Objective: Superficial venous incompetence (SVI) is a common disease that causes significant quality of life (QoL) impairment. There is a need for more health economic evaluations of SVI treatment. The aim of this study was to perform a cost effectiveness analysis in patients with great saphenous vein (GSV) incompetence comparing radiofrequency ablation (RFA), high ligation and stripping (HL/S), and no treatment or conservative treatment with one year follow up.

Methods: Randomised controlled trial economic analysis from an ongoing trial; 143 patients (156 limbs) with GSV incompetence (C in CEAP 2 - 6) were included. Treatment was performed with RFA or HL/S. Follow up was performed up to one year using duplex ultrasound, revised venous clinical severity score (r-VCSS), Aberdeen Varicose Vein Questionnaire (AVVQ), and EuroQol-5D-3L (EQ-5D-3L).

Results: Seventy-eight limbs were treated with RFA and HL/S respectively. No treatment or conservative treatment was assumed to have zero in treatment cost and no treatment benefit. In the RFA group, one limb had reflux in the GSV after one month and three limbs after one year. In HL/S, two limbs had remaining reflux in the treated area at one month and one year. Both disease severity (r-VCSS, p = .004) and QoL (AVVQ, p = .021 and EQ-5D-3L, p = .028) were significantly improved over time. The QALY gain was 0.21 for RFA and 0.17 for HL/S. The cost per patient was calculated as €1 292 for RFA and €2 303 for HL/S. The cost per QALY (compared with no treatment or conservative treatment) was €6 155 for RFA and €13 549 for HL/S. With added cost for days absent from work the cost per QALY was €7 358 for RFA and €24 197 for HL/S. The cost per QALY for both methods was well below the threshold suggested by Swedish National Board of Health.

Conclusion: RFA is more cost effective than HL/S and no treatment or conservative treatment at one year follow up.

Chronic limb-threatening ischemia (CLTI) has a major impact on patient's lives and is associated with a heavy health care burden with high morbidity and mortality. Treatment by endovascular intervention is mostly based on macrocirculatory information from angiography and does not consider the microcirculation. Despite successful endovascular intervention according to angiographic criteria, a proportion of patients fail to heal ischemic lesions. This might be due to impaired microvascular perfusion and variations in the supply to different angiosomes. Non-invasive optical techniques for microcirculatory perfusion and oxygen saturation imaging have the potential to provide the interventionist with additional information in real-time, supporting clinical decisions during the intervention. This study presents a novel multimodal imaging system, based on multi-exposure laser speckle contrast imaging and multi-spectral imaging, for continuous use during endovascular intervention. The results during intervention display spatiotemporal changes in the microcirculation compatible with expected physiological reactions during balloon dilation, with initially induced ischemia followed by a restored perfusion, and local administration of a vasodilator inducing hyperemia. We also present perioperative and postoperative follow-up measurements with a pulsatile microcirculation perfusion. Finally, cases of spatial heterogeneity in the observed oxygen saturation and perfusion are discussed. In conclusion, this technical feasibility study shows the potential of the methodology to characterize changes in microcirculation before, during, and after endovascular intervention.

Objectives

To evaluate postoperative venous haemodynamics and quality of life after treatment of great saphenous vein (GSV) incompetence.

Methods

Radiofrequency ablation and high ligation and stripping were performed in 62 patients (65 limbs) and 58 (65 limbs), respectively. Phlebectomies were performed in both modalities. Strain-gauge plethysmography on the foot combined with superficial venous occlusion was used to measure refilling time after knee bends. Strain-gauge plethysmography, duplex ultrasound and quality of life were assessed before and one month after treatment.

Results

Duplex ultrasound displayed successful intervention in all but two limbs. Refilling time increased similar in radiofrequency ablation and high ligation and stripping after treatment (p < 0.001). Postoperatively, strain-gauge plethysmography detected remaining reflux in 71% of the patients. Multivariate analysis showed that two or more incompetent calf branches were associated with remaining reflux (OR 4.82 (95% CI: 1.33–17.5), p = 0.02). No difference in quality of life was seen in patients with remaining reflux.

Conclusions

Despite successful treatment, a majority of the limbs showed remaining reflux, in which incompetent calf branches appear to play an important role.

Clinicaltials.gov: Lower Limb Venous Insufficiency and the Effect of Radiofrequency Treatment Versus Open Surgery. Nr: NCT02397226

Background Takayasu arteritis (TA) is a rare large-vessel arteritis that primarily affects the aorta and its major branches. The aim of this study was to describe the value of high frequency ultrasound for monitoring of inflammatory activity. Methods Twenty-five patients, range 11-71 years, diagnosed with TA were investigated with duplex ultrasound (DUS) including follow-up studies. Twenty-five healthy controls were also investigated. Nine patients had newly diagnosed active TA. Sixteen patients had stable/inactive disease at baseline DUS, and TA was diagnosed median 4 center dot 5 years previously. Intima-media thickness (IMT), vessel and lumen diameter were measured in the carotid arteries, central neck arteries and the aortic arch. The vessel walls were studied qualitatively. The Takayasu ultrasound index was created for inflammatory activity scoring. Results Intima-media thickness in common carotid artery (CCA) was (median and 25-75 percentile parenthetic) 2 center dot 3 mm (1 center dot 7-2 center dot 9) in clinically active TA, 1 center dot 2 mm (1 center dot 1-1 center dot 6) in clinically stable TA (Pamp;lt;0 center dot 001) and 0 center dot 5 mm (0 center dot 5-0 center dot 6) in healthy controls (Pamp;lt;0 center dot 001). Clinically active TA had prominent increase in IMT and/or increased vessel diameter, and/or intramural arteries, and/or hypoechogenic areas interpreted as oedema in the vessel wall. TA in clinical remission was characterized by increased IMT with medium to high echogenicity with or without fibrotic stripes. The Takayasu ultrasound index was higher in patients with active disease versus treated disease, 2 center dot 55 (1 center dot 60-3 center dot 05) versus 1 center dot 30 (1 center dot 00-1 center dot 58), (P = 0 center dot 003). Conclusion DUS is an excellent tool to monitor inflammatory changes in the vessel wall in TA. Further DUS studies in larger patient populations are warranted.

