Diagnostic et traitement des varices des membres inférieurs - KCE

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10 Varicose Veins KCE Reports 164 1.5.2 Endovenous Laser Therapy Endovenous laser therapy (EVLT) is a minimally invasive treatment of varicose veins. The procedure involves introduction of a laser fibre into the lumen of the saphenous vein, followed by the application of laser energy which destroys the vein wall after local injection of fluid to cause tumescence around the treated vein. The fibre and catheter are slowly withdrawn and the vein lumen collapses, occluding the length of the vein and abolishing venous reflux 33 . 1.5.3 Radiofrequency Ablation A similar technique to EVLT is radiofrequency ablation (RFA). A heat-generating catheter inserted into the vein emits radio-frequency wavelengths for ablation 33 . After tumescent injection, the catheter is heated and slowly withdrawn down the length of the vein, causing contraction of the vein wall and, ultimately, destruction of the vessel 29, 34 . 1.5.4 Sclerotherapy Sclerotherapy involves injecting a sclerosing agent (polidocanol) into the varicose vein, which triggers an inflammatory reaction in the endothelium, causing phlebitis and vein occlusion 35 . Foam sclerotherapy mixes the liquid sclerosant with gas to create a larger surface area by displacing blood within the vein 36 . Foam sclerotherapy can be used for treating the GSV or the SSV or to treat the tributaries. The dose is adapted to the diameter of the treated vein. 1.5.5 Mixed treatments In practice, many surgeons perform a mix of treatments such as surgical ligation and stripping combined with sclerotherapy or EVLT combined with sclerotherapy.
KCE Reports 164 Varicose Veins 11 2 METHODS 2.1 SEARCH STRATEGIES 2.1.1 Diagnostic techniques for varicose veins The following databases were systematically searched for the diagnostic procedures: • The Cochrane Library • OVID Medline • OVID EMBASE • Medion The search strategies (available upon request) combined descriptors of varicose veins and terms describing each of the diagnostic procedures mentioned in 1.4. The search focused on the last 15 years upon advice of the experts clinicians: the rapid evolution of the techniques in this area made the results of older trials obsolete for current practice. One illustration is the use of hand-held doppler, currently replaced by colour duplex ultrasound. 2.1.2 Treatment of varicose veins The wealth of literature on the treatment of varicose veins made a de novo systematic review of literature impractical. In order to manage the volume of literature anticipated, the search was segmented into two phases. During the first phase, systematic reviews of treatments were included. The last systematic review of high quality was identified and the list of its constituent primary studies (RCTs and controlled trials) was completed by the trials included in other systematic reviews. In a second phase the most recent RCTs and controlled trials published after the search date of this systematic review were added. 2.1.2.1 Search for systematic reviews The following databases were systematically searched in October 2010 for systematic reviews: • The Cochrane Library • OVID Medline • OVID EMBASE Databases were searched for publications in English, French, Dutch or German (search strategies available upon request). The initial date limit was 1990 to capture all possible relevant literature. However, given the rapid evolution of treatments and the high number of available systematic reviews (rated as having a low risk of bias), only reviews since 1999 have been considered. Additional hand searching was also undertaken to ensure that no potentially relevant studies were missed. The reference lists of retrieved articles and existing systematic reviews were scanned and websites of INAHTA members were checked in detail (see Appendix 9.1). 2.1.2.2 Search for RCTs The same databases (and www.clinicaltrials.gov) were systematically searched for RCTs of treatment of varicose veins. The treatment searches were limited from 2008 as this was the search date in the most recent selected systematic review (from Rees et al. 29 ). An additional literature search for the drug treatment of varicose veins was limited from 2005 as this was the date of the search from the most recent systematic review in this area 37 . Additional hand searching of reference lists was also undertaken to ensure that no potentially relevant studies were missed.
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