endovenous treatment of incompetent anterior … · the average linear endovenous energy density...

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ENDOVENOUS TREATMENT OF INCOMPETENT ANTERIORACCESSORY SAPHENOUS VEINS WITH A 1540 nm DIODELASER

Alvise CAVALLINI, Daniela MARCER, Salvatore FERRARI RUFFINO

Int Angiol 2014 Jun 19 [Epub ahead of print]

INTERNATIONAL ANGIOLOGYRivista di Angiologia pISSN 0392-9590 - eISSN 1827-1839 Article type: Original Article The online version of this article is located at http://www.minervamedica.it

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Clinical Investigation ENDOVENOUS TREATMENT OF INCOMPETENT ANTERIOR ACCESSORY SAPHENOUS VEINS WITH A 1540 nm DIODE LASER Cavallini Alvise*, MD, PhD, Marcer Daniela, MD and Ferrari Ruffino Salvatore, Md, PhD. Drs. Cavallini Alvise, MD, PhD, Marcer Daniela, MD and Ferrari Ruffino Salvatore, Md, PhD have no conflicts of interest or financial ties to disclose. Running head: endovenous laser treatment of incompetent anterior accessory saphenous veins. Key Words: laser treatment, anterior accessory saphenous vein, endovascular treatment ABSTRACT AIM OF THE STUDY: Endovenous laser treatment (EVLT) is an accepted form of axial vein ablation for symptomatic venous reflux but its role in the treatment of anterior accessory saphenous vein (AASV) has not been well characterized. The aim of this paper is to show the short-term result of EVLT with a ball-tipped fiber and a 1540 nm diode laser of the AASV with preservation of a competent great saphenous vein (GSV). PATIENTS AND METHOD: 9 incompetent AASV veins in 8 patients (6 female) were treated. The gravity of chronic venous disease was determined according to the CEAP classification and the severity of symptoms was scored according to the revised Venous Clinical Severity Score. Patient satisfaction was assessed by a 0 to 3 scale. RESULTS: The average linear endovenous energy density was 60.5 J/cm vein (SD: 7.5). Patients returned to daily activities after a mean of 3.8 days (SD: 1.4). 5 patients (63%) have had pain but of mild intensity. No patients developed paresthesia or phlebitis reactions in the treated area. Post-operative ecchymoses are frequent (89%). During the follow-up period (mean 13 months, range: 7-17 months) all the veins were occluded. The VCSS improved drastically from a mean of 3.2 (SD: 1.3) pre-interventional to 0 (SD: 0.38) at 17 months. All patients were satisfied or very satisfied with the method. No severe complications occurred. CONCLUSION: EVLT of an incompetent AASV with a 1540 nm diode laser is a safe and efficient therapy option, with a high success rate and with no evidence of GSV neo-reflux or recurrent varicosities during the follow-up period. ACKNOWLEDGMENTS We thank Prof. Alice Moio (MD in Translation, University of Bologna), who has thoroughly revised the English language of this paper. We thank also Dr. Alessandro Pieri for permission to edit and use the image of the AASV.

*Corresponding Author: Cavallini Alvise Verona Vein Center Lungadige Cangrande 10, 37126, Verona, Italy Tel.: +393386647913 Fax: +390458341088 e-mail: [email protected]

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INTRODUCTION

In the Western adult population, the prevalence of varicose veins is >20% and incompetence at the

sapheno-femoral junction (SFJ) with an incompetent great saphenous vein (GSV) is the most common cause

(70%)1-3.

In some patients, however, reflux, through the SFJ, may occur in the anterior accessory of the great saphenous

vein (AASV) rather than the GSV.

The AASV in the upper thigh, runs deeply (superficially to the muscular fascia, like the GSV) to a hyperechoic

fascia that resembles the GSV covering;; however, the AASV can be easily identified, because it runs more

anteriorly with respect to the GSV, with a path corresponding to that of the underlying femoral artery and veins4.

It terminates in the SFJ or proximal GSV superficial to the deep fascia of the thigh (fascia lata) but deep to the

saphenous fascia, having progressed from the tributaries of the leg, from laterally to medially in the thigh and

piercing the saphenous fascia (Fig. 1). The intrafascial segment of the vein is typically the most straight and

amenable to thermoablation.

Endovenous laser treatment (EVLT) is an accepted form of axial vein ablation for symptomatic venous reflux but

its role in the treatment of AASV has not been well characterized. A previous retrospective study reported a

significantly higher failure and complication rates in AASV EVLT as compared with GSV treatment, with a failure

of closure of 13.2%5;; in contrast, other authors6 reported excellent results.

