8. Other
Duplex scanning is not mandatory after treatment for saphenous reflux.
L. Kabnick
The goal of routinely performing a postoperative duplex scan after endothermal ablation of the saphenous, veins is to detect endovenous heat-induced thrombosis and to evaluate the treatment’s efficacy.
In the USA, greater than 300 000 endovenous procedures are performed annually. The overall incidence of endothermal heat-induced thrombosis is 3% to 4% and if we exclude thrombosis class 1, which are out of clinical significance, the overall rate falls to 1% to 2%. The majority of these thrombi will disappear within 7 to 10 days with no additional sequelae. The incidence of pulmonary embolism after radiofrequency ablation is, at most, 0.03%, probably less than 0.01% and with no sequelae in Kabnick’s report.
The rate of saphenous vein closure in the immediate postoperative period is reported to be high, close to 99%, and it is obvious that assessing the efficacy of the treatment during a 3-month period with a duplex scan is not of interest.
In terms of a financial point of view, performing a duplex ultrasound during the postoperative period of each endovenous procedure costs $150 000 000 per annum for a wasteful and unnecessary healthcare test: the postoperative morbidity and mortality rates would not be affected.
The place of concomitant phlebectomy.
T. Lane
Clinical experience shows that treatment of the truncal vein does not necessarily resolve varicosities and so the need for a treatment pathway is vital. The principle behind a single treatment is clear and a deferred treatment of the tributaries provides the opportunity for varicose veins to dwindle once the venous hypertension has been resolved. Despite the question about a need for additional procedures, what are the quality of life, clinical outcomes, and safety when looking at the two options? In the randomized controlled study by Carradice, there is clearly clinical evidence for an additional procedure on tributaries combined with the endovenous laser. Three studies also show an improved outcome in early disease quality of life as well as for clinical outcomes as measured by the Vein Clinical Severity Score (VCSS) for patients treated with simultaneous endovenous ablation and varicosity treatment. These treatments are very safe and no cases of deep vein thrombosis (DVT) have been reported.
Improvement in early symptom outcomes and early clinical outcomes are reported in the literature and it is established that patients treated with endovenous ablation alone have a 43-fold relative risk of requiring further procedures. The conclusion of the author is that concomitant phlebectomy has multiple benefits, is appropriate, and should be considered as was suggested recently in the NICE guidelines.
Pneumatic pressure device for prevention of deep vein thrombosis (DVT).
M. Dennis
Heparin and low-molecular-weight heparin (LMWH) reduce asymptomatic, but not symptomatic, deep vein thrombosis (DVT) and they both increase major bleeding. They do not have significant effects on survival as reported by Lederle et al in 2011. The graduate compression stocking does not reduce DVT and may cause skin problems (CLOTS 1 trial [Clots in Legs Or Stockings after Stroke], 2009). Intermittent pneumatic compression (IPC) is an effective form of venous thromboembolism (VTE) prophylaxis. For the author, it is feasible and safe. IPC probably improves overall survival even if no data are available and it is effective in ischemic and hemorrhagic stroke. In conclusion, IPC should be used when lowering the risk of death is considered worthwhile.
EHIT, EFIT, EGIT: a new word is needed for therapy induced thrombosis.
J. Lawson
James Lawson has found an acronym for an unstable clot extension occurring after classic surgery, thermal ablation, and future developments in ablation of superficial veins: it is PACE (Post Ablation Clot Extension). A precise anatomic classification is useless because it is not related to thrombotic events. PACE forces us to find out what the characteristics of the clot extension are using duplex scanning or to find other risk factors like thrombophilia, which are prone to thromboembolic events.
