Perforan Ven Yetmezliğinde; Küçük Kesi ile Ligasyon, Lazer Ablasyon ve Siyanoakrilat ile Embolizasyon Tekniklerinin Karşılaştırılması

Amaç: Bu çalışma inkompetan perforan ven tedavisinin üç ana yönteminin erken ve orta dönem sonuçlarını karşılaştırmak amacı ile planlanmıştır. Yöntemler: Ocak 2012 ve Ocak 2015 arasında sadece inkompetan perforan ven cerrahisi için operasyona alınmış ardışık 84 hastada uygulanmış 174 işlemin verileri retrospektif olarak analiz edilmiştir. Hastalar uygulanan yönteme göre 3 gruba ayrıldı; küçük kesi ile ligasyon 40 (%47,6), lazer ile endovenöz ablasyon 22 (%26,2), siyanoakrilat ile embolizasyon 22 (%26,2). Preoperatif, operatif ve erken dönem takip verileri kayıt edildi. Hastalar polikliniğe çağrılarak ultrason ile nüks açısından tekrar değerlendirildi. Bulgular: Operasyon süresi, küçük kesi ile ligasyon grubunda daha uzundu (p<0.001). Siyanoakrilat grubunda daha kısa süreliğine hastanede kalış (p<0.001), az analjezi ihtiyacı (p<0.001) ve erken işe dönme süresi (p<0.001) gözlendi. Ligasyon grubunda nükse rastlanmazken (p <0.001), Endovenöz lazer grubunda siyanoakrilat grubuna göre daha yüksek nüks saptanmıştır (p<0.001). Kozmetik yakınmalar (hiperpigmentasyon veya skar dokusu) küçük kesi ile ligasyon grubunda daha yüksek bulundu (p =0.003). Endovenöz lazer sonrası parestezi saptandı (p=0.001) Sonuç: Perforan ven yetmezliği tedavisinde ligasyon halen en düşük nüks oranına sahip olsa da kozmetik problemler nedeniyle yerini endovasküler yöntemlere terk etmektedir. Endovenöz ablasyon sonrası yüksek nüks oranı ve parestezi gibi komplikasyonlar siyanoakrilat ile embolizasyonu iyi bir alternatif yapmaktadır.

Anahtar Kelimeler:

venöz yetmezlik, lazer ablasyon, tedavi amaçlı embolizasyon, ligasyon

A Comparison Of Mini-incisional Ligation, Laser Ablation And Cyanoacrylate Embolization For Incompetent Perforating Vein Closure

Objective: Our aim was to compare the short- and the midterm results of three main methods of incompetent perforating vein treatment. Methods: Data of 174 procedures performed between January 2012 and January 2015, in a 84 consecutive patients with incompetent perforating veins were retrospectively analyzed. Patients were divided into 3 groups according to surgical technique: mini-incisional ligation 40 (47.6%), 22 (26.2%) endovenous laser ablation and 22 (26.2%) cyanoacrylate embolization. Preoperative, operative and early follow up data was recorded. All patients were called to assess by ultrasonography for recurrence. Results: Operation time was significantly longer in the mini-incisional ligation group (p<0.001). Cyanoacrylate group showed significantly lower hospital stay (p<0.001), duration of analgesia (p<0.001) and disability (p<0.001). Recurrence was not found in the ligation group (p<0.001), endovenous laser group showed significantly higher recurrence than the cyanoacylate group (p<0.001). Cosmetic problems (hyperpigmentation or scar tissue) were significantly higher in the mini-incisional ligation group (p =0.003). Paresthesia was detected after endovenous laser (p=0.001). Conclusion: Although ligation has still lowest rate of recurrence after incompetent perforating vein surgery, it is being replaced by the endovascular procedure due to cosmetic problems. Cyanoacrylate embolization seems to be a promising alternative for incompetent perforating veins treatment due to higher recurrence and complication rate after endovenous laser ablation.