The aim of this study is to evaluate the safety and short-term efficacy of AASV EVLT with a 1540 nm diode laser

by using a ball-tipped fiber (LASER.COM, Padua, Italy), with preservation of a competent GSV in patients with

isolated SFJ/AASV.

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METHODS

Patients

Between November 2011 and May 2013, 9 incompetent AASV in 8 patients (6 women and 2 men) underwent

EVLT. Two patients were subjected to EVLT of the contralateral GSV in the same session. Patients’

characteristics are presented in Tables 1 and 3.

The gravity of chronic venous disease was determined in each leg according to the Clinical-Etiology-Anatomy-

Pathophysiology classification (CEAP)7. The severity of symptoms was scored according to the revised Venous

Clinical Severity Score (VCSS)8. All patients underwent color flow duplex ultrasound examination with a

high-resolution linear probe (7 to 12 MHz). They all had documented SFJ reflux and the GSV was competent.

Duplex was performed in upright position. Normal flow was defined as anterograde while Reflux was defined as

retrograde flow of >0.5 second duration after a Valsalva maneuver and manual compression and decompression

of the distal limb. The vein diameter was measured. Suitability for AASV EVLT depended upon a ≥10 cm long,

relatively straight segment of AASV immediately distal to the SFJ. Patients who had occlusive arterial disease and

women who were pregnant were excluded as well as patients with a mean venous diameter >15 mm and/or with a

significant dilatation (>15 mm) of SFJ. Excessively dilated GSVs (in particular with a caliber greater to 15 mm) in

fact have a high risk of recanalization and if treated with EVLT the risk of side effects is higher9.

All data was collected retrospectively through a database by two surgeons (CA, FRS), experts in venous disease

and with years of experience in endovascular venous treatment.

EVLT procedure

EVLT was performed with a 1540 nm diode laser and a 600 µc ball-tipped fiber (LASER.COM, Padua, Italy) using

technical criteria previously described10. All patients agreed their data, already collected for clinical

evaluation, to be included in a observational retrospective study, in accordance with the

Declaration of Helsinki. All EVLT procedures were performed with tumescent local anesthesia and

intravenous sedation in an outpatient clinic. All veins except one case were accessed percutaneously with duplex

ultrasonography (US) guidance (Logic Book, GE medical system, Wuxi New District, Jiangsu, China) at the distal

point of reflux with an 18-gauge needle. The AASV is often short in length and is entered at the mid-thigh level

on the anterior aspect. A J-tip guide-wire was then advanced by means of duplex scanning control toward the

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SFJ. A 5F angio catheter was forwarded over the guide-wire, this last was removed and replaced by the

ball-tipped fiber positioned 1-2 cm below the SFJ, just distal to the junction with the main trunk;; at the SFJ, in fact,

the AASV usually enters into a common stump. The stump is typically 0.5 cm in length and is joined by the GSV

prior to draining into the common femoral vein. Therefore, when placing the catheter tip at the SFJ, the angulation

is slightly different than that of the GSV and the ultrasound probe must be manipulated to get a proper view.

Subfascial perivenous anesthesia was administered with a motor pump, using a 25-gauge needle under

ultrasound guide.

EVLT was carried out in a continuous mode with a power of 10 W delivering energy rate of about 60 J/cm.

We decided to carry out the treatment in all patients with the same Linear Endovenous Energy Density (LEED: i.e.

energy amount in joules divided by the treated vein length in centimeters). regardless of the vein diameter, to

obtain a homogeneous sample. In the same session all insufficient tributaries were treated by phlebectomy. Main

treatment parameters are shown in Tables 2 and 3.

Compression with 20-30 mmHg elastic stocking for about one month was applied. In addition, as a precaution

without any further rationale, low-molecular-weight heparin for seven days was given at prophylactic dosage to

all patients. Patients were mobilized immediately after the intervention and were advised to walk regularly during

recovery from treatment. Diclofenac 75 mg was prescribed to be taken in case of post-operative pain.

Follow-up

Patients were re-examined clinically with duplex on the 7th post-operative day and at months two, six, twelve and

seventeen (for two patients) after the procedure by the same phlebologist who performed the treatment. The

entire deep venous system was checked for signs of deep venous thrombosis. VCSS, post-operative pain, patient

satisfaction, side effects, adverse events and recurrence rates were evaluated and recorded at each visit.

