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Clinical Results of a New Strategy (Modified CHIVA) for Surgical Treatment of Anterior Accessory Great Saphenous Varicose Veins
Resultados clínicos de una nueva estrategia quirúrgica (CHIVA modificado) en el tratamiento de las varices dependientes de la vena safena magna accesoria anterior
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A) Situación basal de unas varices dependientes de la VSMAA. B) Cura CHIVA 1<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>2 (tradicional), proceder no hemodinámico: crosectomía de la unión safenofemoral más desconexión de la salida de las varices de la VSMAA y varicectomía extensa. C) Cura CHIVA hemodinámica (procedimiento novedoso): desconexión de la salida de las varices de la VSMAA y varicectomía extensa.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Nicolás Maldonado-Fernández, Jose Patricio Linares-Palomino, Cristina López-Espada, Francisco Javier Martínez-Gámez, Eduardo Ros-Díe" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Nicolás" "apellidos" => "Maldonado-Fernández" ] 1 => array:2 [ "nombre" => "Jose Patricio" "apellidos" => "Linares-Palomino" ] 2 => array:2 [ "nombre" => "Cristina" "apellidos" => "López-Espada" ] 3 => array:2 [ "nombre" => "Francisco Javier" "apellidos" => "Martínez-Gámez" ] 4 => array:2 [ "nombre" => "Eduardo" "apellidos" => "Ros-Díe" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2173507716000752" "doi" => "10.1016/j.cireng.2016.02.020" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true 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array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Gross mortality with an IC of 95% according to the number of procedures in each hospital in (A) oesophageal cancer; (B) gastric cancer; (C) colorectal cancer and (D) pancreatic cancer.</p> <p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">Source: MBSD (Spain, 2006–2009).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Paloma Pérez-López, Marisa Baré, Ángel Touma-Fernández, Antonio Sarría-Santamera" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Paloma" "apellidos" => "Pérez-López" ] 1 => array:2 [ "nombre" => "Marisa" "apellidos" => "Baré" ] 2 => array:2 [ "nombre" => "Ángel" "apellidos" => "Touma-Fernández" ] 3 => array:2 [ "nombre" => "Antonio" "apellidos" => "Sarría-Santamera" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0009739X15002365" "doi" => "10.1016/j.ciresp.2015.09.005" "estado" => "S300" "subdocumento" => "" 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Accessory Great Saphenous Varicose Veins" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "144" "paginaFinal" => "150" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Nicolás Maldonado-Fernández, Jose Patricio Linares-Palomino, Cristina López-Espada, Francisco Javier Martínez-Gámez, Eduardo Ros-Díe" "autores" => array:5 [ 0 => array:3 [ "nombre" => "Nicolás" "apellidos" => "Maldonado-Fernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "Jose Patricio" "apellidos" => "Linares-Palomino" "email" => array:1 [ 0 => "jlinaresp@ugr.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "Cristina" "apellidos" => "López-Espada" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Francisco Javier" "apellidos" => "Martínez-Gámez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Eduardo" "apellidos" => "Ros-Díe" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Angiología y Cirugía Vascular, Complejo Hospitalario de Jaén, Hospital Universitario Médico-Quirúrgico, Jaén, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Cirugía, Universidad de Granada, Granada, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Resultados clínicos de una nueva estrategia quirúrgica (CHIVA modificado) en el tratamiento de las varices dependientes de la vena safena magna accesoria anterior" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1560 "Ancho" => 950 "Tamanyo" => 194754 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">One-year results after surgery: image showing varicose tributaries of the AASV; the left image shows the preoperative mapping, and situation 12 months after surgery is on the right.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Chronic venous insufficiency (CVI) is a disease with a very high prevalence that requires surgical treatment in most cases. It is one of the most frequently performed scheduled surgeries in Spanish hospitals and has one of the largest waiting lists as well as very elevated healthcare costs.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A review of the activity registry of the Spanish Society of Angiology and Vascular Surgery and an analysis of the last five years show how the surgical treatment of varicose veins surpasses 25,000 procedures annually, with a waiting list of some 14,000 patients.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">3–7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Surgical treatment for CVI has two modalities: ablation or destruction therapies (classic saphenectomy, endovenous laser ablation, radiofrequency, venous sclerosis, etc.), and haemodynamic treatments that preserve the saphenous veins like ambulatory conservative haemodynamic correction of venous insufficiency (CHIVA).</p><p id="par0020" class="elsevierStylePara elsevierViewall">The CHIVA strategy has been developed over the past twenty years and is currently the second most frequent surgical method (after saphenectomy) for the surgical treatment of CVI.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">8</span></a> This treatment is a therapy designed for the needs of each patient according to the haemodynamic condition responsible for the venous insufficiency, while also preserving the saphenous axis. Most other similar publications and studies about this subject have been concerned with the great saphenous vein. Cases about the anterior accessory saphenous vein have been included amongst them, and the documentation about the anterior saphenous vein itself is limited.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The aim of this study is to evaluate the safety and efficacy of a modification of the standard CHIVA procedure in patients that present varicose veins related with the anterior accessory saphenous vein, without involving the great saphenous vein or the saphenofemoral junction.