Influence of Warfarin on the Success of Endovenous Laser Ablation (EVLA) of the Great Saphenous Vein (GSV)

AbstractBackgroundAlthough warfarin is routinely stopped prior to varicose vein surgery the absence of incisions may make this unnecessary prior to EVLA. Nevertheless continuing therapy may compromise ablation rates resulting in treatment failure. Since EVLA is particularly suitable for older patients with co-morbidities this study investigates whether warfarin influences outcome.MethodA prospective observational cohort study was designed to assess ablation rates (1 year, duplex ultrasound), Aberdeen varicose vein symptom severity scores (AVVSS) and patient satisfaction following GSV EVLA in 22 patients (“warfarin group”: 12 female, 10 male; 24 limbs) taking warfarin and 24 age/sex and disease-severity matched controls who were not taking anticoagulants (“no-warfarin group”).ResultsComplete ablation of the treated-length of GSV was achieved in 20/24 (83%) limbs in the “warfarin group” versus 23/24 (96%) in the “no-warfarin” group (p=0.347, chi squared). Suboptimal energy densities were delivered to 3/4 failures in the “warfarin group”. A similar, significant (p<0.001, Wilcoxon) improvement in AVVSS occurred in both groups [warfarin: median 14.6 (inter-quartile range 8.9–19.1) to 3.8 (1.9–6.2), no-warfarin: median 13.9 (IQR 7.6–20.1) to 3.5 (2.2–6.4)]. Patients were equally satisfied with outcomes (warfarin=92%, no-warfarin=90%; p=0.391, Mann–Whitney). No major complications occurred.ConclusionsEVLA in patients taking warfarin is safe and effective. Since cessation of therapy is unnecessary it should provide a valuable alternative to surgery in these patients

Angioleiomyoma of the small intestine – a rare cause of gastrointestinal bleeding

<p>Abstract</p> <p>Background</p> <p>Benign tumors are a rare cause of gastrointestinal hemorrhage of which angioleiomyomas constitute a very small minority. They have been reported in literature to present with volvulus, bleeding or intussusceptions.</p> <p>Case presentation</p> <p>An interesting case of a patient presenting with gastrointestinal bleeding from an underlying angioleiomyoma is discussed along with its management options.</p> <p>Conclusion</p> <p>Angioleiomyoma though rare can be managed successfully by surgical and/or minimally invasive endovascular procedures.</p

Superficial venous reflux: Assessment and treatment by endovenous laser ablation (EVLA)

More than 40,000 patients undergo treatment for superficial venous incompetence (varicose veins) in the UK each year. Previously the majority underwent conventional surgery with its associated inconvenience and morbidity. Endovenous laser ablation (EVLA) is a relatively new minimally invasive technique that abolishes superficial venous reflux and is an alternative treatment for some patients. Although early studies have shown it to be safe and effective for great saphenous vein (GSV) reflux there remain many questions relating to optimizing the technique and the range of patients for whom it is suitable. This thesis evaluates factors that may influence EVLA efficacy for GSV reflux and other sites of deep to superficial venous incompetence (small saphenous, anterior accessory GSV, paradoxical reflux). It also assesses changes in venous haemodynamics after EVLA which has led to recommendations on improving treatment outcomes. Further, a prospective database of patients undergoing EVLA and conventional surgery has been maintained (clinical and duplex ultrasound follow-up at 6, 12 & 52 weeks, quality of life data) which has provided additional evidence on the management of patients with varicose veins. Briefly, these studies have confirmed that laser energy density (J/cm) is the crucial factor determining successful truncal vein ablation following EVLA and that appropriate patients can continue warfarin therapy without compromising the safety or efficacy of treatment. Other studies demonstrate the transition of ablated truncal veins from a non-compressible “thrombosed” vein to becoming non-visible 1 year after EVLA. Further, sapheno-femoral junction (SFJ) tributaries remain patent and competent with no adverse impact on clinical outcome whilst SFJ neo-vascularisation occurs much less often after EVLA than surgery. In patients with persistent below-knee GSV incompetence after EVLA residual symptoms are more likely and there is a greater need for sclerotherapy for residual varicosities. A RCT subsequently confirmed that extended ablation of the below-knee GSV achieved superior outcomes