THE RELATIONSHIP BETWEEN PATIENT STATUS AND RECURRENCY RATE FOLLOWING LASER SURGERY OF VARICOSE VEINS Dr Imre Bihari PhD Budapest, Hungary
What can influence laser surgery results? Instrument and method Laser: usage of different wavelength, fibres, amount of energy, tumescent solution Patient and pathology of the vein The other participant of varicose vein surgery: the patient Now we are dealing only with patient conditions
Subjects of studies Ideal cohorts Question: Are we only interested in the results of ideal patients?
Our patients 1 In 8 yrs altogether 1100 limbs (884 pts) were operated on 68.1 % of limbs (748) were followed longer than 1 year (mean 3.1 years) With time, more and more cases were suitable for laser surgery. In the last 5 years no classic surgery, only laser surgery has been performed on varicose veins Three-quarters of our patients (77.5 %) were out of the usual study requirements
Our patients 2 Conditions % Ectasia above 20 mm 1.5 Double saphenous stem 4.6 Re- and rerecurrent varicosities 9.2 BMI > 35 5.3 Bodybuilders, other sport activities or demanding job 6.4 Later pregnancy 1.3 Older than 70 yrs 10.6 CVI (C4-C5) 10.7 Crural ulcer (C6) 3.4 Other treated diseases 21.9 Superficial phlebitis 2.6 Total 77.5
East European Endovascular Method (EEEM, laser crossectomy) The tip of the laser fibre is 0.5 cm from the femoral vein The tumescent local anaesthetic compresses the SFJ Mean 100 J/cm energy is given The delivered energy is different in various regions: more given to the junction and less around the knee and distal to it 5 ml/cm cooled (4 C) tumescent local anaesthetic is given Insufficient perforator veins are treated in every case
F. Zernoviczky P. Dragic S. Kaspar Slovakia Serbia Czech Republic The East European Endovascular Method (EEEM) has been put together with their help Now the Hungarian experience is presented with the emphasis on GSV treatment
Results 43 recurrent varicosity cases (43/748, 5.7 %) What are the reasons for these recurrencies? Which factor has a more and which has a less important role in the recurrency?
Results 1 Extremely dilated varicose veins > 20 mm Before 2 years 3 years 4 of 15 legs, 27%, OR: 6.47
Results 2 Acessory Anterior Saphenous Vein (Double saphenous vein) After 6 yrs Presence of Anterior Accessory Saphenous Vein (6 of 48, 12.5%, OR: 2.6)
Results 3 Classic surgery was before 6 of 92 legs, 7.5%, OR: 1.12
Results 4 Overweight patient BMI>35 Overweight patients: 8 of 53 legs, 19.0 %, OR: 3.35
Results 5 Bodybuilders, sportspeople and people with demanding physical work 7 of 45 legs, 6.4%, OR: 3.41
Results 6 Deep reflux 2 of 4 legs, 50 %
Results 7 Cardiac decompensation 1 patient became decompensated and his varicosity recurred 1 of 1 (100 %)
Results 8 Pregnancy 5 of 15 legs, 33.3 % OR: 9.14
Results 9 There is no varicosity only a pathologic US finding: segmental reflux or refluxive perforator vein Before After 4 years later 8 of 681, 1.2%
Results 10 Recurrencies without any patient risk factors 9 of 339 had no risk factors (3.5 %) 68.1 % of cases were followed longer than 1 year
Risk factors of recurrencies in our cases (there can be combinations) 1. Extremely dilated varicose veins (4 of 15, 27%, OR: 6.5 ) 2. Presence of accessory anterior saphenous stem (6 of 48, 12.5%, OR: 2.6) 3. Surgery of recurrent varicosity (6 of 92, 7.5%, OR: 1.1 ) 4. High BMI>35 (8 of 53, 19.0 %, OR: 3.3) 5. Sporting activity (7 of 45, 6.4%, OR: 3.4) 6. Deep reflux (2 of 4, 50% ) 7. Cardiac decompensation (1 pt, 100% ) 8. Pregnancy (5 of 15, 30%, OR: 9.1 ) 9. No varicosity only pathologic US finding (8 of 681, 1.2% ) 10. No risk factors (6 of 339, 3.5% )
Factors without significance in the recurrency of varicose veins Age Gender Other diseases (except deep venous thrombosis and cardiac decompensation) Varicophlebitis Presence of a crural ulcer
Difficulties in statistical analysis Combination of risk factors: multiple risk factors in 25 % of limbs e.g. recurrent varicosity after classic surgery + high BMI + extremely large veins Small number of recurrent cases, Longer observation period is required to see recurrencies (EEEM can prevent early recurrencies) Changes in techniques with time
Conclusions Some patient conditions are risk factors for recurrent varicosity They have a higher significance than the difference between new laser instruments and fibres The same cases can be operated on with laser surgery as with classic surgery Closure of the SFJ seems to be important also in laser surgery
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