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">This prospective study commenced in January 2010 with the inclusion of the first patients who presented with varicose veins of the anterior accessory saphenous vein.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Selected Patients</span><p id="par0035" class="elsevierStylePara elsevierViewall">Identification of the anterior saphenous vein was done in accordance with the recommendations and consensus guidelines for ultrasound examination and the denomination of the superficial venous system that the International Union of Phlebology published in 2006. According to this consensus, the anterior accessory saphenous vein (AASV) is an ascending venous segment parallel to the great saphenous vein (GSV) in the thigh that is found within its own fascial compartment. There are two ultrasound signs (the “eye sign” and the “alignment sign”) that allow for its identification and differentiation from the GSV.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The ultrasound examination was done with a linear multi-frequency transducer (Esaote Technos, Genoa, Italy) with the patient standing, at which time the saphenofemoral junction, saphenopopliteal junction, deep venous system, saphenous veins and related varicose veins were observed. The Doppler examination allowed us to assess the permeability and competence of the vessels examined, as well as the presence of reflux and the distribution in venovenous shunts. Reflux was defined as a flow that was inverse to the physiological flow for more than 0.5<span class="elsevierStyleHsp" style=""></span>s. We took measurements of the length and diameter of the AASV at its midpoint and of the diameter of the GSV 15<span class="elsevierStyleHsp" style=""></span>cm from its origin. We completed the study with a Reflux Elimination Test (RET) of the AASV, described by Zamboni.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">10</span></a> The venovenous shunts described for the GSV by the European CHIVA Society at the conference in Teupitz in 2002 were adapted to the AASV region.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">11</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The inclusion criteria used were as follows:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0050" class="elsevierStylePara elsevierViewall">Patients with CVI of the AASV with positive RET and anterograde GSV.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0055" class="elsevierStylePara elsevierViewall">Acceptance of surgery and signed informed consent form.</p></li></ul></p><p id="par0060" class="elsevierStylePara elsevierViewall">The exclusion criteria were:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0065" class="elsevierStylePara elsevierViewall">Patients with CVI of the AASV and GSV.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0070" class="elsevierStylePara elsevierViewall">Patients with deep venous insufficiency.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0075" class="elsevierStylePara elsevierViewall">Negative RET test in the AASV.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0080" class="elsevierStylePara elsevierViewall">Patients with limitations to walk normally.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0085" class="elsevierStylePara elsevierViewall">Patients who refused to give their informed consent.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0090" class="elsevierStylePara elsevierViewall">Patients with a saphenous diameter<span class="elsevierStyleHsp" style=""></span>>8.5<span class="elsevierStyleHsp" style=""></span>mm.</p></li></ul></p><p id="par0095" class="elsevierStylePara elsevierViewall">A registry of epidemiological data was created, including: sex, age, pregnancies, body mass index, and CEAP classification.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Surgical Procedure</span><p id="par0100" class="elsevierStylePara elsevierViewall">The modification of the CHIVA strategy consisted of disconnection and removal of the tertiary network from the AASV, interrupting the venovenous shunt and forcing anterograde flow through the AASV itself, without operating on the main leak point located at the saphenofemoral junction (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The surgery was conducted as part of the major outpatient surgery programme at our hospital. A strategic incision was made to disconnect the varicose vein network of the AASV and afterwards multiple complementary incisions were made to eliminate the varices. Local anaesthesia was used, with postoperative wrapping and low molecular weight heparin at prophylactic doses (bemiparin 2500–3500<span class="elsevierStyleHsp" style=""></span>units/day) for 10 days, following known criteria.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">8</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">The duration of surgery was variable and basically depended on the phlebectomy done, although it was always less than 90<span class="elsevierStyleHsp" style=""></span>min.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Follow-up</span><p id="par0110" class="elsevierStylePara elsevierViewall">The first follow-up visit was one month later, and patients were checked for the presence of clinical and haemodynamic complications (deep vein thromboses or saphenous thromboses) as well as the presence of reflux in the AASV. After one year, ultrasound studies were conducted in the same manner.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Treatment was considered haemodynamically successful when there was a reduction in the diameter of the AASV, which became anterograde and lost reflux. Treatment was considered a haemodynamic failure when the AASV presented reflux, the GSV had increased in size or presented reflux, or there was thrombosis of the femoral vein.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Twelve months later, the efficacy of the procedure was determined with the assessment of the clinical results by means of the Fligelstone scale and the absence of recurrences.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">12</span></a> Patient satisfaction was assessed using a numeric scale from 1 to 10.