Raffaele Antonelli Incalzi
Department of Geriatrics, Campus Biomedico University, Rome, Italy - [email protected]
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Abstract A multicenter, prospective observational study has been conducted under the aegis of the French Society of Phlebology, with the participation of the Swiss Society of Phlebology and the Vein group of the French Society of Vascular Diseases to evaluate feasibility, tolerance, results, and satisfaction of thermal ablation (TA) of saphenous vein (SV) in patients aged more than 75 years. Between September 2011 and June 2012, consecutive younger and older patients aged more than 75 years, presenting with an indication to treat SV (great or small) by TA, with CEAP clinical class of C2 to C6, were included in 18 participating centers (13 French and 5 Swiss). TA could be made with either laser (EVLA: 810, 980 and 1470 nm; bare tip and radial fibers) or radiofrequency (RFA: Closure-FAST, or Celon-RFITT). TA could be performed under tumescent local, general or epidural anesthesia according to the modalities of treatment inherent to the practitioner. The therapist had to indicate if TA was performed in the hospital, in the hospital but outside of the operating room or in a private office. Concomitant or delayed treatment of tributary varicose veins could be made by either phlebectomy or sclerotherapy. Seven hundred and seven patients (863 legs) could be included. Thirteen per cent (90 patients, 101 legs) of the patients were older than 75 years (group 1). Mean age of these elderly patients was 80.3 years (75-92); it was 53.5 (21-74) in the younger population (group 2). In group 1, small saphenous veins (SSV) were treated more frequently (27 versus 17%) than great saphenous veins (GSV) and treatment indication was more often medical instead of only aesthetic (strictly medical indication 86.1 versus 52.1%, only aesthetic 2 versus 6.7%, medical and aesthetic 11.9 versus 41.2%). Venous insufficiency was more severe in group 1, with significantly more C4 to C6 of the CEAP classification. Comorbidities, particularly diabetes, cardiac insufficiency, history of thromboembolic disease (TED) were significantly more frequent in the elderly patients. Eighty six per cent of patients were treated with laser. The 1470 nm wavelength was the most used (57%). Radial fiber was the most frequent choice (67%). In 75% of cases, the continuous application mode was chosen. Fourteen per cent were treated with radiofrequency. Significantly more patients older than 75 years were treated in a private office (65 versus 55%), than in an operating room (29 versus 31%) or in the hospital but outside of the operating room (6 versus 14%). Most treatments were performed under strict tumescent local anesthesia (TLA) (86%). Most patients had no concomitant treatments for tributaries in both groups. Seventy five per cent of group 1 received LMWH during 5.4 days versus 82% of group 2 during 5.3 days. Occlusion rate was excellent and identical in both groups, as well as at one week than at three months (100% complete occlusion in the elderly versus 99.5% complete and 0.5% partial occlusions in the younger). The satisfaction rate was identical and very high in both groups (mean 9.3, median 10/10). The rate of paresthesia was significantly higher when thermal ablation was performed under general anesthesia instead of TLA (11.8 versus 2.2%). Short-term results at three months, rate of side effects, tolerance and satisfaction are identical for elderly and younger patients. In elderly patients, TA was performed more often in private offices in town outside of an operating room and under TLA. In this condition, the operation is very well tolerated and the peri- and post-operative pain is low. It is also safer, as the rate of post-operative paresthesia is significantly lower than if TA is performed under general anesthesia. |
Comment by Raffaele Antonelli Incalzi
This study looks very promising as it shows that the elderly benefit as much as the young adult from thermal ablation (TA) of saphenous veins. Given that the reason for TA in the elderly was almost exclusively medical, this finding has special value. However, the Authors do not provide any information about whether difficulty in walking, mental impairment, obesity, arterial obstruction, anticoagulation and large GSV diameters impacted patient impacted selection or response to the therapy. Thus, the reader remains uncertain about whether the studied population was representative of the elderly population with venous insufficiency or represented a selected one, Furthermore, the available data do not allow estimate how much the elderly patients did benefit from TA. Indeed, in elderly people the effects of any therapeutic procedure should be assessed in terms of health status and personal independence. Unfortunately, no such measures were available. In a context characterized by multimorbidity one might doubt about how treating the venous insufficiency would improve the classical geriatric outcomes. Nevertheless, the reported high satisfaction of the elderly patients with TA suggests that at least health status improved. Further supporting the importance of TA as an effective procedure in the elderly is the fact that skin lesions are more likely to chronicize in less active and multimorbid patients frequently experiencing arterial insufficiency or hypoxemia due to respiratory problems. This is a major added value of the procedure. Finally, that tumescent anesthesia was fully effective is remarkable: even sedation and minor anesthesiological procedures, e g for cataract removal and lens implant, are associated with a notable risk of delirium and cognitive deterioration. Curiously, elderly had their procedures performed more commonly in private offices. Could this be consequence of the fact that in public hospitals, non-vital operations in elderly may be limited by financial difficulties and risk fear? In conclusion, the Authors have to be commended for having shed light on a topic of major interest in geriatric medicine. Too frequently, a nihilistic approach results in elderly patients being excluded form procedures able to improve their health status and to reduce the need of care. Though purely observational, these findings strongly support a positive and proactive approach to venous insufficiency in the elderly.
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