Ecchymosis and paresthesia were recorded in regions of the limb adjacent to the ablated vein segments. The

areas of ecchymosis were not measured but were simply recorded as present or absent. Pain was assessed on a

six-point scale ranging from no pain at all (0) to very painful (5).

Patients’ satisfaction was assessed by asking them: ‘Are you satisfied with the method being used?’ (0 = very

satisfied, 1 = satisfied, 2 = fairly satisfied, 3 = not satisfied), ‘Would you choose endovenous laser therapy

again?’ (0 = definitely, 1 = probably, 2 = don’t know, 3 = probably not, 4 = definitely not).

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Statistics

According to the exploratory purposes of the study only descriptive statistics were used.

Mean values and standard deviations were calculated using the statistics tool in Microsoft Excel 2007 version

(Microsoft Corporation, Redmond, Washington, USA).

RESULTS

The results are shown in Tables 3 and 4.

No patient was lost during the follow-up period (mean 13 months, range: 7-17 months). Mean age was 45.6 years

(min: 24, max: 77;; SD: 19.7) and the mean body mass index (BMI) was 26.5 (min: 23, max: 34;; SD: 4.0). 5 patients

(63%) were classified as C2, 3 (37%) as C3 according to CEAP classification. Terminal valve was incompetent in all

cases. The average diameter of treated AASVs, measured with patient in orthostatic position, was 8.8 mm (min: 7

mm;; max: 12 mm;; SD: 2.4). Almost all patients (88%) had symptoms;; the most common was heaviness (5 cases,

63%), followed by pain and itching.

The average length of treated AASVs was 14.0 cm (min: 10 cm, max: 25 cm;; SD: 4.7) with a mean operative time of

29.4 minutes (min: 20;; max: 60;; SD: 13.3). The average Linear Endovenous Energy Density (LEED: i.e. energy

amount in joules divided by the treated vein length in centimeters) was 60.5 J/cm (min: 52.1 J/cm;; max: 72.4 J/cm;;

SD: 7.5).

Patients returned to daily activities after a mean of 3.8 days (SD: 3.5);; no evidence of residual flow or venous

reflux was found on ultra-sound imaging at any time during follow-up. No recurrent varicose veins have occurred

so far.

Treatment effects on the VCSS–related signs or symptoms.

The VCSS improved drastically from a mean of 3.2 (SD: 1.42) pre-interventional to 0.13 (SD: 0.35) at day 30;; it

became 0 at three months and kept at 0 at every subsequent follow up. The EVLT substantially reduced

symptoms.

Complications and side-effects

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We did not observe any clinically-apparent pulmonary emboli or motor nerve lesions. No complications such as

deep venous thrombosis, skin burns, paresthesia or the formation of phlebitis reaction occurred in any treated

legs.

Pain: 5 patients (63%) reported pain with a mean intensity of 1.5 (min: 1;; max: 4;; SD: 1.5) on a scale of intensity

from 0 to 5;; 4 of these patients required analgesic therapy: mean 2.4 tablets (min: 2;; max: 10;; SD: 2.5).

50% of all patients returned to daily activities after 1 day (average of 3.8 days;; SD 3.5).

Ecchymoses: Post-operative ecchymoses in the area/segment of the treated saphenous veins and tributaries were

frequent (89%).

Complications rates are described in Table 4.

Patients’ satisfaction

After 30 days, 7 (88%) patients were very satisfied and 1 (12%) was satisfied;; at three, six, twelve and seventeen

months, all patients were very satisfied with the method. At day 30 the response to the question ‘Would you

choose endovenous laser therapy again?’ was ‘definitely’ in 7 patients (88%), ‘probably yes’ in 1 (12%), ‘do not

know’ and ‘probably would not’ in none. After 3 and 6 months all patients (8) were very satisfied and would

definitely chose EVLT again. At 12 and 17 months of follow-up every patient was very satisfied. Patients’

outcome is shown in Table 5.

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DISCUSSION

The ablation of the incompetent axial veins, which flow into the SFJ junction, causes abolition of SFJ reflux

itself11. AASV ablation eliminates reflux at the SFJ when associated with isolated reflux in this vein and the

subsequent improvement in symptom scores are similar to that achieved after GSV ablation6.

During conventional surgery, many surgeons perform a SFJ ligation with stripping of the incompetent AASV;;

this causes an alteration of the GSV hemodynamics if a common stump is present, also if very short. Some

surgeons even strip the competent GSV because of the possibility that, post-SFJ ligation, neo-vascularization

may subsequently promote GSV reflux and recurrence.

