European Journal of Cardiovascular Medicine

Varicose veins are a prevalent condition, with an estimated prevalence ranging from less than 1% to 73%, varied significantly across different ages, sexes, races, and geographical locations.[1] A significant number of individuals may initially be asymptomatic; nevertheless, as the condition advances, prevalent symptoms include leg pain, swelling, heaviness, itching, and calf cramps, all of which tend to ameliorate with rest, leg elevation, and the application of compression stockings. Severe manifestations encompass skin pigmentation, dermatitis, venous ulceration, cellulitis, superficial thrombophlebitis, and lipodermatosclerosis.[2,3] Varicose veins significantly impair quality of life, especially in advanced stages of the condition, which improves following illness therapy.[4,5] Traditionally, varicosity in the great saphenous vein was treated with high ligation and stripping; however, with the emergence of minimally invasive surgery, alternative methods such as endovascular laser ablation (EVLA) gained popularity.[6] EVLA and traditional surgery are both viable therapy choices; however, EVLA offers advantages typical of minimally invasive procedures, including less postoperative pain and a quicker resumption of normal activities and work.[7] However, the likelihood of reopening of the great saphenous vein and recurrences is similarly elevated with EVLA[8]. The short-term and long-term outcomes of these two modalities require examination to establish a solid foundation of data that supports evidence-based therapy.

Study Centre

The study was conducted in the Department of General Surgery, M.G.M. Memorial Medical College and M.Y. Hospital, Indore.

Duration of Study

The study spanned one year, starting from the date of approval by the Institutional Ethics Committee.

Source of Data

The study involved all cases of varicose veins admitted to and discharged from the Department of Surgery at M.G.M. Medical College and M.Y. Hospital, Indore. Both prospective and retrospective cases were included within the one-year study period.

Method of Collection of Data

Study Design

The study was a prospective and case-control study.

Study Period

The study was conducted over a period of one year from the date of approval by the Surgical Committee.

Place of Study

The study was conducted in the Department of General Surgery, M.G.M. Medical College and M.Y. Hospital, Indore.

Sample Size

A minimum of 30 cases were included, with 15 patients treated using the Endovascular Laser Technique (EVLT) and 15 patients treated using conventional venous stripping.

Inclusion Criteria

• Patients aged between 20 and 80 years.
• Both male and female patients.
• Patients diagnosed with varicose veins, either being treated or discharged.

Exclusion Criteria

• Patients with bleeding disorders or immunodeficiency.
• Patients with contraindications to laser ablation (e.g., pregnancy, deep vein thrombosis).
• Patients with recurrent varicose veins.
• Patients unwilling to provide consent for surgery.

Statistical Analysis

Data collected during the study were analyzed using appropriate statistical software and methods to determine the comparative effectiveness of EVLT and conventional venous stripping.

Methodology

Study Approach

The study was conducted after obtaining approval from the Institutional Ethics Committee. Written informed consent was obtained from all participants after explaining the surgical procedure and potential complications. Patients’ identities were kept confidential.

Patients were divided into two groups:

1. Cases: Treated using the Endovascular Laser Technique (EVLT).
2. Controls: Treated using conventional venous stripping.

Surgical Techniques

Positioning

• The patient was positioned supine with both lower limbs abducted at 30 degrees.
• The surgical field was painted and draped from the umbilicus to the toes, exposing the great saphenous vein (GSV) territory.

Endovascular Laser Technique (EVLT)

• A 600-micrometer radial fiber was used with a 1470 nm diode laser machine.
• Local tumescent anesthesia was administered (a mixture of 5 ml epinephrine, 5 ml bicarbonate, and 35 ml 1% lidocaine diluted in 500 ml saline).

Conventional Venous Stripping

• Respective-sized strippers were used for the procedure.

Postoperative Monitoring

Postoperative complications were observed and recorded at intervals of 1 month, 3 months, and 12 months.

Data Collection and Analysis

• Data were collected and organized into observation tables.
• Statistical analysis was performed to compare the outcomes and complications of EVLT and conventional venous stripping.

Table 1 – Demographic details of study participants

The study compared two groups (Group 1 and Group 2, each with 30 participants) based on age, sex, smoking history, and side of involvement. Age distribution showed a statistically significant difference (p=0.031), with Group 2 having a higher proportion of participants aged >60 years. Sex distribution revealed no significant difference (p>0.05), with males predominating in both groups. Smoking history was more common in Group 1 (24 vs. 16 participants), while Group 2 had a higher number of non-smokers. The side of involvement differed significantly (p=0.002), with bilateral limb involvement more frequent in Group 2 (14 vs. 5 participants).

