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Deep vein insufficiency, not the method choice, determines the outcome of endovascular treatment in CEAP 6 patients

      We have read two interesting reports recently published in JVS-VLD by O'Banion et al.
      • O'Banion L.A.
      • Reynolds K.B.
      • Kochubey M.
      • Cutler B.
      • Tefera E.A.
      • Dirks R.
      • et al.
      A comparison of cyanoacrylate glue and radiofrequency ablation techniques in the treatment of superficial venous reflux in CEAP 6 patients.
      ,
      • Kiguchi M.M.
      • Reynolds K.B.
      • Cutler B.
      • Tefera E.
      • Kochubey M.
      • Dirks R.
      • et al.
      The need for perforator treatment after VenaSealTM and ClosureFastTM endovenous saphenous vein closure in CEAP 6 patients.
      In the first paper, the authors described a short-term outcome of superficial venous reflux treatment using cyanoacrylate (CA) or radiofrequency (RF) ablation in CEAP 6 patients.
      • O'Banion L.A.
      • Reynolds K.B.
      • Kochubey M.
      • Cutler B.
      • Tefera E.A.
      • Dirks R.
      • et al.
      A comparison of cyanoacrylate glue and radiofrequency ablation techniques in the treatment of superficial venous reflux in CEAP 6 patients.
      The second paper concerned the auxiliary perforator treatment in the same patients in the follow-up period.
      • Kiguchi M.M.
      • Reynolds K.B.
      • Cutler B.
      • Tefera E.
      • Kochubey M.
      • Dirks R.
      • et al.
      The need for perforator treatment after VenaSealTM and ClosureFastTM endovenous saphenous vein closure in CEAP 6 patients.
      In both papers, the authors concluded that CA shows superiority over RF in time required to wound healing
      • O'Banion L.A.
      • Reynolds K.B.
      • Kochubey M.
      • Cutler B.
      • Tefera E.A.
      • Dirks R.
      • et al.
      A comparison of cyanoacrylate glue and radiofrequency ablation techniques in the treatment of superficial venous reflux in CEAP 6 patients.
      and requires less perforator interventions.
      • Kiguchi M.M.
      • Reynolds K.B.
      • Cutler B.
      • Tefera E.
      • Kochubey M.
      • Dirks R.
      • et al.
      The need for perforator treatment after VenaSealTM and ClosureFastTM endovenous saphenous vein closure in CEAP 6 patients.
      Although both papers contain valuable observations, in our opinion, they provide the surprising interpretation of attached results.
      The authors concluded that CA is better than RF ablation because, in contrast to the latter, it enables the perforator treatment in the primary approach. However, this statement is unfounded, as the authors did not include the calf segment in the primary RF procedure. They explained their decision by intention to avoid nerve injury, although, actually, it is the matter of accurate and careful vein separation from the adjacent nerve by tumescent anesthesia.
      • Rodriguez-Acevedo O.
      • Elstner K.E.
      • Martinic K.
      • Zea A.
      • Diaz J.
      • Martins R.T.
      • et al.
      Hydrodisplacement of sural nerve for safety and efficacy of endovenous thermal ablation for small saphenous vein incompetence.
      Moreover, in the follow-up period, the authors used RF to close incompetent perforators, even in the CA group.
      • Kiguchi M.M.
      • Reynolds K.B.
      • Cutler B.
      • Tefera E.
      • Kochubey M.
      • Dirks R.
      • et al.
      The need for perforator treatment after VenaSealTM and ClosureFastTM endovenous saphenous vein closure in CEAP 6 patients.
      Interestingly, if patients from the RF group were treated including the calf segment, would they require any auxiliary procedures for their perforators?
      The main limitation of both studies is the significant difference in the venous insufficiency severity between the treated groups. It is noteworthy that the insufficiency of the superficial system alone affected 41% patients from the CA group, whereas in the RF-treated patients, it concerned 9% individuals only.
      • O'Banion L.A.
      • Reynolds K.B.
      • Kochubey M.
      • Cutler B.
      • Tefera E.A.
      • Dirks R.
      • et al.
      A comparison of cyanoacrylate glue and radiofrequency ablation techniques in the treatment of superficial venous reflux in CEAP 6 patients.
      It is obvious that deep vein insufficiency is a much worse condition compared with the sole involvement of the superficial system. Because of higher venous hypertension, those patients reveal the increased risk of ulceration, decreased healing rate, and higher risk of ulcer recurrence.
      • Raffetto J.D.
      • Ligi D.
      • Maniscalco R.
      • Khalil R.A.
      • Mannello F.
      Why venous leg ulcers have difficulty healing: overview on pathophysiology, clinical consequences, and treatment.
      Also, to enable sufficient blood outflow, they require much higher compression compared with others.
      • Szary C.
      • Wilczko J.
      • Grzela T.
      • Partsch H.
      Which pressure of adjustable compression wrap system is necessary to reduce deep vein cross section area in post-thrombotic patients? A proof-of-concept study.
      Thus, to evaluate the impact of particular treatment on wound healing, the assessment of healing rate in each patient before and after the procedure would be required.
      In our opinion, the treatment outcome depends mainly on the vein condition and, to a lesser extent, on the method choice. Although the authors identified this issue, unexpectedly, they missed it in final conclusions.

