Retrospective long-term evaluation of the quality of life and the results of a modified transilluminated powered phlebectomy (TPP) technique

Summary

Introduction: Transilluminated powered phlebectomy (TPP) using the TriVex method has become an established method of treating varicosis of the lateral saphenous branches. Investigations with follow-up times of up to 2 years have shown that TPP requires fewer incisions, is associated with shorter surgery time and shows better cosmetic results than traditional hook phlebectomy. To date, no long-term follow-up studies/results for a period of longer than 2 years are available in the scientific literature, nor has any systematic evaluation of the health-related quality of life after TPP phlebectomy been performed using the SQOR-V score.

Material and methods: Between February 2001 and May 2009, 627 patients with varicoses underwent TPP surgery in the Zollikerberg Clinic, using a modified surgical procedure. A total of 141 of these patients had previously undergone varicose vein surgery using various non-TPP surgical methods. These 141 patients were contacted as part of a retrospective evaluation. SQOR-V and an additional, newly developed internal TPP questionnaire were used. 69 patients gave their informed consent to the data collection, completed the questionnaires and were included in the analysis. The results of TPP and non-TPP surgery were compared exploratively. The postoperative course (6 weeks) was analysed, including photographic documentation obtained pre- and post-surgery. The patients were invited to the clinic for follow-up photographic documentation and clinical assessment. 18 patients accepted this invitation.

Results: The maximum follow-up period was 8 years and 2 months, the minimum period was 2 months (mean: 4.58 y, median: 4.25 y). A moderate to excellent improvement in the cosmetic impression was observed in 70 % of patients after TPP surgery. 87 % of patients had little or no reduction in activities after TPP surgery. 60 % of patients reported minimal or no oedema after TPP surgery. Peripheral thrombosis was observed in two patients after TPP surgery but no deep vein thrombosis was reported. By contrast, 6 patients who had undergone non-TPP surgery suffered deep venous thrombosis of the leg. Following their experience with both types of varicose vein surgery, the patients reported significantly less pain after TPP (p=0.001). The patients were more satisfied, to a statistically significant degree, with the results of TPP surgery (82 %) than with non-TPP surgery (7 %) (p<0.001). After non-TPP surgery, more patients had recurrent varicose veins and venous ulcers than after TPP surgery (recurrence: non-TPP 100 % vs. TPP 42 %; ulcer: non-TPP 3 % vs. TPP 1.4 %). Haematomas were more frequent after TPP surgery (severe 35.3 %, moderate 38.2 %) and persisted for longer (>4 weeks 39.4 %) than after non-TPP surgery (23.9 %, 43.3 %, >4 weeks 32.4 %). Pigmentations were observed more frequently after TPP surgery (31 %) than after non-TPP surgery (18 %).

Discussion: There was greater satisfaction, to a statistically significant degree, with the cosmetic results and lower pain levels after TPP surgery compared with non-TPP surgery. Of clinical significance are the reduced number of recurrent varicose veins and the lower rate of complications after TPP surgery. The haematomas and pigmentations were unfavourable effects but were surprisingly well tolerated. Randomised clinical studies are required, in order to confirm these promising results.

Keywords

Transilluminated Powered Phlebectomy (TPP) - varicosis - minimally invasive - TriVex