Table 2 Post-Operative VAS Score and Bruising

The VAS scores and post-operative bruising were compared between Group 1 and Group 2, each comprising 30 participants. VAS scores showed a statistically significant difference (p<0.0001), with Group 1 reporting higher satisfaction and less pain (18 participants had no pain, VAS 10, compared to none in Group 2). In contrast, Group 2 had higher proportions of participants with miserable (VAS 4) or intense (VAS 2) pain. Post-operative bruising was significantly more prevalent in Group 2 (27 participants) compared to none in Group 1 (p<0.001).

Table 3 Long term Complication of Study subjects

The recurrence rates and complications at follow-up were compared between Group 1 and Group 2, each consisting of 30 participants. Recurrence was significantly higher in Group 2, with 25 participants experiencing recurrence compared to only 1 in Group 1 (p<0.001). Similarly, complications at follow-up were more prevalent in Group 2 across all time points (1, 3, and 12 months), with 25 participants affected at each follow-up, compared to just 1 participant in Group 1. The differences were highly significant (p<0.0001, highly significant).

This study compared the outcomes of endovascular laser technique (Group 1) with conventional venous stripping (Group 2) in patients with varicose veins. The results demonstrate significant differences in various parameters, suggesting the superiority of the endovascular laser technique.

Demographic and Clinical Characteristics

Age and Sex Distribution

While this study found significant age differences between groups (p=0.031), with more elderly patients in the conventional surgery group, other studies have shown mixed results. A large meta-analysis of 1,936 patients found no significant differences in age distribution between endovenous laser ablation (EVLA) and conventional surgery groups[8]. The male predominance observed in both groups contrasts with some studies that report higher prevalence in women, with one study noting varicose veins are visible in approximately 15% of men and 35% of women[9].

Risk Factors and Disease Distribution

The higher smoking prevalence in Group 1 (24 vs 16 patients) is noteworthy, as smoking can affect venous health. Recent studies have shown that smoking induces vasoconstriction and can permanently increase muscle tone, making blood flow through veins more difficult[10]. The significant difference in bilateral involvement (p=0.002) aligns with a propensity score-matched study of 772 patients that found variations in disease distribution between treatment groups[11].

Post-Operative Outcomes

Pain Assessment

The superior VAS scores in the laser group (p<0.0001) are consistent with multiple studies. A randomized controlled trial comparing EVLA with conventional surgery found significantly less post-operative pain in the EVLA group[12]. However, some studies report contrasting findings - a recent meta-analysis showed no significant difference in procedural pain between the two techniques[8].

Post-Operative Complications

The marked difference in post-operative bruising (0 vs 27 patients) supports previous findings. A prospective non-randomized study of 299 patients demonstrated significantly less bruising and post-operative complications in the EVLA group[13]. However, the complete absence of bruising in Group 1 is unusual, as most studies report some degree of bruising with EVLA[14].

Long-Term Outcomes

Recurrence Rates

The dramatically lower recurrence rate in Group 1 (1 vs 25 patients) contrasts with several recent studies. A 5-year randomized controlled trial showed higher recurrence rates with EVLA compared to conventional surgery[15]. Another study reported recurrence rates of 33.33% for EVLA versus 21.46% for conventional surgery[16]. This disparity suggests the need for longer-term follow-up studies.

Complications at Follow-Up

The significantly lower complication rate in Group 1 aligns with some studies but not all. While some research supports reduced complications with EVLA[17], others report comparable complication rates between the two techniques[18].

The results of this study strongly support the superiority of the endovascular laser technique over conventional venous stripping for the treatment of varicose veins. The laser technique demonstrated significant advantages in terms of reduced postoperative pain, minimal bruising, lower recurrence rates, and fewer long-term complications. These findings have important implications for clinical practice, suggesting that the endovascular laser technique should be considered as the preferred treatment option for suitable patients with varicose veins.However, it is important to note that this study has limitations, including the relatively small sample size and potential confounding factors such as age differences between the groups. Future large-scale, randomized controlled trials with longer follow-up periods are warranted to further validate these findings and explore the long-term efficacy and safety of the endovascular laser technique

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