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Doi:10.1016/j.ejvs.2006.04.033Eur J Vasc Endovasc Surg xx, 1e7 (xxxx)doi:10.1016/j.ejvs.2006.04.033, available online on Chronic Venous Disease Treated by Ultrasound Guided Aim. To report the outcome of a series of patients with chronic venous disease due to incompetence of saphenous trunksmanaged by ultrasound guided foam sclerotherapy (UFS).
Patients and methods. A group of 808 patients comprise this series. CEAP clinical class for limbs was C1: 15%, C2:81%, C3: 0.5%, C4: 2%, C5: 0.2%, C6: 0.4%. UFS using 1% polidocanol (107 limbs), 1% sodium tetradecyl (102 limbs),3% sodium tetradecyl (900 limbs) was employed to treat incompetent saphenous trunks. In patients with unilateral varices1 treatment was required in 43% of patients and 2 treatments in 48% of patients to obliterate incompetent saphenoustrunks and varices. For bilateral varices 2 treatments were required in 40% of patients and 3 treatments in 46% of cases.
The clinical outcome and patency of treated veins on duplex ultrasonography was assessed at a mean follow-up interval of 11 months.
Results. A total of 459 limbs were available for assessment at a follow-up interval of 6 months or greater. The CEAP clin-ical stage was C0:182 limbs, C1: 241, C2: 22, C3: 0, C4: 11, C5: 2, C6:1. The GSV had remained obliterated in 88% oflimbs and the SSV in 82% of limbs. Recurrent venous incompetence following previous surgery was as effectively treatedby UFS as primary incompetence.
Conclusions. This technique is useful in the management of chronic venous disease as an alternative to surgery.
Keywords: Varicose veins; Foam sclerotherapy; Duplex ultrasonography; Clinical outcome.
Subsequently a number of authors have publishedclinical series using this treatment including Frullini Surgery for varicose veins is widely used in the UK and Cavezzi who reported a series of 453 patien but recurrence may be expected in 25e50% of patients and Barrett who reported a series of 100 limbs.
at 5 Surgery leaves scars and may result in Cavezzi has subsequently reported a good outcome damage to adjacent structures including nerves, lym- in 93% of 194 patients.This technique has become phatics, major arteries and veins.Deep vein throm- widely used in southern Europe, Australia, New bosis and pulmonary embolism occur.Saphenous Zealand, South America and the USA.In the UK trunks, but not superficial varices, may be obliterated one series has been recently reported involving 60 by radiofrequency obliteration (RF obliteration)or patients comparing surgical treatment with foam scle- endovenous laser treatment (EVLT).Phlebectomy or rotherapy combined with sapheno-femoral ligation.
sclerotherapy are used to manage the residual varices.
The aim of this paper is to report the author’s own The advantage of using these methods is more rapid series of patients treated by ultrasound guided foam post-operative recovery compared to surgery.
(UFS) sclerotherapy for the management of chronic In 1995 Cabrera reported that foam created using ‘physiological gases’ mixed with polidocanol (a deter-gent sclerosant) was effective in the management oftruncal saphenous incompetence.He used ultra- sound guided injection into saphenous trunks.
A total of 808 patients (666 women, 142 men) weremanaged by ultrasound guided foam sclerotherapy *Corresponding author. Philip Coleridge Smith, DM, FRCS, Depart- for chronic venous disease due to truncal saphenous ment of Surgery, Thames Valley Nuffield Hospital, Wexham Street, incompetence. Patients without truncal incompetence Wexham SL3 6NH, UK. Tel.: þ44 1753 665449; fax: þ44 1753 663964.
E-mail address: have been excluded from this series.
1078–5884/000001 + 07 $35.00/0 Ó 2006 Elsevier Ltd. All rights reserved.
All patients were referred to the author for man- trunks and STD was used as either a 1% or 3% solu- agement of varices in private practice (Thames Valley tion for saphenous trunks. Foam was prepared in a Nuffield Hospital, Wexham, Bucks, UK). Patients ratio of 0.5 ml of sclerosant to 1.5 ml of air in keeping were assessed by clinical examination during which the CEAP clinical stage was recorded and all under-went colour duplex ultrasonography (Sonoline, Sie-mens, Germany) using a 5e9 MHz linear transducer.
The author or an assistant trained in venous duplex ultrasound examination undertook all investigations.
