Optimising outcomes in the treatment of superficial venous insufficiency

Wallace, Tom, MD

Medicine
June 2014

Thesis or dissertation


Rights
© 2014 Tom Wallace. All rights reserved. No part of this publication may be reproduced without the written permission of the copyright holder.
Abstract

The traditional “gold-standard” treatment for symptomatic SVI affecting the GSV is conventional open surgery and stripping under general anaesthesia. Despite improved QoL and cost-effectiveness when compared to conservative management, conventional surgery is not without drawbacks. Endovenous ablative treatments have been developed, which seek to address some of these limitations. Randomised clinical trial (RCT) data has demonstrated the superiority of endovenous laser ablation (EVLA) over surgery in the short term. Attention is now focused on evaluating its mid- and long-term outcomes, and to further evolve the technique to improve patient outcomes.

In this thesis, five studies were conceived to address two main objectives. Firstly, two-year follow-up of the HELP-1 RCT of EVLA versus conventional surgery was performed to assess clinical, QoL and duplex ultrasound (DUS) outcomes and identify potential for EVLA technique evolution. Four further studies were performed, aimed at improvement of patient outcomes by modification of the EVLA technique via i) pH buffering of tumescent anaesthesia, ii) concomitant treatment of varicosities, and iii) endovenous energy delivery via longer wavelength laser.

Two-year outcomes from the HELP-1 RCT demonstrated continued superiority of EVLA over conventional surgery in terms of lower clinical recurrence rates, with maintained improvements in clinical and QoL outcomes. DUS outcomes identified patterns of clinical recurrence that can be addressed by simple modifications of the EVLA technique.

Buffering of tumescent anaesthesia resulted in significantly reduced patient-reported periprocedural pain. Concomitant treatment of varicosities with ambulatory phlebectomy under tumescent anaesthesia demonstrated significant benefits in clinical severity and disease-specific QoL over foam sclerotherapy. Use of longer laser wavelength (1470nm) resulted in significantly reduced postprocedural pain in comparison to shorter (810nm) wavelength.

EVLA is demonstrated to have significant short- and medium-term benefits over conventional surgery. Further evolution of the technique, including the modifications described, should provide additional benefit in terms of patient outcomes.

Publisher
Hull York Medical School, The University of Hull and the University of York
Supervisor
Chetter, Ian
Qualification level
Doctoral
Qualification name
MD
Language
English
Extent
4 MB
Identifier
hull:10670
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