During EVLT, selective ablation of the incompetent axial vein can be achieved;; therefore, following AASV EVLT,

the GSV remains in continuity with the SFJ (now competent) in all patients, allowing normal GSV function. In our

experience isolated AASV/SFJ reflux occurs in around 8% of patients, a percentage reported also by other

authors, varying from about 7%5 to 10%6,12. In all these cases, a healthy GSV may be preserved and it will still be

available, if required, for vascular or coronary artery reconstruction.

Chaar et al5 reported a failure rate of 13.2% following the AASV EVLT, a percentage much higher than the GSV or

short saphenous vein (SSV) ablation, despite the use of high energy (up to 120 J/cm) and even though the size of

the failed veins ranged from 5 to 8 mm. Unfortunately they do not report the wavelength used and the mean

follow-up of their patients. Probably they used a Hemoglobin-Specific Wavelength laser (years 2007-2009). The

authors hypothesized that size does not seem to be a predictor of failure of EVLT, especially for SSV and AASV;;

these failures may be because of the shorter length of the vein treated and more large tributaries. However, the

only previously published paper dedicated to EVLT of the AASV, reported 100% success in closing this vein6

after 1 year of follow-up, notwithstanding the tributaries were not treated immediately after EVLT. These authors

have used a 810-nm diode pulsed laser at 12 W power delivering an average LEED of 61 J/cm, very similar to ours

and also their clinical results are similar, with a significant improvement of symptoms.

Although 5 patients had pain after EVLT, all of them are satisfied with the outcome of treatment and would be

content to undergo further treatment using endovenous ablation. In fact, post-operative pain is present, but is

generally mild, of short duration, well tolerated and requires a small intake of analgesics, on average slightly more

than 3 tablets. Ecchymoses are frequent;; we reported the presence of bruising when these were present, without

quantifying them or specifying if they were located along the course of the saphenous vein or phlebectomy. We

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think that bruising or ecchymoses are probably related to the tumescent anesthesia and/or phlebectomy rather

than to the laser technique (Fig. 2). However, these represent only a slight problem for patients;; in fact, at 1

month, in 70% of cases, the ecchymoses have already resolved spontaneously.

CONCLUSION

GSV-sparing EVLT of the AASV abolishes SFJ reflux associated with isolated SFJ/AASV reflux, improves

symptoms with no evidence of GSV neo-reflux or recurrent varicosities during an average follow-up of 13 months.

Although long-term follow-up is required, this technique has proved a safe and efficient treatment option in the

short-term follow-up.

AUTHOR CONTRIBUTIONS Conception and design: CA Analysis and interpretation: CA, MD Data collection: CA, MD Writing the article: CA, MD Critical revision of the article: CA, FRS, MD Final approval of the article: CA, FRS, MD Statistical analysis: CA, MD Obtained funding: Not applicable Overall responsibility: CA Conflict of Interest None. Funding Unfunded.

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REFERENCES 1. McLafferty RB, Lohr JM, Caprini JA, Passman MA, et al. Results of the national pilot screening program for

venous disease by the American Venous Forum. J Vasc Surg. 2007;;45:142-148.

2. Labropoulos N, Leon M, Nicolaides AN, Giannoukas AD, et al. Superficial venous insufficiency: correlation of anatomic extent of reflux with clinical symptoms and signs. J Vasc Surg. 1994;;20:953-8.

3. Myers KA, Ziegnebein RW, Zeng GH, Matthews PG. Duplex ultrasonography scanning for chronic venous

disease: patterns of reflux. J Vasc Surg. 1995;;21:605-12. 4. Caggiati A, Bergan JJ, Gloviczki P, Eklof B, et al;; Interdisciplinary Consensus Committee on Venous

Anatomical Terminology. Nomenclature of the veins of the lower limb: extensions, refinements, and clinical application. J Vasc Surg. 2005 Apr;;41(4):719-24.

5. Chaar CI, Hirsch SA, Cwenar MT, Rhee RY, et al. Expanding the role of endovenous laser therapy: results in

large diameter saphenous, small saphenous, and anterior accessory veins. Ann Vasc Surg. 2011 Jul;;25(5):656-61. doi: 10.1016/j.avsg.2011.02.031.

6. Theivacumar NS, Darwood RJ, Gough MJ. Endovenous laser ablation (EVLT) of the anterior accessory great

saphenous vein (AASV): abolition of sapheno-femoral reflux with preservation of the great saphenous vein. Eur J Vasc Endovasc Surg. 2009 Apr;;37(4):477-81. doi: 10.1016/j.ejvs.2008.11.035. Epub 2009 Feb 7.

