Endovenous management of varicose veins

Varicose veins are a very common condition and have been the subject of a recent proliferation of treatment modalities. The advent of the endovenous treatment era has led to a confusing array of different techniques that can be daunting when making the transition from traditional surgery. All modalities offer excellent results in the right situation, and each has its own treatment profile. Thermal ablation techniques have matured and have a reassuring and reliable outcome, but the arrival of nonthermal techniques has delivered further options for both patient and surgeon. This article provides an overview of the different treatment devices and modalities available to the modern superficial vein surgeon and details the currently available evidence and summation analysis to help surgeons to make an appropriate treatment choice for their patients

The risk of harm whilst waiting for varicose veins procedure.

INTRODUCTION: Varicose veins (VV) negatively impact quality of life (QoL) and have risks of major complications including bleeding, ulceration and phlebitis. During the COVID-19 pandemic, the VSGBI (Vascular Society of Great Britain and Ireland) and GIRFT (Get It Right First Time) classified VVs as lowest priority for intervention. OBJECTIVE: This study aims to determine harm caused and the impact on the QoL on patients waiting for their VVs procedures for more than 1 year. METHODS: This was a prospective study conducted at the Norfolk and Norwich University Hospital (NNUH). Patients with VVs awaiting intervention for >1 year were included in the study. Patients with CEAP C6 disease were considered to be too high risk to be invited for treatment during the Covid-19 pandemic. Patients were sent QoL questionnaires and underwent a telephone consultation to assess harm. Both generic (EQ-VAS and EQ-5D) and disease-specific (AVVQ and CIVIQ-14) instruments were utilised. There were no control groups available for comparison. RESULTS: 275 patients were identified (37.1% male) with median time on waiting list of 60 weeks (IQR 56-65). 19 patients (6.9%) came to major harm, including phlebitis (3.6%), bleeding (1.8%) and ulceration (1.8%). Fifty-two patients (18.9%) had minor harm, including worsening pain (12.7%) and swelling (6.2%). 6.9% reported psychological harm. Rising CEAP stage was also associated with worsening level of harm in patients with C5-6 disease (p < 0.0001). Only 8.7% stated they would decline surgery during the pandemic. 104 QoL questionnaires were returned. Median EQ-VAS and EQ-5D was 75 (IQR: 60-85) and 0.685 (0.566-0.761), respectively. Median AVVQ score was 23.2 (14.9-31.0) and CIVIQ-14 score was 33 (21-44).ConclusionsThis study highlights the impact of delaying VVs surgery during a pandemic. A significant rate of both major and minor as well as psychological harm was reported. In addition, VVs had a significant detriment to quality of life

A multi-centre randomised controlled trial comparing radiofrequency and mechanical occlusion chemically assisted ablation of varicose veins - final results of the Venefit versus Clarivein for varicose veins trial

BACKGROUND: Endovenous thermal ablation has revolutionised varicose vein treatment. New non-thermal techniques such as mechanical occlusion chemically assisted endovenous ablation (MOCA) allow treatment of entire trunks with single anaesthetic injections. Previous non-randomised work has shown reduced pain post-operatively with MOCA. This study presents a multi-centre randomised controlled trial assessing the difference in pain during truncal ablation using MOCA and radiofrequency endovenous ablation (RFA) with six months' follow-up. METHODS: Patients undergoing local anaesthetic endovenous ablation for primary varicose veins were randomised to either MOCA or RFA. Pain scores using Visual Analogue Scale and number scale (0-10) during truncal ablation were recorded. Adjunctive procedures were completed subsequently. Pain after phlebectomy was not assessed. Patients were reviewed at one and six months with clinical scores, quality of life scores and duplex ultrasound assessment of the treated leg. RESULTS: A total of 170 patients were recruited over a 21-month period from 240 screened. Patients in the MOCA group experienced significantly less maximum pain during the procedure by Visual Analogue Scale (MOCA median 15 mm (interquartile range 7-36 mm) versus RFA 34 mm (interquartile range 16-53 mm), p = 0.003) and number scale (MOCA median 3 (interquartile range 1-5) versus RFA 4 mm (interquartile range 3-6.5), p = 0.002). 'Average' pain scores were also significantly less in the MOCA group; 74% underwent simultaneous phlebectomy. Occlusion rates, clinical severity scores, disease specific and generic quality of life scores were similar between groups at one and six months. There were two deep vein thromboses, one in each group. CONCLUSION: Pain secondary to truncal ablation is less painful with MOCA than RFA with similar short-term technical, quality of life and safety outcomes