Keywords:

venous insufficiency, laser ablation, therapeutic embolization, ligation,

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1. Van den Bos R, Arendis L, Kockaert M, et al. Endovenous therapies of lower extremity varicosities: a meta-analysis. J Vasc Surg. 2009;49:230-39.
2. Rasmussen LH, Lawaetz M, Bjoern L, et al. Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose veins. Br J Surg. 2011;98:1079-87.
3. Gloviczki P, Comerota AJ, Dalsing MC, et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011;53:2S-48S.
4. Pierik EGJM, van Urk H, Hop WCJ, Wittens CHA. Endoscopic versus open subfascial division of incompetent perforating veins in the treatment of venous leg ulceration; a randomized trial. J Vasc Surg. 1997;26:1049-54.
5. Gloviczki P. Subfascial endoscopic perforator surgery: indications and results [review]. Vasc Med. 1999;4:173-80.
6. Hissink RJ, Bruins RM, Erkens R, et al. Innovative treatments in chronic venous insufficiency: endovenous laser ablation of perforating veins: a prospective short-term analysis of 58 cases. Eur J Vasc Endovasc Surg. 2010;40:403-6.
7. Lawrence PF, Alktaifi A, Rigberg D, et al. Endovenous ablation of incompetent perforating veins is effective treatment for recalcitrant venous ulcers. J Vasc Surg. 2011;54:737-42.
8. Almeida JI, Kaufmann J, Gockeritz O, et al. Radiofrequency Endovenous Closure FAST Versus Laser Ablation for the Treatment of Great Saphenous Vein Reflux: a multicenter, single-blinded, randomized study (RECOVERY Study). J Vasc Interv Radiol. 2009;20:752-9.
9. Vaidya S, Tozer KR, Chen J. An overview of embolic agents. Semin Intervent Radiol. 2008;25:204-15.
10. Almeida JI, Javier JJ, Mackay EG, et al. First human use of cyanoacrylate adhesive for treatment of saphenous vein incompetence. J Vasc Surg: Venous and Lym Dis. 2013;1:174-80.
11. Toonder IM, Lam YL, Lawson J, Wittens CH. Cyanoacrylate adhesive perforator embolization (CAPE) of incompetent perforating veins of the leg, a feasibility study. Phlebology. 2014;29:49-54.
12. Eklöf B, Rutherford RB, Bergan JJ, et al. Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg. 2004;40:1248-52.
13. Özgür Ö, Alimoğlu E, Çeken K, et al. Chronic venous insufficiency patterns in lower extremity veins detected by Doppler Ultrasound. Dicle Med J. 2013; 40:543-48.
14. Sybrandy JE, van Gent WB, Pierik EG, Wittens CH. Endoscopic versus open subfascial division of incompetent perforating veins in the treatment of venous leg ulceration: long-term follow-up. J Vasc Surg. 2001;33:1028-32.
15. Elias S, Peden E. Ultrasound-guided percutaneous ablation for the treatment of perforating vein incompetence. Vascular. 2007;15:281-89.
16. Queral LA, Criado FJ. Miniincisional ligation of incompetent perforating veins of the legs. J Vasc Surg. 1997;25:437- 41.
17. Hingorani AP, Ascher E, Marks N, et al. Predictive factors of success following radio-frequency stylet (RFS) ablation of incompetent perforating veins (IPV). J Vasc Surg. 2009;50:844-48.
18. Morrison N, Gibson K, McEnroe S, et al. Randomized trial comparing cyanoacrylate embolization and radiofrequency ablation for incompetent great saphenous veins (VeClose). J Vasc Surg. 2015;61:985-94.
19. Proebstle TM, Alm J, Göckeritz O, et al. European Closure Fast Clinical Study Group. Three-year European follow-up of endovenous radiofrequency-powered segmental thermal ablation of the great saphenous vein with or without treatment of calf varicosities. J Vasc Surg. 2011;54:146-52.
20. Min RJ, Zimmet SE, Isaacs MN, Forrestal MD. Endovenous laser treatment of the incompetent greater saphenous vein. J Vasc Interv Radiol. 2001;12:1167-71.
21. Zerweck C, von Hodenberg E, Knittel M, et al. Endovenous laser ablation of varicose perforating veins with the 1470-nm diode laser using the radial fibre slim. Phlebology. 2014;29:30-6.
22. Masuda E.M, Kessler D.M, Lurie F, et al. The effect of ultrasound-guided sclerotherapy of incompetent perforating veins on venous clinical severity and disability scores. J Vasc Surg. 2006;43:551–56.
23. Thomasset SC, Butt Z, Liptrot S, et al. Ultrasound guided foam sclerotherapy: factors associated with outcomes and complications. Eur J Vasc Endovasc Surg. 2010;40:389-92