Primary saphenous vein insufficiency: prospective studies on diagnostic duplex ultrasonography and endovenous treatment with endovenous radiofrequency-resistive heating

Tero Rautio

Department of Surgery, P.O.Box 5000, FIN-90014 University of Oulu , Finland

Abstract

patients admitted for operative treatment of varicose veins in the tributaries of the primary long saphenous vein were randomly assigned to endovenous obliteration (n = 15) or stripping operation (n = 13). The patients were followed up for 7–8 weeks postoperatively and examined by duplex ultrasonography. The comparison of costs included both direct medical costs and costs due to lost of productivity. All operations were successful, and the complication rates were similar in the two groups. The sick leaves were significantly shorter in the endovenous obliteration group [6.5 (SD 3.3) vs. 15.6 (SD 6.0), 95 % CI 5.4 to 12.9, p < 0.001, t-test]. When the value of the lost working days was included, the endovenous obliteration was societally cost-saving.

Dedication

To Emma and Anna

Table of Contents
Acknowledgements
Abbreviations
List of original publications
1. Introduction
2. Review of literature
2.1. Surgical anatomy of the saphenous veins
2.2. Normal venous function
2.3. Pathophysiology of chronic venous disease
2.3.1. Uncomplicated chronic venous disease
2.3.2. Complicated chronic venous disease
2.4. Risk factors and etiology of chronis venous disease
2.5. Epidemiology of chronic venous disease
2.6. Classification of chronic venous disease
2.7. Diagnosis of chronic venous disease
2.7.1. Symptoms and signs
2.7.2. Clinical examination and tests
2.7.3. Hand-held Doppler
2.7.4. Duplex ultrasonography
2.7.5. Fluoroscopy examinations
2.7.6. Comparison of diagnostic methods
2.8. Conservative treatment
2.9. Operative treatment
2.9.1. Indications for surgery
2.9.2. Planning of the operation for primary saphenous vein insufficiency
2.9.3. Stripping operations
2.9.4. Local phlebectomies
2.9.5. Endovenous obliteration
2.9.6. Other treatment approaches
2.10. Outcome of operative treatment
2.10.1. Postoperative convalescence
2.10.2. Complications
2.10.3. Recurrence
3. Purpose of the present study
4. Patients and methods
4.1. Ethical aspects
4.2. Patients
4.3. Diagnostic methods and pathway (I-II)
4.3.1. Hand-held Doppler (I-II)
4.3.2. Duplex ultrasonography
4.3.3. Planning of treatment
4.4. Surgery
4.4.1. Anesthesia
4.4.2. Phlebectomy and sclerotherapy (III-IV)
4.4.3. Stripping operation (IV)
4.4.4. Endovenous obliteration (III-IV)
4.5. Postoperative care and follow-up (III-IV)
4.6. Calculation of costs (IV)
4.7. Statistical analysis
5. Results
5.1. Diagnostic methods (I-II)
5.1.1. Accuracy of hand-held Doppler (I-II)
5.1.2. Planning of the treatment of varicose veins (I-II)
5.2. Feasibility of endovenous obliteration (III)
5.3. Comparison of results after endovenous obliteration vs. stripping operation (IV)
5.3.1. Efficacy of endovenous obliteration and stripping operation and related complications
5.3.2. Sick leave and postoperative convalescence
5.3.3. Procedure-related costs
6. Discussion
6.1. Diagnostic methods (I-II)
6.2. Planning of the treatment (I-II)
6.3. Feasibility of endovenous obliteration (III)
6.4. Comparison of endovenous obliteration and stripping operation (IV)
7. Conclusions
References
List of Tables
1. Prevalence (%) of lower-limb venous disease in adults (Callam 1994)
2. Classification of chronic lower extremity venous disease(Porter & Moneta 1995)
3. CEAP Clinical classification of chronic lower extremity venous disease (Porter & Moneta 1995).
4. Venous Clinical Severity Score (VCSS)
5. Venous Disability score (VDS)
6. Studies comparing HHD and duplex ultrasonography
7. Patients’ characteristics (I and II).
8. Patient characteristics (IV)
9. Costs of endovenous obliteration and conventional surgery in the treatment of primary varicose veins (USD*) (IV).
10. Comparison of the findings of hand-held Doppler examination and duplex scanning (I).
11. Accuracy of the hand-held Doppler in detecting saphenous vein reflux at different sites in 142 limbs (Studies I and II).
12. Postoperative complications after endovenous obliteration (III and IV) and stripping operation (IV).
List of Figures
1. Superficial veins: LSV; long saphenous vein, SSV; short saphenous vein, SFJ; saphenofemoral junction, PAV; posterior arch vein, SPJ; saphenopopliteal junction. (Picture drawn by Pentti Rautio)
2. Anatomy of the right saphenofemoral junction: AL; anterolateral tributary, FV; femoral vein, IL; inguinal ligament, PM; posteromedial tributary, SCI; superficial circumflex iliac vein, SE; inferior superficial epigastric vein, SEP; superficial external pudendal vein. (Picture drawn by Pentti Rautio)
3. Trial Profile (Study IV).
4. Duplex examination of the LSV trunk (photography by Auvo Hietaharju).
5. Duplex examination of the popliteal fossa (photography by Auvo Hietaharju).
6. Radiofrequency energy generator (VNUS Closure®) (Picture modified from original article III published in Journal of Vascular and Interventional Radiology).
7. Radiofrequency catheters (VNUS Closure®) The arrows indicate uninsulated microthermocouples. (Picture modified from original article III published in Journal of Vascular and Interventional Radiology).
8. Schematic view of endovenous obliteration with radiofrequency-resistive heating. SFJ, saphenofemoral junction; SEV, superficial epigastric vein.
9. Diagnostic pathway (study II).
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