CARDIOVASCULAR JOURNAL OF AFRICA • Volume 35, No 3, September – October 2024 AFRICA 169 The treatment of incompetent saphenous vein insufficiency with closure techniques using NBCA has been presented as a very current and effective method.10,12 Eroğlu et al. found that NBCA treatment success was similar to that of the endothermal ablation technique after two years of follow up.13 Also, compared to other endovascular techniques, it has been reported as an advantage that it can be applied with local anaesthesia without requiring tumescent anaesthesia, leading to less postoperative pain and faster recovery.10,12 However, it has been shown that a larger saphenous vein diameter was associated with a high recurrence rate among three different vessel sizes, even when using the endothermal ablation technique for the treatment of venous insufficiency.14 Similarly, in the literature, higher recurrence rates in patients with large pre-operative diameters of the saphenous vein were emphasised during NBCA treatment techniques.15,16 In a study by Chan et al., 8-mm and larger diameters were defined as the independent predictor of recanalisation for saphenous veins closed with NBCA.17 Kubat et al. published their results on four different techniques, namely high ligation + stripping (HLS), RFA, NBCA closure and EVLA procedures at 980- and 1.470-nm wavelengths, for the treatment of saphenous vein insufficiency with a diameter over 10 mm. In this study, the authors found that NBCA treatment seemed to yield a higher recurrence rate in large saphenous vein diameters.15 In another study, the NBCA closure technique was also reported to yield high rates of recanalisation in patients with vein diameters greater than 10 mm.16 In our study, although the saphenous vein diameter was less than 10 mm in group 1 where the classical technique was performed (without the use of an esmarch bandage), higher recanalisation rates were detected, while higher closure rates were found in groups 2 and 3 in which an esmarch bandage was used. In another report on saphenous vein insufficiency, the postprocedure thrombosis rate was emphasised. In this study, it was found that the most basic and only risk factor for superficial thrombus formation after ablation was a saphenous vein diameter over 10 mm.18 These and similar data led to the addition of saphenous vein diameter to the inclusion or exclusion criteria in studies investigating planned endovenous closure techniques, and studies can be planned accordingly.19 Thrombosis has been shown to be one of the most common complications in endovenous techniques, although the overall complication rate is low, according to data from another study.20 In fact, it has been reported that the rate of partial thrombosis after intervention is higher for various reasons in patients with larger vessel diameters. Thrombophlebitis and venous thrombosis have been reported as the most prominent postoperative complications after ablation with chemical agents, such as polydicanol.21 With EVLA, RFA and other techniques, these complications were found to be more common in patients with saphenous vein diameters greater than 8 mm.21 According to results obtained from the studies, the rate of thrombotic events is between zero and 8% in techniques such as EVLA and RFA, which are based on heat transfer, regardless of vessel diameter, while similar clinical results have been reported with NBCA.22 From the results of the study by Bissacco et al. with 918 patients, the major complications after saphenous vein ablation with NBCA were reported as 4.8% postoperative pain and 2.1% superficial vein thrombosis.23 In our study, while the rates of thrombophlebitis were consistent with the literature in groups 1 and 2, thrombophlebitis was not found in group 3, where the saphenous vein diameter was the largest, and an esmarch bandage was used. In a study by Favard et al., in which NBCA was applied to the intravascular area, it was observed that NBCA stimulated the local intravascular inflammatory response by triggering thrombosis and causing sclerosis but it did not cause an advanced reaction.24 It has been suggested that exposure to blood cells further enhances the inflammatory process.25 Other factors have been suggested, such as the proximity of the vein to the skin and the diameter of the vein.26 Although the exact effect of NBCA has not been clarified, it has been hypothesised to be a type IV delayed hypersensitivity reaction caused by a foreign substance, rather than a localised inflammation. In pre-clinical studies, it has been shown that exposure of the endothelium to NBCA resulted in subacute vasculitis and chronic granulomatous foreign body reactions, depending on the concentration of the substance. Fibrosis and partial recanalisation related to the density of the contact with the substance were detected around the exposure area.25–27 Extremity wrapping with an esmarch bandage is a method that is frequently used during orthopaedic interventions to prevent exsanguination and to keep the surgical field clean by providing compression of the extremity vascular structures and blocking blood flow to the extremity. In this way, both venous and arterial blood flow is stopped and vascular structures are reduced in diameter.28,29 Table 1. Demographic and clinical variables in the groups Variables Group 1 (n = 48) Group 2 (n = 23) Group 3 (n = 18) p-value* Age 36.44 ± 18.03 37.22 ± 10.99 47.83 ± 10.66 0.010 Gender (female), n (%) 13 (27.0) 15 (65.2) 12 (66.6) 0.001 CEAP C2 15 1 7 0.000 C3 32 3 4 C4 1 17 4 C5a 0 2 3 Severity scoreb 5.1 ± 2.6 5.6 ± 2.1 5.8 ± 1.8 0.000 Great saphenous vein diameter 6.4 ± 2.4 12.3 ± 1.6 18.4 ± 3.8 0.000 Removal of branch veins, n (%) 12 (25.0) 10 (43.4) 10 (55.5) 0.000 aC5: clinical classification 5 (same columns were combined); banalysed by using one-way analysis of variance. *Kruskal–Wallis H-test and Mann–Whitney U-test as post hoc analysis, p < 0.05 is significant. CEAP: clinical, aetiological, anatomical and pathophysiological classification of venous disorders. Table 2. Postoperative clinical outcomes in the groups Outcomes Group 1 (n = 48) Group 2 (n = 23) Group 3 (n = 18) p-value* Thrombophlebitis, n (%) 2 (4.2) 2 (8.7) 0 (0) 0.001 Ecchymosis, n (%) 3 (6.2) 2 (8.7) 1 (5.5) 0.448 Insufficient closure or continuing reflux 1st month, n (%) 0 (0) 0 (0) 0 (0) – Insufficient closure or continuing reflux 3rd month, n (%) 2 (4.2) 1 (4.3) 0 (0) 0.021 Insufficient closure or continuing reflux 6th month, n (%) 3 (6.3) 1 (4.3) 0 (0) 0.001 Postoperative severity scoreb 0.9 ± 1.4 1.2 ± 1.0 1.7 ± 1.3 0.000 bAnalysed using one-way analysis of variance. *Kruskal–Wallis H-test and Mann–Whitney U-test as post hoc analysis, p < 0.05 is significant.
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