title: Combined saphenous ablation and iliac stent placement for complex severe chronic venous disease.
abstract: BACKGROUND
  Severe chronic venous disease frequently has a complex pathophysiology. This study describes results after combined interventions to correct outflow obstruction and superficial reflux, even in the presence of deep venous reflux.
  
  
  METHODS
  Between 1997 and 2005, 99 limbs in 96 patients had percutaneous iliofemoral venous stenting combined with great saphenous vein (GSV) stripping (39 limbs), or percutaneous GSV ablation performed by radiofrequency (27 limbs) or laser (33 limbs). Clinical severity score in CEAP was C4 in 51 limbs, C5 in eight limbs, and C6 in 40 limbs; median age was 56 years (range, 27 to 87 years); left-right limb ratio, 2.3:1; female-male ratio, 1.8:1; primary-secondary etiology, 58:41. Perioperative investigations included visual analogue pain scale (VAS), degree of swelling (grade 0 to 3); quality-of-life questionnaire; venous filling index in milliliters per second (VFI90), venous filling time in seconds (VFT), percentage in ambulatory venous pressure drop (AVP), duplex Doppler scanning, and radiologic studies.
  
  
  RESULTS
  Clinical follow-up was performed in 97 (98%) of 99 for up to 5.5 years. Axial deep reflux was found in 27% (27/99). At least three venous segments were refluxing in 40% of limbs. Preoperative hemodynamic parameters reflected the presence of reflux and improved significantly (P < .01) after the procedure (VFI90, 3.8 to 2.3 mL/s; VFT, 11 to 16 seconds; AVP, 55% to 65%). No patients died, and the morbidity with endovenous GSV ablation was largely limited to ecchymosis and thrombophlebitis in the thigh area. Cumulative primary, assisted primary, and secondary stent patency rates at 4 years were 83%, 97%, and 97%, respectively. After treatment, limb swelling and pain substantially improved. The rate of limbs with severe pain (>or=5 on VAS) fell from 44% to 3% after intervention. Gross swelling (grade 3) decreased from 30% to 6% of limbs. Cumulative analysis showed sustained complete relief of pain (VAS = 0) and swelling (grade 0) after 4 years in 73% and 47% of limbs, respectively. Ulcers healed in 26 (68%) of 38 ulcerated limbs. Cumulative ulcer-healing rate was 64% at 48 months. All quality-of-life categories significantly improved after treatment.
  
  
  CONCLUSIONS
  The single-stage combination of percutaneous venous stenting and superficial ablation in patients with severe chronic venous disease is safe, gives excellent symptom relief and improvement of quality of life, and a well-maintained ulcer-healing rate. It seems logical to initially perform multiple minimally invasive interventions rather than open surgery. Any associated deep reflux can initially be ignored pending clinical response to the combined intervention.
authors.affiliation: River Oaks Hospital, Jackson, MS, USA. neglenmd@earthlink.net
authors.forename: Peter
authors.initials: P
authors.lastname: Neglén
authors.forename: Kathryn C
authors.initials: KC
authors.lastname: Hollis
authors.forename: Seshadri
authors.initials: S
authors.lastname: Raju
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019917:Blood Vessel Prosthesis Implantation / Q000295:instrumentation*; D017115:Catheter Ablation / Q000379:methods*; D002908:Chronic Disease; D005260:Female; D005268:Femoral Vein / Q000601:surgery; D005500:Follow-Up Studies; D006801:Humans; D007084:Iliac Vein / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D010690:Phlebography; D010991:Plethysmography; D012189:Retrospective Studies; D012501:Saphenous Vein / Q000601:surgery*; D012720:Severity of Illness Index; D015607:Stents; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex; D014689:Venous Insufficiency / Q000000981:diagnostic imaging / Q000601:surgery*