Duplex ultrasound outcomes following ultrasound-guided foam sclerotherapy of symptomatic recurrent great saphenous varicose veins
by Michel Perrin, Lyon, France
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Recurrent varicose veins after operative treatment are a common, complex, and costly problem for both patients and physicians. To deal with this problem an international consensus meeting was held in Paris in 1998, which resulted in guidelines for the definition and description of REcurrent Varices After Surgery (REVAS).1 These guidelines were very cautious, given the absence of conclusive studies.
Thirteen years later data on outcome after repeated operative treatment are available, but despite new procedures a strong recommendation regarding REVAS management is still not possible. 2-10 Four studies deal with ultrasound-guided foam sclerotherapy (USGFS), but none is a randomized controlled trial comparing the outcomes of available operative treatments. This could explain why in the AVF-SVS clinical practice guidelines document all redo procedures are listed including ligation of the saphenous stump, ambulatory phlebectomy, sclerotherapy, and endovenous thermal ablation, and are given a weak recommendation, ie, 2C. 11
Consequently this well documented study presenting 1-year outcome after redo treatment by USGFS has to be reviewed in depth.
First, the term recurrence is used as defined in the Vein-Term consensus document. Knowing that it is frequently difficult to distinguish between true recurrence, residual vein, and disease progression, they must all be considered and the term recurrent varicose veins used, or better still the acronym PREVAIT (PREsence of Varices After – any kind of – operatIve Treatment).12
Second, the outcome of treatment by USFGS presented in this article is in accordance with published reports (Table I), but is better documented, particularly reflux extension and location as well as repeated USFGS sessions. As the pattern of recurrence was clearly identified (see Table 1 of the article), it is a pity there is no separate evaluation of outcome in patients presenting either incompetent saphenofemoral junction in the great saphenous vein or neovascularization in the proximal thigh great saphenous vein or isolated great saphenous vein remnant reflux.
Also missing are clinical improvement (signs and symptoms) data as well as patient satisfaction, but perhaps the Birmingham group intend to report them in a forthcoming paper.
As stated by the authors, the present paper adds further evidence that USFGS is a safe and clinically effective treatment for REVAS in the great saphenous vein system. This statement may be extrapolated to other operative treatments: thermal ablation and other open surgery procedures including those preserving the great saphenous vein. Knowing that randomized controlled trials would be very difficult to undertake in PREVAIT patients, we should consider that USFGS has become the first-line treatment of varicose vein recurrence after operative treatment.
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