      References

        • O'Banion L.A.
        • Reynolds K.B.
        • Kochubey M.
        • Cutler B.
        • Tefera E.A.
        • Dirks R.
        • et al.
        A comparison of cyanoacrylate glue and radiofrequency ablation techniques in the treatment of superficial venous reflux in CEAP 6 patients.
        J Vasc Surg Venous Lymphat Disord. 2021; 9: 1215-1221
        • Kiguchi M.M.
        • Reynolds K.B.
        • Cutler B.
        • Tefera E.
        • Kochubey M.
        • Dirks R.
        • et al.
        The need for perforator treatment after VenaSealTM and ClosureFastTM endovenous saphenous vein closure in CEAP 6 patients.
        J Vasc Surg Venous Lymphat Disord. 2021; 9: 1510-1516
        • Rodriguez-Acevedo O.
        • Elstner K.E.
        • Martinic K.
        • Zea A.
        • Diaz J.
        • Martins R.T.
        • et al.
        Hydrodisplacement of sural nerve for safety and efficacy of endovenous thermal ablation for small saphenous vein incompetence.
        Phlebology. 2017; 32: 482-487
        • Raffetto J.D.
        • Ligi D.
        • Maniscalco R.
        • Khalil R.A.
        • Mannello F.
        Why venous leg ulcers have difficulty healing: overview on pathophysiology, clinical consequences, and treatment.
        J Clin Med. 2020; 10: 29
        • Szary C.
        • Wilczko J.
        • Grzela T.
        • Partsch H.
        Which pressure of adjustable compression wrap system is necessary to reduce deep vein cross section area in post-thrombotic patients? A proof-of-concept study.
        Phlebology. 2020; 35: 207-214

      Linked Article

      • A comparison of cyanoacrylate glue and radiofrequency ablation techniques in the treatment of superficial venous reflux in CEAP 6 patients
        Journal of Vascular Surgery: Venous and Lymphatic DisordersVol. 9Issue 5
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          Venous leg ulcers (CEAP [clinical, etiologic, anatomic, pathophysiologic] class 6) represent the most severe form of chronic venous insufficiency. As closure techniques for superficial venous reflux evolve, direct outcome comparisons of treatments are integral, because many studies have already demonstrated that early endovenous intervention improves wound healing. The present study compared the rates of venous wound healing between two techniques of superficial vein closure: ClosureFast radiofrequency ablation (RFA) and adhesive closure (VenaSeal; both Medtronic, Inc, Minneapolis, Minn).
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        Journal of Vascular Surgery: Venous and Lymphatic DisordersVol. 9Issue 6
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          We appreciate Szary et al's interest and letter to the editor regarding our papers comparing outcomes of CEAP 6 patients undergoing cyanoacrylate vs thermal ablative techniques.
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