Foam sclerotherapy versus ambulatory phlebectomy for the treatment of varicose vein tributaries: study protocol for a randomised controlled trial

Background Ambulatory phlebectomies and foam sclerotherapy are two of the most common treatments for varicose vein tributaries. Many studies have been published on these treatments, but few comparative studies have attempted to determine their relative effectiveness. Methods/design This is a prospective single-centre randomised clinical trial. Patients with primary truncal vein incompetence and varicose vein tributaries requiring treatment will be assigned randomly to either ambulatory phlebectomies or foam sclerotherapy. The primary outcome measure is the re-intervention rate for the varicose vein tributaries during the study period. The secondary outcomes include the degree of pain during the first two post-operative weeks and the time to return to usual activities or work. Improvements in clinical scores, quality of life scores, occlusion rates and cost-effectiveness for each intervention are other secondary outcomes. The re-intervention rate will be considered from the third month. Discussion This study compares ambulatory phlebectomies and foam sclerotherapy in the treatment of varicose vein tributaries. The re-intervention rates, safety, patient experience and the cost-effectiveness of each intervention will be assessed. This study aims to recruit 160 patients and is expected to be completed by the end of 2019. Trial registration ClinicalTrials.gov, NCT03416413. Registered on 31 January 2018

Predicting features of visceral stent failure in fenestrated endovascular aortic aneurysm repair

Purpose: Visceral stents in fenestrated endovascular aortic repair (FEVAR) have a significant risk of complications and carry a considerable burden of reinterventions. The aim of this study is to identify preoperative and intraoperative predictors of visceral stent failure. Materials: A retrospective review of 75 consecutive FEVARs in a single center from 2013 to 2021 was undertaken. Data on mortality, stent failure, and reintervention pertaining to 226 visceral stents were collected. Methods: Anatomical features including aortic neck angulation, aneurysm diameter, and angulation of target viscerals were obtained from preoperative computed tomography (CT) scans. Stent oversizing and intraprocedural complications were recorded. Postoperative CT scans were analyzed to determine the length of cover of target vessels. Results: Only bridging stents through fenestrations to visceral vessels were considered; 28 (37%) cases had 4 visceral stents, 24 (32%) had 3, 19 (25%) had 2, 4 (5%) had 1. Thirty day mortality was 8%, a third of which was related to visceral stent complications. Intraprocedural complexity was documented during the cannulation of 8 (3.5%) target vessels, with a technical success rate of 98.7%. A significant endoleak or visceral stent failure was identified in 22 stents (9.8%) postoperatively, of which 7 (3%) had in-patient reintervention within 30 days. Further reinterventions at 1, 2, and 3 years were 12 (5.4%), 2 (1%), and 1 (0.4%), respectively. Most reinterventions were for renal stents (n=19, 86%). A smaller stent diameter and a shorter length of visceral stent were significant predictors of failure. No other anatomical feature or stent choice was found to be a significant predictor of failure. Conclusions: The modality of visceral stent failures varies, but renal stents with a smaller diameter and/or shorter length are more likely to fail over time. Their complications and reinterventions are common and carry a significant burden; therefore, close surveillance must be continued long term. Clinical impact: With this work we share the methodology adopted at our centre to treat juxtarenal aneurysm with FEVAR. Thanks to this detailed review of anatomical and technical features we provide guidance for endovascular surgeons to face hostile aneurysm with peculiar visceral vessels anatomy. With our findings will also motivate industries in their attempt to produce improved technologies able to overcome issues identified in this paper