Patients stood during ultrasound examination and The author’s preparation for this clinical series in- venous reflux was assessed by manual compression cluded treating 50 patients in clinical trials under of the calf followed by release. Reverse flow in the the supervision of an experienced practitioner of ul- vein under examination exceeding 0.5 seconds indi- trasound guided foam sclerotherapy. The author also cated venous incompetence.The diameter of incom- has 20 years of experience of vascular duplex ultraso- petent saphenous veins and perforating veins was nography. Patients lay supine during canulation of the recorded in a computer database. The extent of previ- veins and during treatment to minimise the amount of ous varicose vein surgery and recurrent varices blood in the vein and to avoid syncope. With all can- shown by duplex ultrasound was also recorded. The nulae and Butterflies in place the limb to be treated definition of ‘recurrent’ used here is a saphenous was elevated to an angle of about 30 to empty the trunk or system where previous junction ligation or veins and foam was injected. The progress of foam stripping had been carried out. Limbs in which sur- was monitored using ultrasound imaging. No specific gery had been carried out to another vein e.g. previ- measures were taken to avoid foam entering the deep ous SSV surgery in a patient with GSV reflux, were veins but only 2 ml of foam per injection was given at classified as ‘primary GSV reflux’. Incompetence of a time. The total amount of foam injected in one treat- the anterior accessory saphenous vein (AASV) in ment session was limited to 20 ml in order to avoid limbs where previous GSV surgery had been per- local or systemic complications. Saphenous trunks formed was considered to be recurrent reflux accord- were injected first and any residual varices treated ing to recent anatomical definitions.
in subsequent sessions. Blood flow in the deep veins All treatments were carried out in a consulting was encouraged after each injection by asking the room without sedation or general anaesthesia using patient to perform as series of dorsiflexions at the ankle in order to minimise the risk of DVT.
The great saphenous vein (GSV) was canulated with Prophylactic heparin was not given routinely in an 18g IV cannula (Optiva 2, Medex Medical Ltd, this series. A small number of patients with duplex Rossendale, UK) at the level of the knee or just above ultrasound evidence of post-thrombotic deep vein with ultrasound guidance. The GSV below the knee damage was treated. All received a 5 day course of was injected via a 23 g Butterfly needle (Abbot prophylactic LMWH and none developed a DVT.
Ireland, Sligo, Eire). In the small saphenous vein the Short stretch compression bandaging was applied cannula was placed in the proximal part of the calf to limbs where saphenous trunks and varices had 10e15 cm from the sapheno-popliteal junction. The been injected. Pehahaft cohesive bandage (PehahaftÒ, distal SSV was injected using a 23 g Butterfly. Correct positioning of the cannula or Butterfly was confirmed (VelbandÒ, Johnson & Johnson Medical, Ascot, Berk- by the injection of 0.9% saline solution. Saphenous shire, UK) cotton wool padding applied over the saphe- varices (3 mm diameter or greater) were injected nous trunks to increase compression. A class 2 medical through either a 23 g Butterfly or 30 g needle attached compression stocking was measured and applied over to a 2 ml syringe. Transverse ultrasound images of the the bandage to secure the bandage (CredelastÒ, veins were used to guide injections.
Credenhill, Ilkeston, Derbyshire, UK). Initially bandag- The Tessari method of preparing foam was used in ing was left in place for 3e5 days but later in the series which sclerosant and air was mixed in two syringes this was increased to 10e14 days to minimise the inci- dence of thrombophlebitis. Treatment sessions were used were either polidocanol (POL e ScleroveinÒ, carried out at intervals of 2 weeks. Duplex ultrasonog- Resinag AG, Zurich, Switzerland) and purified so- raphy was used to check the treated veins for complete- dium tetradecyl sulphate (STD e FibroveinÒ, STD ness of occlusion. Veins containing a substantial Pharmaceuticals Ltd, Hereford, UK). POL was used amount of residual thrombus after sclerotherapy were as a 1% solution to create the foam to treat saphenous managed by aspiration using a 19 g needle.