7. Eklöf B, Rutherford RB, Bergan JJ, Carpentier PH, et al;; American Venous Forum International. Ad hoc

committee for revision of the CEAP classification. Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg. 2004;;40:1248-52.

8. Vasquez MA, Rabe E, McLafferty RB, Shortell CK, et al;; American Venous Forum Ad Hoc Outcomes Working Group. Revision of the venous clinical severity score: venous outcomes consensus statement: special communication of the American Venous Forum Ad Hoc Outcomes Working Group. J Vasc Surg. 2010;;52:1387-96.

9. Lin JC, Peterson EL, Rivera ML, Smith JJ, et al. Vein mapping prior to endovenous catheter ablation of the

great saphenous vein predicts risk of endovenous heat-induced thrombosis. Vasc Endovascular Surg. 2012 Jul;; 46 (5) :378-83. Epub 2012 May 30.

10. Cavallini A, Marcer D, Ferrari Ruffino S. Endovenous ablation of incompetent saphenous veins with a new 1540 nm diode laser and ball-tipped fiber. Ann Vasc Surg. In Press.

11. Theivacumar NS, Dellagrammaticas D, Beale R, Mavor AI, et al. The fate and clinical significance of

sapheno-femoral junction tributaries following endovenous laser ablation of great saphenous vein. Br J Surg. 2007;;94:722-5.

12. Garcia-Gimeno M, Rodriguez-Camarero S, Tagarro-Villalba S, Ramalle-Gomara E, et al. Duplex mapping of 2036

primary varicose veins. J Vasc Surg. 2009;;49:681-689. 13. Pieri A, Vannuzzi A, Moretti R, Gatti M, et al. Color-Duplex investigation of sapheno-femoral and

sapheno-popliteal junction. Venous valves and collateral veins. Phlébologie. 2002;;55(4):317-328.

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http://www.google.com/url?q=http%3A%2F%2Fwww.ncbi.nlm.nih.gov%2Fpubmed%3Fterm%3DChaar%2520CI%255BAuthor%255D%26cauthor%3Dtrue%26cauthor_uid%3D21724104&sa=D&sntz=1&usg=AFQjCNHCjQV3Kl03BGInCSyUmaJJ4LpNJQ

http://www.google.com/url?q=http%3A%2F%2Fwww.ncbi.nlm.nih.gov%2Fpubmed%3Fterm%3DHirsch%2520SA%255BAuthor%255D%26cauthor%3Dtrue%26cauthor_uid%3D21724104&sa=D&sntz=1&usg=AFQjCNG-PhOY6YU3y5FDDS_z_zh8yuSP5g

http://www.google.com/url?q=http%3A%2F%2Fwww.ncbi.nlm.nih.gov%2Fpubmed%3Fterm%3DCwenar%2520MT%255BAuthor%255D%26cauthor%3Dtrue%26cauthor_uid%3D21724104&sa=D&sntz=1&usg=AFQjCNHt7zxdGKSEQTj8qSdsCJr4fhnbIg

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Table 1. Main characteristics, clinical features, vein type and size

Patient Age and

gender BMI Vein Saph D;; (*) Signs and

symptoms VCSS CEAP

DIL F, 74 23,50 AASV sx + tributaries dx 12 Mild pain,

itching 4 C2sEpAsPr5

QM M, 41 34,00 GSV dx;; AASV sx 10;; 12 (20) Edema 6 C2EpAsPr2,5;; C2,3sEpAsPr5

DG F, 30 24,50 GSV dx and AASV sx 7

Edema, mild pain, heaviness, cramps, itching

3 C2,3sEpAsPr2,3,5;; C2,3sEpAsPr,5

FM F, 77 26,00 AASV dx 7 heaviness, mild pain 4 C2sEpAsPr5

RD F, 24 24,00 AASV bilateral 7 Aesthetic 2 C2EpAsPr5

MR F, 33 22,50 AASV dx + tributaries dx 12 Heaviness 2 C2sEpAsPr5

BD M, 40 31 AASV dx 8 (13) Itching,

heaviness, edema

4 C2,3sEpAsPr5

LP F, 46 26.6 GSV dx and AASV sx 7 heaviness,

aesthetic 2 C2EpAsPr2,3;; C2sEpAsPr5

GSV: great saphenous vein;; AASV: anterior accessory great saphenous vein;; CEAP: clinical, aetiological, anatomical and pathological elements;; VCSS: venous clinical severity score;; Saph D: saphenous diameter at 3-5 cm distal to the SFJ, Patient in orthostatic position;; * presence of segmental vein dilatation



