CARDIOVASCULAR JOURNAL OF AFRICA • Volume 35, No 3, September – October 2024 AFRICA 167 successful treatment rates with this method, as well as with EVLA and RFA.10 However, all these endovenous methods are generally used in the treatment of insufficiency of saphenous veins less than 10 mm in diameter. Although successful results have been reported in larger vessels, discussions on the subject continue. In this study, a new technique was described to investigate the success level of NBCA ablation of saphenous veins larger than 15 mm, and the aim was to determine the outcome. The pre-ablation bandaging technique was used as a new technique and its clinical results were evaluated in the light of the literature. Methods This study was designed as a prospective, cross-sectional study. After the steps of the study were determined, ethics committee approval was obtained by applying to the clinical research local ethics committee (approval no. 18-04/21). All steps of the study were carried out in accordance with good clinical practices and the principles of the Declaration of Helsinki. Informed consent was obtained from all patients. Patients were included in the study if they had superficial venous insufficiency at the saphenofemoral junction in a Doppler ultrasonography performed at the cardiovascular surgery clinic, a great saphenous vein diameter of over 6 mm and they opted for surgery. The vessel diameters of all patients were confirmed by an independent surgeon using colour Doppler (Philips Lumify linear transducer, Philips Healthcare, Cambridge, MA). Patients with a vessel diameter of less than 5.5 mm, a history of previous vascular surgery, chronic or acute deep venous thrombosis and those who did not agree to participate in the study were excluded from the study. A total of 89 patients were included in the study. Patients were divided into three groups according to great saphenous vein diameter: less than 10 mm (group 1, n = 48), between 10 and 15 mm (group 2, n = 23), and over 15 mm (group 3, n = 18). Ablation treatment with NBCA was planned for each group. Also, an esmarch bandage was applied during the vessel ablation procedure in all patients with a vessel diameter greater than 10 mm. The standard treatment was used for those with a vessel diameter of less than 10 mm. After the patient was covered with a sterile drape, the saphenous vein was located with venous Doppler at the knee level. After local anaesthesia, a 7F sheath was inserted into the saphenous vein using the Seldinger method. Under the guidance of ultrasound, the saphenous vein diameter was measured under the junction (Fig. 1A, B) and a Venex (Vesta Medical Devices, Ankara, Turkey) catheter was advanced up to the saphenofemoral junction. The catheter was then retracted 2 cm distal to the junction, and compression was applied to the saphenofemoral junction with an ultrasound probe. The diffuse saphenous vein was closed by applying NBCA through a catheter. This process was the same in all groups. However, in groups 2 and 3, with a large saphenous diameter, after the catheter was placed at the saphenofemoral junction, it was completely wrapped with an esmarch bandage from the knee to the groin before starting the closure procedure (Fig. 1C, D). The ablation procedure was then initiated. The aim was to reduce the vessel diameter of patients with large vessel diameters using compression and to de-bloat the operation area. Varicose side branches were removed by mini-flebectomy. After the procedure, the extremities were completely wrapped with an elastic bandage and the patients were observed for one hour and then discharged. All patients were called for routine one-, three- and six-month follow up, and vessel diameters (Fig. 1E, F), clinical complaints and additional conditions (needle puncture ecchymosis, thrombophlebitis) under ultrasound were recorded. Revised venous clinical severity score (rVCSS) values before and after the procedure were processed into the data, as described in the previous literature.11 Statistical analyses Statistical analyses were performed using a software program (SPSS v 22.00, IBM, Armonk, NY). Continuous variables are presented as the mean ± standard deviation (SD) and ranges. Ratios were compared using the chi-squared test. After using the Mann–Whitney U-test as a post hoc analysis, the difference between postoperative findings was evaluated using the Kruskal– Wallis H-test. The rVCSSs were compared using a one-way analysis of variance (ANOVA). The statistical significance was accepted at p < 0.05. Results When the demographic distribution of the groups was evaluated, it was observed that the patients in the group with a saphenous vein diameter over 15 mm (group 3) were older (p = 0.010), and the saphenous vein diameters were larger in the females (p = 0.001). Table 1 summarises the demographic distribution of the groups. Also, as expected, both clinical classification and rVCSS scores were higher in patients in group 3, where the saphenous veins had the largest diameters. The mean saphenous vein diameter was 6.4 ± 2.4 mm in group 1, 12.3 ± 1.6 mm in group 2 and 18.4 ± 3.8 mm in group 3. Additional mini-phlebectomy was performed in 12, 10 and 10 patients in groups 1, 2 and 3, respectively (Table 1). When the groups were compared in terms of postoperative complications, thrombophlebitis was found in two patients in groups 1 and 2 and not in any in group 3. No recanalisation or residual leakage was observed in any group in the first month after the operation. At the third month, minimal saphenofemoral reflux was observed in two (4.2%) patients in group 1 and in one (4.3%) in group 2. At the sixth month, minimal saphenofemoral reflux was detected in three (6.3%) patients in group 1 and in one (4.3%) in group 2. No residual leakage was observed in group 3 (p = 0.001). In all groups, rVCSS regressed significantly at six months postoperatively (p = 0.000). However, the most significant symptomatic regression was observed in group 3, which had the largest vein diameters and we had used an esmarch bandage during closure (p = 0.000). Postoperative findings are compared in Table 2. Discussion Our study is the first to investigate the effects of the esmarch bandage in the endovascular treatment of varicose veins.
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