Eur J Vasc Endovasc Surg Vol xx, Month xxxx Chronic Venous Disease Treated by Foam Sclerotherapy Patients were invited to return for follow up visits 6 reflux but patients from all CEAP clinical stages are months after treatment. The patients were asked included. Some saphenous trunks shown to be incom- about symptoms and recurrence of varices. The petent on duplex ultrasound were not treated since CEAP clinical stage was recorded at each visit and du- they gave rise to few or no varices. In all 1109 limbs plex ultrasonography used to assess the state of occlu- were managed by foam sclerotherapy. A surprisingly sion of saphenous trunks and varices. In addition, the high proportion of patients had undergone previous competence of all other saphenous trunks and deep surgery for varicose veins in the vessel being treated, veins of the thigh and calf were assessed.
30% of GSVs and 17% of SSVs. Four limbs were Where recurrent or residual reflux was found in treated in which post-thrombotic deep vein incompe- tributaries or trunks, further UFS was used. The diam- tence was found in association with GSV or SSV eter of recurrent incompetent saphenous trunks fol- lowing earlier foam sclerotherapy was much smaller than at the initial treatment. Subsequent foam sclero- were performed in all 808 patients to obliterate incom- therapy was no more technically complex than at petence trunks and varices. In 99% of patients with the first treatment and usually resulted in obliteration unilateral varices and 92% of bilateral varices 3 treat- of the re-treated saphenous trunk. Longer term ments were sufficient to obliterate all veins. The me- follow-up in retreated saphenous trunks has not been dian volume of sclerosant foam required to achieve completed. No patient required surgical treatment.
this outcome over all sessions was 14 ml (inter-quartile range, IQR 9e21 ml, range 1 mle72 ml). Themedian volume of foam used per limb over all sessions was 10 ml (IQR 6e14 ml). In treating theGSV the median volume of foam used was 10 ml Data are represented by the mean and range for the age and median and interquartile range for all other e14 ml) and for the SSV 6 ml (IQR 5e10 ml).
Initially in this series, 1% POL foam was used to data, which were not normally distributed. Tests of treat saphenous trunks. Later 1% and 3% STD were statistical significance have not been used. These employed. The aim of using stronger sclerosants were not considered appropriate in a clinical series was to minimise the risk of recanalisation of saphe- where differences may have arisen as a consequence nous trunks. 1% POL was used in 13% of saphenous veins, 1% STD in 9% and 3% STD in 78%.
Thrombophlebitis occurred in a small number of patients (5%) and was managed by analgesia, com-pression and aspiration of thrombus. Calf vein throm- A total of 808 patients are included in this series in bosis was confined to isolated gastrocnemius veins or whom 1411 limbs were affected by venous disease.
to part of the posterior tibial vein (10 cases). All re- The clinical and duplex ultrasound findings are sum- solved with compression by stocking or bandage and exercise without use of anticoagulants. In one limbs were affected by uncomplicated varicose veins case a short occlusive thrombus arose in the common (CEAP C2, n ¼ 1154, 81%) attributable to GSV or SSV femoral vein 2 weeks following treatment of the GSV Table 1. Patients included in study e clinical data CEAP stage e limbs with venous disease considered for treatment, total 1411C1 Duplex ultrasound findings in 1109 limbs which were treated by UFSGSV reflux, alone Eur J Vasc Endovasc Surg Vol xx, Month xxxx Table 2. Number of treatments received per patient Outcome of treatment of GSV
probably due to direct extension of thrombus from the Number of limbs 100
GSV into the femoral vein. This case was managed byanticoagulation using low molecular weight heparin and warfarin continued for six months. The occluded femoral vein recanalised within 4 weeks and at six months of follow-up no residual scarring or valve CEAP Clinical class
damage could be demonstrated on duplex ultraso- Fig. 1. CEAP clinical stage before and at an average of 11 nography. In two further cases non-occlusive throm- months after UFS carried out to the GSV.
bus extended from the SFJ and SPJ (one case each)into the femoral and popliteal vein. The extent ofthe thrombus was limited and firmly adherent to the The data in has been subdivided to assess fac- vein wall. This was managed by compression stock- tors which might influence the outcome including ings and exercise whilst monitoring the extent of the diameter of the vein, type of sclerosant and whether thrombus by duplex ultrasonography. In these cases primary or recurrent varices were treated. A greater the thrombus resolved without further intervention.
incidence of recanalisation was seen in GSVs and No major systemic complication such as anaphy- SSVs larger than 5 mm in diameter. The recurrence laxis, stroke or transient ischaemic attack occurred in rates are similar with both sclerosants used in the this series. A number of patients (14, 2% of all patients treatment. A substantial proportion (30%) of patients treated) reported visual disturbance following treat- were treated for recurrent varices of the GSV follow- ment. Patients with a previous history of migraine ing previous surgery. The outcome for this group with visual aura were especially at risk of this prob- was similar to that for patients with primary varices.