Outcomes of patients with varicose veins

Introduction Varicose vein disease is a common ailment affecting the population. It is associated with causing an adverse effect on the quality of life of patients, with treatment of the condition known to improve it. The introduction of endovenous ablation has enabled the cost-effective treatment of the condition with procedures being carried out as day cases with an earlier return to normal activities. However, with healthcare expenditure increasingly under scrutiny, newer pathways are needed to continue the evolution of varicose vein management. Aim 1. To explore and compare the current and newer endovenous methods of treatment 2. To assess patients’ views of the current management of the condition 3. To evaluate a new referral and treatment pathway of varicose vein disease 4. To assess possible improvement in the post-procedural management of varicose veins Methods 1. A randomised controlled trial was conducted to compare radiofrequency ablation to mechanochemical ablation as well as a pilot study evaluating the use of a new cyanoacrylate adhesive sealing system. In addition, a systematic review and cost-effectiveness analysis was undertaken to evaluate the newer endovenous ablation methods. 2. A patient survey was carried out to understand the reasons for their referral as well as exploring a new management pathway. 3. A pilot study was undertaken to evaluate the feasibility of a One Stop Vein Clinic, offering same day diagnosis and treatment. 4. A randomised controlled trial comparing the use of compression stockings following endovenous ablation. Results 1. (a) With 170 patients recruited, the randomised controlled trial comparing radiofrequency and mechanochemical ablation shows that pain score during the procedure was less with the latter method, and that there were no other major differences between the two techniques. (b) This pilot study of 20 patients in the use of the new cyanoacrylate demonstrates that it is a safe and effective method, though a larger study would be able to provide further evidence of efficacy. (c) The systematic review shows that surgery and the endothermal methods seem to have lower re-intervention rates compared to foam sclerotherapy. However, a lack of comparative studies involving the non-thermal techniques meant that this analysis was unable to provide sufficient evidence as to their re-intervention rates and cost-effectiveness. 2. The patient survey of 106 patients revealed that they favoured less waiting time between appointments and their treatment. A high proportion of patients were also keen on attending a One Stop Clinic. 3. The early results of this pilot study of One Stop Vein Clinic shows that patients waited on average 4 weeks from being referred by their GP, but this study was hampered by unavailability of the treatment room for long periods and reduced possibility to add patients to the veins lists. 4. One hundred and nine patients have been recruited to the randomised controlled trial of the use of compression stockings. This shows that patients in the compression group had significantly less discomfort in the first few days following treatment, but there were no major differences by 2 weeks. Conclusions This work illustrates that varicose vein treatment is fast evolving. The newer technologies show promise, but currently, there is insufficient evidence to demonstrate their superiority over conventional endothermal methods. The One Stop Vein Clinic also shows potential, but may be difficult to incorporate into current practice without clear protocols between the different departments. The use of compression stockings following endothermal ablation indicates that it might be advantageous in the first few days, but may not necessarily have a long-term benefit.Open Acces

