Anke A M Biemans1, Renate R van den Bos1, Loes M Hollestein1, M Birgitte Maessen-Visch2, Yvonne Vergouwe3, H A Martino Neumann1, Marianne G R de Maeseneer4, Tamar Nijsten5. 1. Department of Dermatology, Erasmus MC, Rotterdam, The Netherlands. 2. Department of Dermatology, Rijnstate Hospital, Arnhem, The Netherlands. 3. Department of Public Health, Erasmus MC, Rotterdam, The Netherlands. 4. Department of Dermatology, Erasmus MC, Rotterdam, The Netherlands; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium. 5. Department of Dermatology, Erasmus MC, Rotterdam, The Netherlands. Electronic address: t.nijsten@erasmusmc.nl.
Abstract
OBJECTIVE: Phlebectomy of varicose tributaries is usually considered an additional treatment after or during saphenous ablation. As phlebectomies alone affect the hemodynamics of the venous system, this treatment can be effective as primary intervention in selected patients. The objective of this study was to analyze hemodynamic, clinical, and patient-reported outcomes after phlebectomies in a prospective multicenter study to determine predictors for treatment success, that is, restoration of great saphenous vein (GSV) competence. METHODS: Patients with symptomatic GSV and tributary incompetence (reflux > 0.5 second) at the level of the thigh were included. Duplex ultrasound (DUS) was used to assess GSV and tributary characteristics, and a reflux elimination test was performed. Three and 12 months after phlebectomy of the tributary, reflux and GSV diameter were evaluated with DUS. Clinical outcome measures were C class of the Clinical, Etiologic, Anatomic, and Pathologic (CEAP) classification and Venous Clinical Severity Score; patients' reported outcome was determined by the Aberdeen Varicose Vein Questionnaire. To evaluate differences between the success and failure groups, baseline DUS characteristics, Venous Clinical Severity Score, CEAP class, and Aberdeen Varicose Vein Questionnaire score were compared. Multivariable logistic regression including all clinically relevant variables following a backward variable elimination process was used to determine predictors for success. The model was internally validated by 1000 bootstrap samples. RESULTS: The study included 94 patients (65 women, 29 men) with a mean age of 53 years. The majority had C2 or C3 disease. One year after treatment, GSV reflux had disappeared in 50% of patients (P < .01), and GSV diameter had decreased significantly (P < .01). Clinical outcome and Aberdeen Varicose Vein Questionnaire score improved significantly (P < .01) and symptoms had disappeared in 66%. Of 47 patients with persisting GSV incompetence, 15 did not receive additional treatment because they were asymptomatic. Independent predictors for success were low C class of the CEAP classification, low number of refluxing GSV segments, small diameter of the GSV above the tributary, and positive reflux elimination test result (P < .0001). The reflux elimination test appeared to be an important independent predictor, with >65% chance of success when the result was positive. CONCLUSIONS: At 1-year follow-up, treatment with single phlebectomies of a large tributary was effective to abolish GSV reflux in 50% of patients and to free 66% of patients from symptoms. Patients with limited disease progression and mild DUS alterations are most likely to benefit from this approach.
OBJECTIVE: Phlebectomy of varicose tributaries is usually considered an additional treatment after or during saphenous ablation. As phlebectomies alone affect the hemodynamics of the venous system, this treatment can be effective as primary intervention in selected patients. The objective of this study was to analyze hemodynamic, clinical, and patient-reported outcomes after phlebectomies in a prospective multicenter study to determine predictors for treatment success, that is, restoration of great saphenous vein (GSV) competence. METHODS:Patients with symptomatic GSV and tributary incompetence (reflux > 0.5 second) at the level of the thigh were included. Duplex ultrasound (DUS) was used to assess GSV and tributary characteristics, and a reflux elimination test was performed. Three and 12 months after phlebectomy of the tributary, reflux and GSV diameter were evaluated with DUS. Clinical outcome measures were C class of the Clinical, Etiologic, Anatomic, and Pathologic (CEAP) classification and Venous Clinical Severity Score; patients' reported outcome was determined by the Aberdeen Varicose Vein Questionnaire. To evaluate differences between the success and failure groups, baseline DUS characteristics, Venous Clinical Severity Score, CEAP class, and Aberdeen Varicose Vein Questionnaire score were compared. Multivariable logistic regression including all clinically relevant variables following a backward variable elimination process was used to determine predictors for success. The model was internally validated by 1000 bootstrap samples. RESULTS: The study included 94 patients (65 women, 29 men) with a mean age of 53 years. The majority had C2 or C3 disease. One year after treatment, GSV reflux had disappeared in 50% of patients (P < .01), and GSV diameter had decreased significantly (P < .01). Clinical outcome and Aberdeen Varicose Vein Questionnaire score improved significantly (P < .01) and symptoms had disappeared in 66%. Of 47 patients with persisting GSV incompetence, 15 did not receive additional treatment because they were asymptomatic. Independent predictors for success were low C class of the CEAP classification, low number of refluxing GSV segments, small diameter of the GSV above the tributary, and positive reflux elimination test result (P < .0001). The reflux elimination test appeared to be an important independent predictor, with >65% chance of success when the result was positive. CONCLUSIONS: At 1-year follow-up, treatment with single phlebectomies of a large tributary was effective to abolish GSV reflux in 50% of patients and to free 66% of patients from symptoms. Patients with limited disease progression and mild DUS alterations are most likely to benefit from this approach.