Objective: Venous insufficiency is associated with histological changes and structural remodelling of the venous wall. The effects of these changes on global venous function remain uncertain. The aim was to evaluate venous compliance in patients with great saphenous vein (GSV) insufficiency before and after treatment by radiofrequency ablation (RFA) and in controls.

Methods: Eleven patients (14 limbs) underwent endovenous RFA treatment for GSV incompetence. Duplex ultrasound and strain gauge plethysmography (SGP) were performed before and after RFA. SGP time (seconds) to reach 50% of maximum venous volume (T50) with and without superficial occlusion was used to assess global venous reflux. Venous occlusion plethysmography was used to evaluate pre- and post-operative calf venous compliance. Venous compliance was also assessed in 12 age and sex matched controls.

Results: Pre-operative calf venous compliance was lower in patients than in controls (p < .001). Post-operative calf venous compliance was reduced vs. pre-operative measurements (p < .002). The pre-operative reflux parameter T50 improved from 8.0 ± 2.0 seconds to 17.3 ± 1.9 seconds (p < .001) after RFA. The post-operative T50 without superficial occlusion was similar to pre-operative T50 with superficial occlusion (17.1 ± 2.5 vs. 17.3 ± 1.9 seconds, p = .84).

Conclusions: Calf venous compliance is reduced in patients with GSV insufficiency. Venous reflux parameters markedly improved after RFA, whereas venous compliance displayed a further reduction vs. the pre-operative state, implicating generalised changes in the lower limb venous vessel wall.Previous article in issue

Objective: To evaluate quantitative duplex ultrasound (DUS) parameters of reflux in patients with isolated great saphenous vein insufficiency.

Methods: 20 limbs were studied. DUS derived reflux time (RT, sec), peak reflux velocity (PRV, cm/s) and reflux volume flow (ml/min) were evaluated and related to expelled volume (EV, ml) and half refilling time (T50, sec) measured by water-based foot volumetry with and without compression of superficial veins.

Results: Reflux volume flow correlated significantly to all hemodynamic parameters assessed by foot volumetry, i.e., EV (p = 0.003), ΔEV (p = 0.006), T50 (p = 0.004) and ΔT50 (p = 0.011). PRV displayed a weaker correlation to foot volumetry parameters EV (p = 0.027) and T50 (p = 0.008). No significant correlation was found between RT and foot volumetry.

Conclusion: These results indicate that reflux volume flow may be a potential parameter in future attempts to quantify reflux using DUS in patients with isolated great saphenous vein insufficiency.

Snabbspår med ultraljudsundersökning är långt ifrån standard, trots att metoden visat sig vara viktig för att snabbt ställa diagnosen jättecellsarterit. I Linköping har man redan infört en fungerande modell.

Nutcracker Syndrome (NCS) or Left Renal Vein (LRV) entrapment is rare and may be caused by compression of the vein between the aorta and the Superior Mesenteric Artery (SMA). LRV hypertension may lead to varicosities. The syndrome is characterized by a complex of symptoms with substantial variations, the diagnosis is difficult and therefor often delayed. The diagnosis may be settled by many imaging methods, such as renal angiography, retrograde phlebography, Computed Tomography (CT), Magnetic Resonance Imaging (MRI) and Doppler Ultrasonography (DUS). The degree of stenosis may be detected measuring Doppler flow velocities by DUS.

A 50-year old female with Crohn´s disease treated by ileocecal resection, performed 20 years ago, and symptomatic epilepsy treated by a vagal stimulator, had newly added symptoms of abdominal pain, weight loss, dizziness, irregular bowel movements, and increasing fatigue. Blood parameters and physical examination were normal. CT showed no signs of active Crohn´s disease. The left renal veins and the left ovarian vein were dilated and the aorto-mesenteric angle was only 22 degrees.

DUS (Siemens S2000, 6 and 9 MHz transducers) performed one month later confirmed the findings of the CT with typical findings of NCS. DUS will play a crucial role in Nutcracker syndrome considering flow velocity, diameter measurement, anatomy and aorto-mesenteric angle. DUS is a non-invasive, cheap modality that gives a very good resolution that can define vessel walls and evaluate flow velocity conditions. This patient had mild symptoms that led to a conservative treatment whereas epilepsy and Crohn ́s disease was the main problem. If severe symptoms occur different kinds of treatments are available, such as stenting of LRV, open surgical interventions, ablation of collateral pelvic veins and coil embolization.