Energy Audit of Mauritian Industries

Abstract Three companies namely Esko &amp; Co Ltd, Cuttings Work Ltd and The Message Ltd were targeted for the purpose of this project study. The first one is Esko &amp; Co Ltd. The company has diversified its production activities to produce sweets, bubble gums, chocolates, wafers and noodles both for the local market and export purposes. Cuttings Works Ltd is the second leading company in the manufacturing of top grade products using the best possible gemstones for the jewellery grade. The company is also diversifying and expanding its market. On the other hand ‘The message Ltd’ is another company involved in the designing and make up of high class casual wear. Previously the company was only designing and preparing samples and the bulk order done in another textile factory. With respect to the highly demanding market, they have now started the production of their shirts in-house. Being exposed to competition threats from other local and overseas suppliers, it is imperative for these factories to investigate on cost saving possibilities and process improvement opportunities. A walk-through audit was carried out where data were collected. The objective of the audit was to obtain energy savings through low cost improvements that optimise the building systems and process operation so that the companies operate efficiently and effectively. On the basis of observations and calculations, the following cost savings options can be suggested:’ 1.       Savings on Fuel (HFO) used at Esko &amp; Co Ltd. A saving on fuel consumed of MUR 458 572 [PH1] (Euro 11 464 based on exchange rate of Euro 1 = MUR40) per year can be achieved by recovering the heat loss through the flash steam for pre-heating the feed-water to the boiler. Another saving on fuel of MUR 105 578 (Euro 2639) per year can be done by recovering the heat loss from the Wafers machine exhaust. Also by recovering the heat loss from the boiler chimney exhaust a saving of MUR 137 457 (Euro 3436) per year can be achieved. 2.       Savings on Electrical components. It was found that in a big manufacturing company like Esko &amp; Co Ltd, a direct saving of MUR13 278 (Euro 332) per year can easily be achieved by substituting the existing Fluorescent tube lights (18W) by 9W-T8 lamp with a return on investment of 2.8 years. However in smaller scale enterprise like The Message ltd and Cuttings Ltd, the shift on economic lamp can also lead to savings of MUR 3700 (Euro 92.5) and MUR 1386 (Euro 34.7) yearly. Most often large scale enterprise was found to be always paying a penalty fee for power factor. Hence the investment on an Automatic Correction Unit will also help doing savings. For instance, Esko &amp; Co Ltd can save MUR 3200 (Euro 80) monthly on its electricity bill with a payback of 3.1 years for the power corrector unit. Next we noticed that big companies are used to a penalty fee for power factor. As this fee is for a period of six months for every month of excess power consumed, it is worth investing on an Automatic Power Correction unit. As such foe Esko &amp; Co Ltd we found that a saving of MUR 3200 Euro 80) per month will be made with a payback period of 3.1 years for the equipment. Furthermore it was found that the power consumed by air conditioning units is quite significant. For instance for Esko &amp; Co Ltd 33 % of the total power consumed are by the air conditioning units. A direct saving in this respect is achievable by only increasing the set point temperature by 1 to 2 oC. Other simple measures can be shading of windows to prevent sunlight or using wind curtains at doors and to switch on the AC when needed can largely help to decrease the air conditioning load However there is also room for future investment in variable speed drive for the compressors of the air conditioning units which is still costly at present. 3.       Steam leakage optimisation Reduction of steam leakage can be done by replacing the return condensate line from the oil heat exchanger at Esko&amp; Co Ltd by a smaller one. It was not possible to calculate the savings as the leaks could not be measured – however results will show in the fuel bills. 4.       Reduction of heat dissipated Insulating the exhaust pipes from the Wafer machine at Esko&amp; Co Ltd by using mineral wool of thickness 57mm will considerably decrease the heat dissipated to the surrounding by 80 % and hence improving the working environment around the machine since no air conditioner is found in that room. Air conditioning load in other rooms are expected to reduce and once again here it is difficult to conduct any calculations on how much can be saved. But by taking this measure the effects are immediately seen. 5.       Transport Fuel optimisation Normally big companies like Esko&amp; Co Ltd which has many lorries for their product delivery that consume around 2330 litres of diesel monthly. As the transportation fuel is continuously increasing, this area also requires monitoring and optimisation. Simple measures like smooth driving, regular tuning and servicing of your engine can help improving the fuel economy of the company. 6.       Use of solar energy To alleviate the increasing world oil prices, the use of renewable energies are becoming important. As such we found that in a country like Mauritius where there is great potential for solar energy, the latter can be an option for companies to invest on. It was found that a grid connected system will be more advantageous and depending on an agreement with the local grid, a payback of less than 5 years can be achieved for a tariff around MUR 3 (Euro 0.08) per kWh. 7.       Avoided carbon dioxide emissions. To decrease the impact of global warming, it is important to cut down the emissions of greenhouse gases as it will be a serious threat to the third world countries and small island states in the first place as they are the most vulnerable. With the savings in the amount of HFO burned at Esko&amp; Co Ltd, we found that the avoided amount of GHG emissions amounts to 98.96 kg CO2-e/year

The advent of non-thermal, non-tumescent techniques for treatment of varicose veins

Varicose veins are common and their management has undergone a number of changes over the years. Surgery has been the traditional treatment option, but towards the 21st century, new endovenous thermal ablation techniques, namely, radiofrequency ablation and endovenous laser ablation, were introduced which have revolutionised the way varicose veins are treated. These minimally invasive techniques are associated with earlier return to normal activity and less pain, as well as enabling procedures to be carried out as day cases. They are, however, also known to cause a number of side-effects and involve infiltration of tumescent fluid which can cause discomfort. Non-thermal, non-tumescent methods are believed to be the answer to these unwelcome effects. Ultrasound-guided foam sclerotherapy is one such non-thermal, non-tumescent method and, despite a possible lower occlusion, has been shown to improve the quality of life of patients. The early results of two recently launched non-thermal, non-tumescent methods, mechanochemical ablation and cyanoacrylate glue, are promising and are discussed