%) of 177 of patients reported no complications. The majority (151 [85.8%] of 176) were satisfied with their treatment. In all, 16 (25.4%) of 62 of patients treated for recurrent VVs were dissatisfied versus 9 (7.9%) of 114 of those with primary VVs (P = .0026). Conclusions: The majority of patients are satisfied with results following endothermal ablation. Dissatisfaction may be more likely following treatment for recurrent VVs.

Background: Endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) are both associated with excellent technical, clinical and patient-reported outcomes for the treatment of varicose veins. The aim of this study was to compare the techniques in a randomized clinical trial. Methods: Consecutive patients with primary great saphenous vein reflux were randomized to EVLA (980 nm) or RFA (VNUS  ClosureFAST TM ) at a single centre. The primary outcome measure was postprocedural pain after 3 days. Secondary outcome measures were quality of life at 6 weeks, determined by the Aberdeen Varicose Vein Questionnaire (AVVQ) and Short Form 12 (SF-12  ), and clinical improvement assessed by the Venous Clinical Severity Score (VCSS). Analyses were performed on the basis of intention to treat using multivariable linear regression. Results: Some 131 patients were randomized to EVLA (64 patients) or RFA (67). Mean(s.d.) pain scores over 3 days were 26·4(22·1) mm for RFA and 36·8(22·5) mm for EVLA (P = 0·010). Over 10 days, mean(s.d.) pain scores were 22·0(19·8) mm versus 34·3(21·1) mm for RFA and EVLA respectively (P = 0·001). The mean(s.d.) number of analgesic tablets used was lower for RFA than for EVLA over 3 days (8·8(9·5) versus 14·2(10·7); P = 0·003) and 10 days (20·4(22·6) versus 35·9(29·4) respectively; P = 0·001). Changes inAVVQ, SF-12  andVCSS scores at6 weeks weresimilar inthetwo groups:AVVQ

The peri-operative use of antiplatelet, anticoagulant and other drugs for patients undergoing carotid endarterectomy (CEA) is unclear and consensus is lacking. This study aimed to assess the current practice of European vascular surgeons with respect to antiplatelet and other medications.

A variety of endothermal treatments are currently available for the treatment of varicose veins, offering the prospect of less discomfort and quicker return to normal activities compared to traditional surgery. The aim of this study was to evaluate which factors may contribute to post-operative pain following endothermal ablation procedures. Patients treated with endovenous laser ablation (EVLA) or radiofrequency ablation (RFA) completed the Aberdeen Varicose Vein Questionnaire (AVVQ) before surgery and a 100mm visual analogue diary card to record post-operative pain scores. Initial VCSS and CEAP scores were assessed by a clinician and recorded along with demographic and operative details. Independent risk factors for post-operative pain were identified using a multivariate linear regression model. Over a 6 month period, 75 patients completed diary cards. RFA was performed in 43/75 and EVLA in 32/75. The median (range) age was 48 years (27-78) and 57/75 were female. Median (range) AVVQ and VCSS scores were 17.59 (2.47-74.3) and 4 (0-13) respectively. Age, sex, AVVQ, VCSS and CEAP scores were comparable between the treatment groups (p=0.528, 0.862, 0.186, 0.930 & 0.240 respectively, Mann Whitney U test). Overall median (range) pain scores after 3 and 10 days were 20mm (1-81mm) and 17mm (1-85mm). Pain scores were significantly higher after EVLA compared to RFA after 3 days (31mm (2-80mm) versus 16mm (1-81mm) p=0.016 Mann Whitney U) and after 10 days (24 mm (1-85mm) versus 13mm (1-68mm), p=0.003 Mann Whitney U). Using a multivariate analysis, we found that none of the other factors assessed predicted post operative pain score at 3 days or at 10 days. Table 1. Results of multivariate linear regression analysis (outcome - average post-operative pain score over 3 days and 10 days).Tabled 1Multivariate linear regression analysis over 3 daysMultivariate linear regression analysis over 10 daysRisk factor assessedHR95% CIP valueHR95% CIP valueMale sex−0.064(−16.702-10.620)0.657−0.065(−13.143-8.196)0.644Patient age−0.063(−0.532-0.346)0.672−0.225(−0.610-0.075)0.123Pre-op AVVQ−0.040(−0.707-0.558)0.814−0.071(−0.601-0.387)0.666Pre-op VCSS0.256(−1.059-6.529)0.1540.310(−0.295-5.632)0.077Pre-op CEAP grade0.066(−6.311-8.978)0.7280.064(−4.927-7.015)0.727Bilateral surgery0.008(−12.564-13.217)0.960−0.070(−12.350-7.786)0.651Total length of vein ablated−0.072(−0.284-0.180)0.657−0.130(−0.256-0.106)0.410 Open table in a new tab Pain scores were lower after RFA compared to EVLA, however, sex, age, AVVQ, VCSS, CEAP score, bilateral intervention or the length of vein ablated were not predictive of post operative pain.

Restricted accessAbstractFirst published online September 18, 2009Tenth Meeting of the European Venous Forum: Copenhagen, Denmark, 5–7 June 2009Volume 24, Issue 5https://doi.org/10.1258/phleb.2009.09a003