• References

• 1 Spitz GA BJ, Bergan JJ. Outpatient varikosis vein surgery with transilluminated powered phlebectomy. Vasc Surg 2000; 34: 547-55.
• 2 Arumagasamy M, McGreal G, O’Connor A, Kelly C, Bouchier-Hayes D, Leahy A. The technique of transilluminated powered phlebectomy – a novel, minimally invasive system for varikosis vein surgery. Eur J Vasc Endovasc Surg 2002; 23: 180-182.
• 3 Cheshire N, Elias SM, Keagy B. et al. Powered phlebectomy (TriVex) in treatment of varikosis veins. Ann Vasc Surg 2002; 16: 488-494.
• 4 Antignani PL. Classification of Chronic Venous Insufficiency: A review. Angiology 2001; 52: 17-26.
• 5 Widmer LK. Peripheral venous disorders. Basle Study III. Hans Huber Publishers; Berne: 1978: 43-50.
• 6 Allegra C, Antignani PL, Bergan JJ, Carpentier PH, Coleridge-Smith P, Cornu-Thénard A, Eklof B, Partsch H, Rabe E, Uhl JF, Widmer MT. The „C„ of CEAP: Suggested definitions and refinements: An International Union of Phlebology conference of experts. J Vasc Surg 2003; 37: 129-131.
• 7 Eklöf B, Rutherford RB, Bergan JJ, Carpentier PH, Gloviczki P, Kistner RL, Meissner MH, Moneta GL, Myers K, Padberg FT, Perrin M, Ruckley CV, Smith PC, Wakefield TW. Revision of the CEAP classification for chronic venous disorders: Consensus statement. J Vasc Surg 2004; 40: 1248-1252.
• 8 Rutherford RB, Padberg FT, Comerota AJ, Kistner RL, Meissner MH, Moneta GL. Venous severity scoring: An adjunct to venous outcome assessment. J Vasc Surg 2000; 31: 1307-1312.
• 9 Guex JJ, Zimmet SE, Boussetta S, Nguyen C, Taieb C. Construction and validation of a patient-reported outcome dedicated to chronic venous disorders: SQOR-V (specific quality of life and outcome response – venous). J Mal Vasc 2007; 32 (Suppl. 03) 135-140.
• 10 Guex JJ. Outcome assessment after varicose veins treatment. Phlebologie 2008; 37: 205-209.
• 11 Kluess HG. Leitlinie zur Diagnostik und Therapie der Krampfadererkrankung. Phlebologie 2010; 39: 271-292.
• 12 Rabe E, Pannier-Fischer F, Bromen K, Schuldt K, Stang A, Poncar Ch, Wittenhorst M, Bock E, Weber E, Jöckel KH. Bonner Venenstudie der Deutschen Gesellschaft für Phlebologie. Phlebologie 2003; 32: 1-14.
• 13 Revicki DA. Seven interesting things I’ve learned about health outcome research. 2007 President’s award adress: http:/www.isoquol.org
• 14 Randall WF, Hartman JF, Wright ML. Treatment of Varikosis Veins by Transilluminated wered Phlebectomy Surgery: a 9 Year Experience. Int J Angiol 2012; 21: 201-208.
• 15 Kristman V, Mano M, Coté P. Loss to follow up in cohort studies, how much is to much?. Eur J Epidemiol 2004; 19: 751-760.
• 16 Dietrich F, Imhoff M. Standartisierung in der Medizin: Qualitätssicherung oder Rationierung?. Schattauer. 2003 ISBN-10: 3794522680
• 17 Ware JE JR, Kosinski M, Keller SD. A 12-item Short-Form-Health Survey: construction of scales and perliminary test of rialibility and validity. Med Care 1996; 34: 220-233.
• 18 Perrin M, Dedieu F, Jessent V, Blanc MP. Evaluation of the new severity scoring system in chronic venous disease of the lower limbs; an observational study conducted by French angiologists. Phlebolymphology 2006; 13: 6-16.
• 19 Chetter IC, Mylankal KJ, Hughes H, Fitridge R. Randomized clinical trial comparing multiple stab incision phlebectomy and transilluminated powered phlebectomy for varicose veins. Br J Surg 2006; 93 (Suppl. 02) 169-174.
• 20 Franz RW, Knapp ED. Transilluminated powered phlebectomy surgery for varicose veins: a review of 339 consecutive patients. Ann Vasc Surg 2009; 23 (Suppl. 03) 303-309.
• 21 Shamiyeh A, Schrenk P, Huber E, Danis J, Wayand WU. Transilluminated powered phlebectomy: advantages and disadvantages of a new technique. Dermatol Surg 2003; 29 (Suppl. 06) 616-619.
• 22 de Zeeuw R, Wittens C, Loots M, Neumann M. Transilluminated powered phlebectomy accomplished by local tumescent anaesthesia in the treatment of tributary varicose veins: preliminary clinical results. Phlebology 2007; 22 (Suppl. 02) 90-94.
• 23 Luebke T, Brunkwall J. Meta-analysis of transilluminated powered phlebectomy for superficial varicosities. J Cardiovasc Surg (Torino) 2008; 49 (Suppl. 06) 757-764.
• 24 Chetter IC, Mylankal KJ, Hughes H, Fitridge R. Randomized clinical trial comparing multiple stab incision phlebectomy and transilluminated powered phlebectomy for varicose veins. Br J Surg 2006; 93 (Suppl. 02) 169-174.
• 25 Kahn SR, M´lan CE, Lamping DL, Kurz X, Bérard A, Abenhaim A. Relationship between clinical classification of chronic venous disease and patient-reported quality of life: Results from an international cohort study. J Vasc Surg 2004; 39: 823-828.
• 26 Kristman V, Mano M, Coté P. Loss to follow up in cohort studies, how much is to much?. Eur J Epidemiol 2004; 19: 751-760.
• 27 Lim H, Kim HJ, Cho YS. Active bleeding in abdominal wall developing after liposuction. Emerg Med J 2008; 25: 814.