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Please verify this study on varicose veins?

Q: The problem of varicose veins is not only faced by me but a large number of Indians and others all over the world, the percentage being in the range of over 28%. I was trying to find out the latest in the treatment options and I stumbled upon a study conducted by Robert J. Min, Neil Khilnani and Steven E Zimmet, it was a report of long term follow up results of endovenous laser treatment for great saphenous vein (GSV) reflux caused by saphenofemoral junction (SFJ) incompetence. Four hundred ninety nine GSVs in 423 subjects with varicose veins were treated over a 3 year period with 810 nm diode laser energy delivered percutaneously into the GSV via a 600 um fibre. Tumescent anaesthesia (100-200ml of 0.2% lidocaine) was delivered perivenously under ultrasound (US) guidance. Patients were evaluated clinically and with duplex US at 1 week, 1 month, 3 months, 6 months, 1 year and yearly thereafter to access treatment efficacy and adverse reactions. Compression sclerotherapy was performed in nearly all patients at follow up for treatment of associated tributary varicose veins and secondary telangiectasia. RESULTS: Successful occlusion of the GSV, defined as absence of flow on colour doppler imaging was noted in 490 of 499 GSVs (98.2%) after initial treatment. One hundred thirteen of 121 limbs (93.4%) followed for 2 years have remained closed with the treated portions of the GVSs not visible on duplex imaging. Of note, all recurrences have occurred before 9 months with the majority noted before 3 months, bruising was noted in 24% of patients and tightness along the course of the treated vein was present in 90% of limbs. There have been no skin burns, paresthesias or cases of deep vein thrombosis. I feel that every patient suffering from the varicose vein disease should visit the www.evlt.com site to have a complete data on this disease. The manufacturer of Diode lasers Diamond has helped many in India by its entry into the Indian market. Deenanath Mangeshkar Hospital in Pune is using this Diode unit since the last 7 years.

A:I have been treating varicose veins for the last 30 years and feel that Endo venous laser treatment of the varicose veins, which I am familiar with is an added armamentarium and not a path breaking advance as implied in the above query. The EVLT only addresses one part of the varicose vein problem, the GSV incompetence and is of very little value in whole host of associated components of the varicose vein disease, i.e. perforator incompetence, short saphenous incompetence, Saphena varix, lateral tributary/medial tributary incompetence and of course not to talk of multiple tortuous varicosities particularly in the lower leg. It also does not address the issue of the venous eczema and not to mention about bleeding and venous ulcers. Most importantly it would be most unhelpful in valve salvage by valvoplasty in early cases of incompetence. The various studies which have published the results of the EVLT have only talked about the GSV occlusion on a medium term follow up. I am willing to accept that to be true, there is no mention of the presence or absence of the alternate and recurrent development of the Sapheno-femoral incompetence from the other tributaries. One cannot rationalise how a laser ablation of the GSV 3 cms from the Sapheno-femoral junction, which is the safe distance maintained for discharging laser pulses, so the placement of laser fibre to protect the femoral vein; how would one tackle the problem of the other tributaries of the GSV which are within those 3 cms distance from femoral vein particularly in thin patient? There is also difficulty in steering the laser fibre through tortuous varicose veins and one cannot take the risk of damaging deeper leg veins using laser ablation of the leg perforators, assuming that these are accurately located. Even surgically at times these can be difficult to locate. I am not even commenting about the cost of the equipment and procedure. I also feel that with added cost of the learning curve of the operator the cost of the procedure will be prohibitive for a country like India. I would like to mention here that I am at present treating Varicose vein in United Kingdom and have not seen the EVLT being used here. I suspect that it has yet to prove itself before it can be labelled panacea for varicose vein disease. I still feel that Graduated compression stocking is by far the most effective, cheap, safe and non-controversial treatment of Varicose vein disease. One has to select patients for invasive and minimally invasive treatment, these shall undoubtedly include, conventional surgery, sclerotherapy, Laser ablation (EVLT) and thermal ablation (Radio frequency current), and the other procedures which are under development like SEPS (Subfascial endoscopic perforator surgery), TIPP (Transilluminated powered phlebectomy), PVVB (Percutaneous Vein valve bioprosthesis), Cryosurgery for epifascial varicose veins and of course various surgical valvoplasties with or without prosthesis. Ultimately it is not the type of the treatment but the knowledge and understanding of the disease process in a given patient by the treating doctor that will determine the ultimate result of the management.


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