lem. The visual aura was precipitated by sclerother- Residual skin pigmentation and palpable lumps apy and resolved in most cases within 30 minutes.
were sometimes seen at follow-up. Skin pigmentation Patients experiencing one episode of visual distur- was seen in 115 of 459 limbs at 6 months and palpable bance were prone to further episodes. These patients lumps were present in 21 limbs. The skin pigmenta- were managed by inviting them to rest supine for tion was almost always of a minor extent and contin- ued to fade with time. 1 year or more following Although all patients were invited for follow-up examinations at 6 months following treatment, by nomeans all patients returned despite reminders. In all459 limbs have been reviewed at 6 months or more Outcome of treatment of SSV
following treatment, average 11 months, range 6e46 months. This includes 363 of 886 GSVs and 141 of before and after sclerotherapy in these limbs. A sub- stantial improvement in clinical venous disease wasobtained. Duplex examination of the GSVs showed occlusion had been obtained in 318 of 363 (88%). In the SSVs occlusion was present in 116 of 141 (83%).
The data in show the outcome of treatment for the GSV and SSV. Where incompetence or varices arose in a major tributary of the GSV or SSV this was also considered to comprise treatment failure.
In 4 cases reviewed after 6 months the anterior acces- sory saphenous vein developed reflux and in one case Fig. 2. CEAP clinical stage before and at an average of a medial thigh tributary of the GSV was incompetent.
11 months after UFS carried out to the SSV.
Eur J Vasc Endovasc Surg Vol xx, Month xxxx Chronic Venous Disease Treated by Foam Sclerotherapy Table 3. Outcome in 363 (of 886) GSVs and 141 (of 263) SSVs where follow-up had been completed at 6 months or more (mean11 months following treatment) treatment skin pigmentation was present in 11 of 115 Varicose vein surgery is imperfect. Neurological limbs. Small palpable lumps were sometimes detect- injury and an unsatisfactory outcome are common able in the calf and comprised residual elements causes for litigation, damage to the femoral artery of treated veins. In contrast to surgical series, no and vein also occurs.Rautio found that patients un- scars, neurological damage or lymphatic injuries dergoing varicose vein surgery required on average 16 days off work compared to 6.5 days following RFclosure of the saphenous trunk.Recurrence ofvaricose veins following surgery is a common event and is often attributable to neovascularisation.Fischer reviewed 125 limbs in 77 patients after an The publication of a clinical series cannot replace average of 34 years following SFJ ligation and a randomised controlled trial (RCT) in the evaluation GSV stripping and found recurrence in 60%.Wood of a new treatment. The author acknowledges one et al. reported that neurological injury may be present RCT has been published, however both groups of pa- in 27% of patients treated surgically six weeks post- tients underwent surgical ligation of the SFJ with scle- operatively.Ouvry reports an 8.7% rate of lymphatic rosant foam or stripping being used to manage the complications amongst 30 surgeons surveyed.
saphenous trunA further randomised clinical trial Surgical treatment which is widely regarded as the of VarisolveÒ, a polidocanol foam, compared against reference standard, carries the risk of significant surgery in 650 patients has been completed and re- post-operative complications, necessitates significant ported at a scientific meeting (UIP Chapter meeting, time off work and despite this does not prevent San Diego, USA, 2003) but not yet published. The final endpoint is the efficacy with which a treatment elim- In my series foam sclerotherapy required 30 min- inates varicose veins after an extended period of utes per treatment session, patients could walk from follow-up. Hobbs found that a follow-up period of the room afterwards and in most cases patients only 10 years was required fully to distinguish the failures took time off on the days in which treatment was of injection-compression treatment from surgery given. Discomfort at the time of treatment was mini- Such long studies are difficult to complete and mal and in the majority of patients, symptoms in the many authors now base their conclusions on the use 2 weeks following treatment were few, although of duplex ultrasound imaging as a surrogate end- thrombophlebitis was seen in 5%. Patients main com- point. There is a good correlation between duplex re- plaints related to the compression bandage applied currence at the SFJ 1 year after treatment and clinical after each session. Few other problems were encoun- recurrence 5 years after treatment.Duplex ultraso- tered with skin pigmentation at follow-up being the nography has been used as a predictor of the final out- most frequent. This was usually mild and continued to resolve with the passage of time.