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Table 2. Therapy with main parameters

Patient Joule Lenght treated vein (cm) LEED (j/cm) Total time

(min) DIL 910 13 70,0 40 QM 600 10 60,0 20 DG 680 13 52,3 20 FM 970 15 64,7 60

RD vein 1 1377 25 55,1 20 RD vein 2 628 10 62,8 20

MR 521 10 52,1 25 BD 1086 15 72.4 30 LP 832 15 55.4 30



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Table 3. Main parameters and clinical characteristics analysis

Variables

Patients (n) 8 Age (years), mean (SD) 45.6 (19.7) Female gender, n (%) 6 (75%) BMI (kg/m2), mean (SD) 26.5 (4.0) CEAP (highest classification per limb) C2, n (%) 5 (63%) C3, n (%) 3 (37%) C4, n (%) 0 C5, n (%) 0 C6, n (%) 0

All patients: Ep As Pr5 VCSS, mean (SD) 3.2 (1.4) Length of treated vein, mean (SD) 14.0 (4.7) LEED, mean (SD) 60.5 (7.5)

OP time (min) (EVLA + phlebectomies), mean (SD) 29.4, (13.3)

BMI, body mass index;; OP, operation



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Table 4. Pain, ecchymoses and return to daily activities after EVLA

Variables Outcome Postoperative pain Patients with pain after the procedure n (%) Pain score at day one, mean (SD), n of patients Pain score at days 2–10 , mean (SD), n of patients Pain score days at 11–30 mean (SD), n of patients Patients without analgesics after the procedure, n (%)

1 (13%) 0.1 (0.4), 1 1.3 (1.6), 4 0.6 (1.2), 2 7 (87%)

Analgesics Analgesic tablets (n) at day one, mean (SD) n of patients Analgesic tablets (n) from day two to day 10,mean (SD) n of patients Analgesic tablets (n) from day 11 to day 30,mean (SD) n of patients Analgesic tablets (n) total, mean (SD)

0.1 (0.4), 1 2.4 (3.5), 4 1.3 (3.5), 1 3.3 (6.6))

Return to daily activities (days), mean (SD) 3.8 (3.5) Ecchymoses Limbs with ecchymoses at day one, n (%) Limbs with ecchymoses at day 10, n (%) Limbs with ecchymoses at day 30, n (%)

8 (89%) 8 (89%) 3 (33%)



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Table 5. Patient’s outcome after EVLA The data reported in the table refer to a year because the majority of patients have reached such period.

Variables 1 month 3 months 6 months 12 months

Patients at follow-up (n) 8 8 8 6 Patients lost to follow-up (n) 0 0 0 0 Occlusion rate, n (%) 8 (100%) 8 (100%) 8 (100%) 6 (100%)

Modified VCSS, mean (SD) 0.13 (0.35) 0.00 (0.00) 0.00 (0.00) 0.00 (0.00)

Satisfaction patients n (%) Very satisfied 7 (88%) 8 (100%) 8 (100%) 6 (100%) Satisfied 1 (12%) 0 (0%) 0 (0%) 0 (0%) Fairly satisfied 0 (0%) 0 (0%) 0 (0%) 0 (0%) Willing to choose EVLA again, n (%) Definitely Yes 7 (88%) 8 (100%) 8 (100%) 6 (100%) Probably Yes 1 (12%) 0 (0%) 0 (0%) 0 (0%) Did not know 0 (0%) 0 (0%) 0 (0%) 0 (0%) Probably Not 0 (0%) 0 (0%) 0 (0%) 0 (0%)



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ICONOGRAPHY. Explanation of Tables and Figure. Table 1. Main characteristics, clinical features, vein type and size Table 2. Therapy with main parameters Table 3. Main parameters and clinical characteristics analysis

Table 4. Pain, ecchymoses and return to daily activities after EVLA

Table 5. Patient’s outcome after EVLA The data reported in the table refer to a year because the majority of patients have reached such period. Figure 1. Schematic view of AASV. Figure 2. AASV incompetence (C2EpAsPr5) with voluminous thigh and leg varicose veins. Treatment with 1540 nm diode LASER and ball-tipped fiber;; results 1 week (a) and 1 month (b) later. Ecchymosis are present all along the site of flebectomies.



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