A one stop vein shop: the ideal option? Professor Alun H Davies Section of Vascular Surgery Imperial College, Charing Cross & St Mary s Hospitals London
Conflicts of Interest None to declare
Which treatment?
Truncal Veins
Branch Varicosities Despite adequate treatment superficial varicosities may not resolve The treatment of residual varicosities is currently a matter of debate
Phlebectomies Concomitant Delayed One stop treatment Shorter initial procedure Greater anaesthetic requirements Can monitor for varicosity regression Longer procedure Need for secondary procedures? Over-treating patients
Recommendations 6/7/8 -Treatment
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Search Outcomes Study Study Type Participants (Simultaneous/ Delayed) Follow Up (weeks) Intervention Anaesthesia Outcomes Measured Carradice (2009) RCT 50 (25/25) 52 EVLA +/Phleb LA Phleb/QOL Theivacumar (2008) RCT 68 (22/46) 12 EVLA +/UGFS LA Phleb/QOL Kim (2009) Case Series 265 (132/133) 104 EVLA +/Phleb GA/LA Phleb Knipp (2008) Case Series 456 (135/321) 28 EVLA +/Phleb GA/LA DVT Puggioni (2009) Case Series 293 (90/203)? EVLA +/Phleb GA/LA DVT Marsh (2010) Case Series 2820 (2470/350) 1 EVLA +/Phleb GA/LA DVT RCT Randomised Controlled Trial. EVLA Endovenous Laser Ablation. Phleb Phlebectomy. UGFS Ultrasound Guided Foam Sclerotherapy. QOL Quality of Life. DVT Deep Venous Thrombosis.
Quality of Life Outcomes Two RCTs assessed Aberdeen Varicose Vein Questionnaire scores Scores at 6 weeks Scores at 12 weeks Small but significantly improved QoL with simultaneous phlebectomy within the first 6 weeks of treatment The difference is not maintained at 12 weeks
Need for further intervention Two Randomised Controlled Trials Significant trend to favouring combined procedures Total randomised number 118
Deep Venous Thrombosis Three studies examined the role of combined phlebectomy and venous ablation in the incidence of DVT Retrospective analyses DVT Deep Venous Thrombosis. EHIT Endovenous Heat Induced Thrombosis Significant difference in favour of delayed phlebectomies in order to prevent DVT DVT rate 0.13% under LA
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36% vs 2% RR 18.36 2014
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But of those screened and deemed suitable fo entry to the trial over 50% declined the trial as they had a preference for single visit treatment 2014
Conclusion There is substantial evidence in favour of combined venous ablation and varicosity treatment at a single treatment.
Current Patient Pathway
Proposed New Clinic
Questionnaire Survey Questionnaire Survey of patients attending Vascular Outpatient Clinic for venous complaint at Charing Cross Hospital Assess patient perception of current varicose vein provision Determine whether patients might be interested in alternative options to reduce waiting times
Results 106 patients (62% females) recruited Mean age: 51 ± 15 years (range: 22-88 years) Most common symptom: Pain/Achiness (73%) Waiting times: O/P Clinic and venous scan: 90% think should be no more than 1 month O/P Clinic and treatment: 85% believed should be within 1 month Patients favoured less appointments Half wanted only 2 appointments 44% thought same day diagnosis and treatment would be ideal
Results 106 patients (62% females) recruited Mean age: 51 ± 15 years (range: 22-88 years) Most common symptom: Pain/Achiness (73%) Waiting times: O/P Clinic and venous scan: 90% think should be no more than 1 month O/P Clinic treatment: 85% believed beclinic within 1 90%and of patients would attend such a Oneshould Stop Vein month Patients favoured less appointments Half wanted only 2 appointments 44% thought same day diagnosis and treatment would be ideal
Conclusion Current provision of varicose vein service potentially inadequate and need improvement One Stop clinic model appears to be a preferred option with patients and need exploring further
Methods Patients selected from GP referral letters and invited to attend One Stop Clinic Information pack sent: Information about the clinic Information about varicose vein procedures Consent form QoL questionnaires
One Stop Vein Clinic SAME DAY DIAGNOSIS & TREATMENT Outpatient Clinic Treatment Venous Duplex
Inclusion & Exclusion Criteria Inclusion Criteria Exclusion Criteria Adults > 18 years Unilateral symptoms suggestive of venous disease (from referral letter) Recurrent varicose veins ABPI < 0.8 Current DVT Patients withdrawing their consent Inability to complete questionnaires Currently enrolled in other venous studies
Potential Benefits Reduction of waiting time to be seen in clinic Increased satisfaction of patients Sooner improvement in QoL scores for patients Clinic appointment slots could be used for more urgent cases Cost savings to the trust
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