Laser-assisted strategy for reflux abolition in a modified CHIVA approach

Abstract

The aim of this study was to assess feasibility and efficacy of an endovenous laser (EL) assisted saphenous-sparing strategy in chronic venous disease (CVD). Fourteen CVD patients (C2,3,4s Ep As Pr1,2,3) underwent a saphenofemoral junction (SFJ) treatment by EL just from below the superficial epigastric vein downward for a limited tract, together with a flush ligation of the incompetent tributaries of the great saphenous vein (GSV) along the leg. The following GSV parameters were assessed 15 cm below the SFJ: reflux time, caliber, peak systolic velocity (PSV), end diastolic velocity (EDV), resistance index (RI). Venous clinical severity score and the Clinical, Etiological, Anatomical, and Pathophysio logical (CEAP) classification clinical classes were assessed. At 1 year follow up 3 cases were considered failures because of a GSV thrombosis, even if they presented a GSV recanalization with a laminar flow within at the 2 years follow-up. Eleven procedures succeeded because neither minor nor major peri-procedural complications were reported, apart 2 cases of self-healing bruising. In these last 11 cases the procedure led to a GSV reflux suppression (from 3.1±0.4 s to a retrograde laminar draining flow), to a GSV caliber reduction (from 9.4±0.5 to 3.1±0.2 cm, P<0.001), to a PSV reduction (from 50.2±4.6 to 18.4±3.5 cm/s, P<0.001), to a RI reduction (from 0.9±0.2 to 0.51±0.2, P<0.005) and to an oscillatory flow suppression (EDV from -8.9±1.6 to 6.2±2.3 cm/s, P<0.001). Both CEAP and venous clinical severity score improved from 3 to 1 (P<0.001) and from 7±2 to 2±1 (P<0.05), respectively. The GSV flow reappeared below the shrunk tract draining into the re-entry perforator. Sapheno-femoral reflux suppression can be obtained by just a GSV segmental closure. An almost 80% of success rate of the present investigation paves the way for an even wider diffusion of endovenous techniques, moreover erasing the surgical requirements for those who would like to perform a saphenoussparing strategy. In this way new devices could be used inside equally innovative strategies.

Segmental saphenous ablation for chronic venous disease treatment

“…Our research group published preliminary results showing the feasibility and safety of a segmental endovenous sapheno–femoral junction (SFJ) ablation by EVLA in a saphenous sparing strategy, 10 with a shrinkage of maximum 10 cm length of GSV, starting from just distal to the superficial epigastric vein.…”

“…8 Moreover, in 2019, the improved recurrence rate following a saphenous sparing surgical approach was confirmed in the comparison to endovenous ablation. 9 Our research group published preliminary results showing the feasibility and safety of a segmental endovenous sapheno-femoral junction (SFJ) ablation by EVLA in a saphenous sparing strategy, 10 with a shrinkage of maximum 10 cm length of GSV, starting from just distal to the superficial epigastric vein.…”

Mini-invasive high-tie by clip apposition versus crossectomy by ligature: Long-term outcomes and review of the available therapeutic options

“…32 Investigations aimed at combining the mini-invasiveness of modern endovenous devices with the efficacy of a saphenous sparing strategy were reported but just by preliminary data. 33,34 An interesting strategic option has been recently proposed by Okazaki through a small skin incision and an echo-guided GSV ligation during endovenous ablation procedures. However, the ligation is performed 2 cm from the SFJ so not representing the same proper high ligation flush on the femoral.…”

Endovascular laser treatment of mixed shunt

“…Other Authors already reported EVLT according to CHIVA principles with good results. 7,8 In our case, performing a standard laser procedure of the GSV would be useless (proximal GSV and terminal valve were competent) and especially harmful, because interrupting OBS would meet unavoidable varicose veins recurrence, very difficult to manage.…”