Eur J Vasc Endovasc Surg Vol xx, Month xxxx Patients followed up for more than 6 months repre- assistance of the following members of my team for assis- sent only 40% of the overall group. This is a potential tance in completing this work: Paola Buresta MD, Maria disadvantage since it might lead to bias in the overall Cork RGN, Frances Devine RGN, Sue Topp RGN. I am assessment. Patients were all invited to attend at an in- also indebted to the many experts in venous disease who terval of 6 months following initial treatment but have provided advice in the preparation of this manuscript.
many defaulted. In some instances patients returnedwith residual or recurrent varices due to recanalisationof the treated vein. Further invitations for review havenow been sent to those who have not attended so far at Examination of shows that the main factor VAN RIJ AM, JIANG P, SOLOMON C, CHRISTIE RA, HILL GB. Re-currence after varicose vein surgery: a prospective long-term influencing recurrence was the size of the vein prior clinical study with duplex ultrasound scanning and air plethys- to treatment. Both GSVs and SSVs of 6 mm dia or mography. J Vasc Surg 2003;38:935e943.
greater were more likely to recur than those of 5 mm INTERBORN RJ, FOY C, EARNSHAW JJ. Causes of varicose vein re- currence: late results of a randomized controlled trial of strip- dia and below. For the GSV, treatment of recurrent ping the long saphenous vein. J Vasc Surg 2004;40:634e639.
varicose veins was as successful as for primary vari- 3 FISCHER R, LINDE N, DUFF C, JEANNERET C, CHANDLER JG, SEEBER P.
Late recurrent saphenofemoral junction reflux after ligation ces. Operations for recurrent varicose veins are usu- and stripping of the greater saphenous vein. J Vasc Surg 2001; ally technically more difficult and prone to a high complication rate compared to that for primary vari- 4 PERRIN MR, GUEX JJ, RUCKLEY CV, DEPALMA RG, ROYLE JP, EKLOF B et al. Recurrent varices after surgery (REVAS), a consensus doc- ces.Foam sclerotherapy carries little risk and may ument. REVAS group. Cardiovasc Surg 2000;8:233e245.
be a satisfactory solution in patients with recurrence 5 CAMPBELL WB, FRANCE F, GOODWIN HM, Research and Audit Com- mittee of the Vascular Surgical Society of Great Britain andIreland. Medicolegal claims in vascular surgery. Ann R Coll In the series of patients presented here, no case of neovascularisation was seen at the SFJ or SPJ although 6 VAN RIJ AM, CHAI J, HILL GB, CHRISTIE RA. Incidence of deep vein this would have been expected following surgical thrombosis after varicose vein surgery. Br J Surg 2004;91:1582e1585.
treatment. The mode of recurrence following UFS 7 SRILEKHA A, KARUNANITHY N, CORBETT CRR. Informed consent: was recanalisation of previously treated veins. It is what do we tell patients about the risk of fatal pulmonary embo- likely that surgical treatment itself promotes neovas- lism after varicose vein surgery? Phlebology 2005;20:175e176.
cularisation. If varicose veins can be closed without ERCHANT RF, PICHOT O, Closure Study Group. Long-term out- comes of endovenous radiofrequency obliteration of saphenous surgical intervention then the risk of neovascularisa- reflux as a treatment for superficial venous insufficiency. J Vasc Comparison of UFS to other endovenous techniques UNDY L, MERLIN TL, FITRIDGE RA, HILLER JE. Systematic review of endovenous laser treatment for varicose veins. Br J Surg reveals similar outcomes. In a series of 1006 patients treated by RF obliteration with follow-up to 5 years the occlusion rate for saphenous trunks was 88% at OMINGUEZ GARCIA OLMEDO. Nuevo metododel de esclerosis en las varices tronculares. Patologia Vasculares 1995;4:55e73.
one year.Endovenous laser treatment (EVLT) been 11 FRULLINI A, CAVEZZI A. Sclerosing foam in the treatment of vari- reviewed recentlyIn 13 clinical series 88 cose veins and telangiectases: history and analysis of safety and complications. Dermatol Surg 2002;28:11 treated saphenous trunks were obliterated. Reported 12 BARRETT JM, ALLEN B, OCKELFORD A, GOLDMAN MP. Microfoam complications of both techniques include skin burns, ultrasound-guided sclerotherapy of varicose veins in 100 legs.
