Reconsidering the endovenous revolution

Nelzén, Olle

doi:10.1002/bjs.10192

Cited by 12 publications

(8 citation statements)

References 11 publications

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“…1e4 The report of Hamann et al strongly supports fears presented in a leading article in the British Journal of Surgery in 2016. 5 The 5 year results show that open surgery generates less groin recurrence than laser and foam, and matches laser treatment results in other areas. This was clearly pointed out by the authors, but they failed to draw conclusions from what were for many, unexpected results.…”

supporting

confidence: 61%

Re: “Editor's Choice—Five Year Results of Great Saphenous Vein Treatment: A Meta-analysis”: The Results Call for Guideline Revisions

Nelzén

2018

European Journal of Vascular and Endovascular Surgery

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The meta-analysis by Hamann et al. gives results that do not match the current treatment recommendations from multiple organisations, which clearly favour endothermal treatments before foam and open surgery. 1e4 The report of Hamann et al. strongly supports fears presented in a leading article in the British Journal of Surgery in 2016. 5 The 5 year results show that open surgery generates less groin recurrence than laser and foam, and matches laser treatment results in other areas. This was clearly pointed out by the authors, but they failed to draw conclusions from what were for many, unexpected results. In most treatment guidelines open surgery has been removed and is only recommended if endovenous treatments cannot be given. I believe a result like this ought to call for an urgent revision of existing guidelines and a resurrection of open surgery, which has been unjustly discounted. It is now important to reinforce that properly conducted open surgery is still one of the best ways of treating varicose veins and, in fact may cause fewer groin recurrences instead of more, which was the original hypothesis. It is too early to call open surgery a treatment of the past when, from a recurrence point of view, it seems to generate the best long-term results. Not all surgeons have been able to invest in endothermal alternatives, but with these results there is no need to feel ancient or inferior for using the open surgery alternative. Open surgery has also been modernised over time and is today less invasive and traumatic than during the days of Babcock some 100 years ago. From a scientific point of view there is still a place for high ligation and stripping.

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supporting

confidence: 61%

Re: “Editor's Choice—Five Year Results of Great Saphenous Vein Treatment: A Meta-analysis”: The Results Call for Guideline Revisions

Nelzén

2018

European Journal of Vascular and Endovascular Surgery

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“…Recently, in Europe, data suggesting that side-branch regurgitation from the SFJ stump left following HT+S or EVA resulted in a significantly higher rate of symptomatic REVAS than Neo. 17 – 19 ) There are reports in immunohistological studies 20 ) denying Neo as a neovascularization. The other report demonstrated that it is a mere innocent bystander unrelated to REVAS.…”

Section: Discussionmentioning

confidence: 99%

Clinical Results 5 Years after Great Saphenous Vein Stripping

Kusagawa¹,

Ozu²,

Inoue³

et al. 2021

Annals of Vascular Diseases

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Background: As a standard treatment for the varicose vein of the great saphenous vein (GSV) type, endovenous ablation (EVA) is the main approach. However, as a background to this, in Europe and the United States, neovascularization (Neo) following high ligation (HL) of the saphenofemoral junction (SFJ) at the time of GSV stripping has been emphasized as one of the reasons for the high rate of recurrence. However, in Japan, almost no similar mid- or long-term results of GSV stripping have been reported. Patients and Methods: From September 2011 to March 2014 when EVA was not my surgical option, 413 consecutive legs of patients underwent GSV stripping by myself using the same procedure. The patients were contacted by phone 5 years later, and recurrent varices after surgery (REVAS) and reoperation (REDO) were investigated. A total of 270 legs of the 391 living cases (69%) underwent venous ultrasonography (VUS). HL of the SFJ was performed via central flash ligation with towing and pulling out of the peripheral side branches containing the accessory saphenous veins. In principle, GSV stripping was performed using the invagination method in the range of the entire reflux region from the HL cut section to the confluent section of the side branch causing branch varicose veins. The range of stripping was to the upper thigh in 3 legs, to the middle thigh in 3 legs, to the lower thigh in 7 legs, to the knee in 46 legs, to the upper calve in 83 legs, to the middle calve in 52 legs, and over the full length in 76 legs. Stab avulsion was performed as much as possible for the side-branch varices. On VUS, the SFJ’s stump of GSV, the presence of side-branch remnants and their reflux, the presence or absence of Neo, and the recurrent lesions in other sites were evaluated. REVAS were classified as follows: Level 1, symptomatic recurrent lesion for which surgery is indicated; Level 2, asymptomatic recurrent lesion possibly requiring future surgery; and Level 3, asymptomatic recurrent lesion that is unlikely to require future surgery. Results: Of the 391 legs of patients who could be contacted, REDO was performed in 23 (6%), including 15 limbs, immediately after this investigation, and symptomatic REVAS were observed in 29 (7%). In 270 legs examined by VUS, REVAS were diagnosed as follows: 29 legs with Level 1 lesion, 40 legs with Level 2 lesion, and 27 legs with Level 3 lesion. Level 1 REVAS that occurred at the SFJ were observed only in 3 legs (1.1%), Level 1 REVAS due to incompetent perforating veins (IPVs) were observed in 14 legs (5%), and Level 1 solitary tributary varices were observed in 9 legs (3%). Conclusion: In this study, REVAS at the SFJ were significantly less than those in the past reports. It has been shown that REVAS due to IPVs or solitary tributary varices were more important than those at the SFJ. (This is a translation of Jpn J Phlebol 2019; 30(3): 259–265.)

