Comment to: Six-year follow-up of endovenous laser ablation for great saphenous vein incompetence, by Spreafico G, Piccioli A, Bernardi E, Giraldi E, Pavei P, Borgoni R, Ferrini M, Baccaglini U. J Vasc Surg 2013;1:20-5.

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Stefano Ricci *
Fedor Lurie
(*) Corresponding Author:
Stefano Ricci | vandl@tiscali.it

Abstract

A prospective cohort study to assess the efficacy of endovenous laser ablation (EVLA) for treatment of great saphenous vein (GSV) insufficiency over a 6-year follow-up period was conducted at the Multidisciplinary Centre of Outpatient Surgery - University Hospital, Padua (Italy). Patients were recruited between January 2003 and July 2004, and the follow-up phase lasted until July 2010.
Two hundred and four patients underwent EVLA procedure at the outpatient surgery unit. A 980-nm diode laser and tumescent echo color doppler (ECD) guided perivenous anesthesia were used. The most prominent varices were treated with stab-vein avulsion immediately after the EVLA procedure. All patients had to wear 35-mm Hg elastic compression stockings for 24 h daily during the first week after EVLA, and then switch to second-class graduated elastic compression stockings for 4 weeks more. Patients were scheduled for clinical and ECD assessments at 3, 7, 30, and 90 days after EVLA; and thereafter once a year, for 6 years. The main outcome of the study was the incidence of clinical (e.g., lack of improvement or worsening of leg symptoms) and ECD-confirmed (e.g., finding of measurable venous reflux in the treated segment) EVLA failures (ECEFs) during the planned 6-year follow-up period.
The ECEFs were categorized as type 1 (venous reflux limited to the junction and/or the residual saphenous stump, for a maximum length of 5 cm from the junction, without reflux in its collaterals); type 2 (reflux also in a collateral vein without clinically evident recurrent varices ); or type 3 (same as 2 with clinically evident recurrent varices, either symptomatic or asymptomatic). One hundred and twenty four patients (60.8%) underwent stab-vein avulsion as well; and 65 patients (32.8%) with residual varicose veins received sclerotherapy within 12 weeks from the procedure. Fourteen (6.8%) out of 204 patients were lost for follow up. No deep vein thrombosis was detected during the follow-up period.
After 6 years, 168 (88.4%) patients reported a symptomatic improvement; of them, 87 patients had no residual symptoms, and 81 experienced a significant reduction of their leg complaints. Fourteen patients complained of persistent symptoms, six reported unsatisfactory aesthetic results, and two patients had worsened skin alterations. Of these 22 patients, only two had an ECEF as well.
Patients with a competent saphenous junction and a persistently occluded saphenous trunk were 70.0% (133/190); therefore, 57 (30.0%) had an ECEF. Of them, 20 patients had a type 1 ECEF, 18 had a type 2 ECEF [three of which were at the anterior accessory saphenous vein (ASSV)], and 19 had a type 3 ECEF (12 of which were at the ASSV). An atypical junction or one with a diameter ≥8 mm and a mean trunk diameter ≥8 mm, were highly significantly associated with ECEF.
Expected EVLA results, either from a clinical or technical (ECD) perspective, were obtained in 88.4% and 70.0% patients, respectively, and persisted throughout the 6-year follow-up period. All failures were observed within the first 2 years from EVLA.
The unexpectedly high (57/190; 30.0%) rate of ECEF is possibly due to the systematic application of the Valsalva maneuver during ECD; this probably accounts for the high rate of type 1 ECEF. It is likely that most of the technical failures observed will soon be eliminated thanks to the use of adequate linear endovenous energy density (LEED) (at least 70 joules/cm), which was not in use in the period studied, and to the latest implements now available.


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