thrombosis, ecchymosis, paraesthesia, induration and AVEZZI A, FRULLINI A, RICCI S, TESSARI L. Treatment of varicose veins by foam sclerotherapy: two clinical series. Phlebology This clinical series demonstrates that ultrasound guided foam sclerotherapy can be used effectively to 14 BREU FX, GUGGENBICHLER S. European consensus meeting on foam sclerotherapy [April, 4-6, 2003, Tegernsee, Germany]. Dermatol manage a wide range of chronic venous disease on an outpatient basis without the need to resort to sur- 15 BOUNTOUROGLOU DG, AZZAM M, KAKKOS SK, PATHMARAJAH M, gical intervention. The efficacy and rates of complica- YOUNG P, GEROULAKOS G. Ultrasound-guided foam sclerotherapycombined with sapheno-femoral ligation compared to surgical tion are similar to those reported for the other ‘new’ treatment of varicose veins: early results of a randomised controlled trial. Eur J Vasc Endovasc Surg 2005.
16 VAN BEMMELEN PS, MATTOS MA, HODGSON KJ, BARKMEIER LD, RAMSEY DE, FAUGHT WE et al. Does air plethysmography correlate with duplex scanning in patients with chronic venous insuffi-ciency? J Vasc Surg 1993;18:796e807.
I am grateful to Attilio Cavezzi MD for introducing me to AGGIATI A, BERGAN JJ, GLOVICZKI P, EKLOF B, ALLEGRA C, PARTSCH H et al. Nomenclature of the veins of the lower limb: extensions, foam sclerotherapy and to David Wright FRCS for guidance refinements, and clinical application. J Vasc Surg 2005;41: concerning the technique. I acknowledge the valuable Eur J Vasc Endovasc Surg Vol xx, Month xxxx Chronic Venous Disease Treated by Foam Sclerotherapy 18 CABRERA J, CABRERA Jr J, GARCIA-OLMEDO MA. Treatment of vari- 24 VAN RIJ AM, JONES GT, HILL GB, JIANG P. Neovascularization and cose long saphenous veins with sclerosant in microfoam form: recurrent varicose veins: more histologic and ultrasound evi- long term outcomes. Phlebology 2000;15:19e23.
19 TESSARI L. Nouvelle technique d’obtention de la scle´ro-mousse Phle´bo- 25 WOOD JJ, CHANT H, LAUGHARNE M, CHANT T, MITCHELL DC. A prospective study of cutaneous nerve injury following long 20 HOBBS JT. Surgery or sclerotherapy for varicose veins: 10-year re- saphenous vein surgery. Eur J Vasc Endovasc Surg 2005;30: sults of a random trial. In: TESI M, DORMANDY JA, eds. Superficial and deep venous diseases of the lower limbs. Turin: Panminerva 26 OUVRY PA, GUENNEGUEZ H, OUVRY PAG. Complications lympha- tiques de la chirurgie des varices. Phlebologie 1993;46:563e568.
21 DE MAESENEER MG, VANDENBROECK CP, HENDRIKS JM, LAUWERS PR, 27 HAYDEN A, HOLDSWORTH J. Complications following re-exploration VAN SCHIL PE. Accuracy of duplex evaluation one year after of the groin for recurrent varicose veins. Ann R Coll Surg Engl varicose vein surgery to predict recurrence at the sapheno- femoral junction after five years. Eur J Vasc Endovasc Surg 2005; 28 MERCHANT RF, PICHOT O, Closure Study Group. Long-term out- comes of endovenous radiofrequency obliteration of saphenous 22 PERALA J, RAUTIO T, BIANCARI F, OHTONEN P, WIIK H, HEIKKINEN T reflux as a treatment for superficial venous insufficiency. J Vasc et al. Radiofrequency endovenous obliteration versus stripping of the long saphenous vein in the management of primary vari- 29 MUNDY L, MERLIN TL, FITRIDGE RA, HILLER JE. Systematic review cose veins: 3-year outcome of a randomized study. Ann Vasc Surg of endovenous laser treatment for varicose veins. Br J Surg 23 SARIN S, SCURR JH, COLERIDGE SMITH PD. Assessment of stripping the long saphenous vein in the treatment of primary varicose Eur J Vasc Endovasc Surg Vol xx, Month xxxx
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