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“…Specifically, the clinical risk for early groin recurrence and especially neovascularization seems to have been overestimated or could have been the result of inadequate open surgical technique used in some RCTs [8,9]. These findings have also been confirmed by long term follow-up from several RCTs, included in systematic reviews and meta-analyses, that show more groin recurrence long term from endovenous techniques than from open surgery [10][11][12].…”

Section: Discussionmentioning

confidence: 99%

“…That re-do surgery leads to inferior results has been clearly shown underlining that it is extremely important to avoid recurrent varicose veins by performing a thorough primary intervention [13]. The most important measure is not to leave SFJ stumps behind, which is probably the reason for the higher numbers of groin recurrences long term from endovenous ablations in RCTs [10][11][12]. By employing a safety margin of 1-2 cm to avoid EHIT the result is in most cases a stump left behind, often connecting to tributaries and most often the anterior accessory saphenous vein.…”

Section: Discussionmentioning

confidence: 99%

“…This despite most RCTs showing at least equal results regarding long term disease improvement and QoL. The longterm results seem to indicate that open surgery in fact leads to a lesser risk of developing groin recurrence that oven time might become symptomatic [9][10][11]. Based on results from open surgery it takes on average 8-9 years to develop symptoms from saphenous stumps [24].…”

Section: Discussionmentioning

confidence: 99%

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A One-Year Audit of Varicose Vein Surgery at a Vascular Surgical Unit with a Long-Term Duplex and Quality of Life Follow-Up

Nelzén¹,

Fransson²

2021

SCR

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Objective: With the introduction of endovenous treatments, open varicose veins surgery was discarded due to a claimed high risk of neovascularisation. A one-year audit was set up to look at results from performing mainly open surgery. Methods: All varicose vein interventions were registered and prospectively followed with colour Duplex assessments after 4-6 weeks, 1 and >5 years. In addition, Aberdeen Varicose Vein Questionnaire (AVVQ) was used in addition to Varicose Vein Severity Score (VCSS) to assess patients’ quality of life (QoL) and the disease severity. Results: During the year, 236 patients/252 legs were operated and 28% were re-do procedures. Median age was 55 years (16-87) and 70% were females. Duplex at 4-6 weeks showed a primary success rate of 91%. Neovascularisation was noted in 8% one year after primary surgery. The long-term assessment was done after a median of 69 months (39-75) and 67% of all legs were examined. After primary surgery 16% showed neovascularisation compared with and 27% after re-do procedures. VCSS improved significantly from 6 (range 1-22) to 2 at the long-term follow-up (p<0.001). The AVVQ score improved from 20 (range 3-55) down to 10 (p<0.001). Conclusion: The risk for neovascularisation seems to have been overestimated and good long-term results can be achieved following modern open surgery. The major problem is to avoid varicose vein recurrence since results from re-do procedures seem less favourable long term.

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Reconsidering the endovenous revolution

Abstract: Not as cost‐effective as you might think

Cited by 12 publications

References 11 publications

Re: “Editor's Choice—Five Year Results of Great Saphenous Vein Treatment: A Meta-analysis”: The Results Call for Guideline Revisions

Re: “Editor's Choice—Five Year Results of Great Saphenous Vein Treatment: A Meta-analysis”: The Results Call for Guideline Revisions

Clinical Results 5 Years after Great Saphenous Vein Stripping

A One-Year Audit of Varicose Vein Surgery at a Vascular Surgical Unit with a Long-Term Duplex and Quality of Life Follow-Up

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