The endovenous ASVAL method: principles and preliminary results.

Diagn Interv Radiol 2016; 22: 59–64 INTER VENTIONAL R ADIOLOGY © Turkish Society of Radiology 2016 ORIGINAL ARTICLE The endovenous ASVAL method: principles and preliminary results Mehmet Mahir Atasoy Levent Oğuzkurt PURPOSE We aimed to investigate the feasibility and safety of the endovenous ambulatory selective varicose vein ablation under local anesthesia (eASVAL) method in a selected group of patients with varicose disease and present the short-term results of one-year ultrasonographic follow-up. METHODS Three hundred and ninety-five consecutive patients with varicose veins who had been treated with endovenous laser ablation (EVLA) were retrospectively reviewed over a period of two years. From this group, 41 patients who were treated using the eASVAL technique and had the great saphenous vein (GSV) preserved were included in the study. These patients had only limited segmental GSV reflux accompanied by a competent terminal valve. The eASVAL technique can be defined as EVLA of the proximal straight segments of the major tributaries connecting the symptomatic varicose veins with the GSV, followed by ultrasound-guided foam sclerotherapy of the superficial varicose veins themselves. The patients were assessed before and after the treatment by duplex scan findings and clinical assessment scores. RESULTS The GSVs were successfully preserved in all 41 cases, and all patients showed significant clinical improvement using the eASVAL approach (P < 0.001). Segmental reflux was no longer present in 75.3% of patients. The mean diameters of the GSVs were significantly reduced at one-year follow-up (8.5 mm vs. 7.5 mm, P < 0.001). CONCLUSION eASVAL is a feasible and safe procedure in selected patients, with promising results at one-year ultrasonographic follow-up. However, prospective studies are required, comparing this approach with the standard techniques. A From the Department of Radiology (M.M.A.  ), Maltepe University School of Medicine, İstanbul, Turkey; Department of Radiology (L.O.), Bahçelievler Medical Park Hospital, İstanbul, Turkey. Received 10 April 2015; revision requested 12 May 2015; final revision received 27 June 2015; accepted 2 July 2015. Published online 9 November 2015. DOI 10.5152/dir.2015.15161 mbulatory selective varicose vein ablation under local anesthesia (ASVAL) is a surgical treatment for varicose veins based on the ascending hypothesis that venous insufficiency progresses in an ascending manner, from the superficial tributaries to the saphenous vein (SV) and then to the sapheno-femoral junction (SFJ). Recent scientific data based on precise and detailed duplex scanning support this hypothesis (1–6). The ASVAL method recommends preserving the great saphenous vein (GSV), unless there is a serious terminal valve insufficiency, and suggests the surgical removal (phlebectomy) of the superficial varicose reservoir (SVR) as a primary treatment. The major argument in favor of preserving the GSV is the essential physiologic role that the GSV could play in superficial drainage and, to a lesser extent, its availability as revascularization material. Although the original ASVAL method is performed using simple phlebectomies, many patients refuse to have this treatment because they regard it as a surgical operation that would likely yield poor cosmetic results. Thermal endovenous techniques and foam sclerotherapy are less aggressive and are reported to be as effective as traditional surgical treatments (7). The question arises as to whether the ASVAL approach can be performed using endovenous techniques. To the best of our knowledge, this research will be a preliminary study describing the endovenous technique for the ASVAL approach. The purpose of this study was to investigate the feasibility and safety of endovenous ASVAL (eASVAL) technique and to present the short-term results with one-year ultrasonography (US) follow-up in a selected group of patients. 59 Methods Three hundred and ninety-five consecutive patients who were treated with endovenous laser ablation (EVLA) were reviewed retrospectively between August 2011 and October 2013. Within this group, 41 patients had been treated with the eASVAL technique and had their GSVs preserved. All patients presenting with varicose veins were evaluated by clinical exam and duplex scanning by a vascular interventional radiologist. General exclusion criteria for EVLA were as follows: patients with severe peripheral arterial disease, active thrombophlebitis, severe deep vein insufficiency, pregnancy, known thrombophilia or coagulation disorders, or a history of deep vein thrombosis. The eASVAL technique can be defined as EVLA of the proximal straight segment(s) of the major tributary or tributaries connecting the symptomatic varicose veins, while sparing the incompetent segment of the GSV, followed by ultrasound-guided foam sclerotherapy (UGFS) of the superficial varicose veins themselves. The purpose of EVLA of the straight proximal segments of major tributaries was to decrease the foam from gaining access to the GSV, since the goal of ASVAL is to preserve the GSV. Patients with any grade of terminal valve reflux were not included in this study group, and they were assigned to a standard GSV ablation treatment. Main points • Ambulatory selective varicose vein ablation under local anesthesia (ASVAL) is a surgical treatment for varicose veins based on the theory that venous insufficiency progresses in an ascending manner, from the superficial tributaries to the saphenous vein and then to the sapheno-femoral junction, which is known as the “ascending hypothesis.” • The ASVAL method recommends preserving the great saphenous vein, unless there is a serious terminal valve insufficiency, and suggests the surgical removal of the superficial varicose reservoir as a primary treatment. • ASVAL approach can also be performed using endovenous techniques and, to our knowledge, this research will be a preliminary study describing the endovenous technique for the ASVAL. • The endovenous ASVAL method is feasible and has very good technical success rates and clinical results for treating varicose vein disease in patients with segmental GSV reflux and a competent terminal valve. The inclusion criteria were competent terminal valve, GSV segment showing reflux <10 cm in length, refluxing GSV diameter ≤10 mm, GSV without tortuosity, one (or more) large tributary veins with a straight proximal segment, and targeted major tributary vein diameter >5 mm (considered to be large). If all of the above criteria were met, patient was treated with eASVAL. If the patient did not meet one of the first five criteria, standard EVLA procedure was the treatment of choice. If the major tributary vein diameter, which is associated with the superficial varicose veins, was less than 5 mm in diameter, these patients were also excluded from the study. Only eight patients were excluded due to narrowness of the tributary vein. These patients w (...truncated)