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Study Variables and Statistical Analysis</span><p id="par0125" class="elsevierStylePara elsevierViewall">The predictive variables that were contemplated included age, sex, excess weight (BMI<span class="elsevierStyleHsp" style=""></span>>25), reoperation of varices, length of AASV (longer or shorter than 10<span class="elsevierStyleHsp" style=""></span>cm), diameter of the GSV (75th percentile greater than 7.5<span class="elsevierStyleHsp" style=""></span>mm) and type of haemodynamic shunt (type 3 or type 5). We have considered variables resulting from haemodynamic success or failure (anterograde flow or reflux), saphenous vein thrombosis and the presence of varicose recurrence, all one year later.</p><p id="par0130" class="elsevierStylePara elsevierViewall">The data were processed statistically with SPSS v21 software. To determine whether there was a relationship between certain variables and the presence of recurrence, saphenous vein thrombosis and haemodynamic failure, the corresponding analyses were completed. For qualitative variables, Fisher's exact test or the chi-squared test were used. For quantitative variables, prior to the analysis normality was checked with the Shapiro–Wilk test. For the variables that followed a normal distribution, Student's test was applied; when this was not verified, the non-parametric Mann–Whitney <span class="elsevierStyleItalic">U</span> test was applied. The multivariate analysis was conducted by means of nominal logistic regression.</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Demographic Data</span><p id="par0135" class="elsevierStylePara elsevierViewall">The 12-month follow-up was completed by 65 patients, who were predominantly female: 58 women and 7 men. Mean age was 46. A previous internal saphenectomy had been done in 6 (9%) patients. The female subjects had an average of 2 prior pregnancies. Twenty-six (40%) patients were overweight. CEAP distribution was class II in 27 (41%) cases, class III in 20 (31%) and classes IV, V or VI in 18 (28%) cases, with four open ulcers.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Haemodynamic Results</span><p id="par0140" class="elsevierStylePara elsevierViewall">Data were collected for ultrasound and haemodynamic parameters. The most frequent type of venovenous shunt described in the AASV was type III (50, 77%) followed by type V (14, 22%) and only one case of IIa (1%). The new CHIVA strategy applied in all the cases was haemodynamic. The AASV was less than 10<span class="elsevierStyleHsp" style=""></span>cm in 33 cases (51%), and greater than 10<span class="elsevierStyleHsp" style=""></span>cm in the 32 (49%) remaining cases. The mean starting diameter of the AASV was 6.4<span class="elsevierStyleHsp" style=""></span>mm; after 12 months, this had been reduced to 3.4<span class="elsevierStyleHsp" style=""></span>mm, with a mean reduction of 3<span class="elsevierStyleHsp" style=""></span>mm. The GSV diameter was not modified (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). A favourable haemodynamic result was observed in 53 (82%) patients, while reflux persisted in the AASV in 12 (18%) cases (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Clinical Results</span><p id="par0145" class="elsevierStylePara elsevierViewall">The application of the Fligelstone scale showed clinical and aesthetic improvement in all patients (<a class="elsevierStyleCrossRefs" href="#tbl0010">Tables 2 and 3</a>). A search for clinical recurrence revealed 5 (8%) cases of recurrent varices larger than 5<span class="elsevierStyleHsp" style=""></span>mm.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0150" class="elsevierStylePara elsevierViewall">Overall patient assessment of the treatment defined by the numerical scale showed that none of the patients gave our performance poor marks. Their evaluations were predominantly positive, with an excellent average score of 9.4.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Complications</span><p id="par0155" class="elsevierStylePara elsevierViewall">Three (5%) haematomas were detected, none of which required surgical treatment. There were no deaths, hospitalisations, deep venous or symptomatic superficial thromboses, infections or episodes of neuritis. Early ultrasound tests detected 7 (11%) partial thromboses of the AASV, although no patients reported spontaneous symptoms requiring emergency room attention.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Analysis of the Results</span><p id="par0160" class="elsevierStylePara elsevierViewall">The statistical analysis used to determine whether there was a correlation between the variables and the presence of clinical recurrence, saphenous thrombosis and the haemodynamic results showed no statistically significant association with sex, prior intervention, length of the AASV or shunt type. In contrast, the initial diameter of the AASV<span class="elsevierStyleHsp" style=""></span>>7.5<span class="elsevierStyleHsp" style=""></span>mm and excess weight were statistically significant as factors associated with a poor haemodynamic result, without showing significance for clinical recurrence (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>).</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Discussion</span><p id="par0165" class="elsevierStylePara elsevierViewall">The AASV is responsible for 11% of the varices of the extremities, 10%–43% of recurrent varicose veins and poorer results after treatment, according to some authors.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">13–17</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">The classic treatment for varicose veins originating in the groin with distribution in the region of the anterior saphenous vein involves standard crossectomy of the saphenofemoral junction, with ligature and disconnection of all the tributaries, including the AASV and GSV, as well as internal saphenectomy, to reduce the number of recurrences. In the last decade, several authors have treated the AASV exclusively, without removing or operating on the healthy GSV. In a study from 2001, Prinz recommended that, in cases of AASV-related varices with a competent GSV, standard crossectomy should be done of the saphenofemoral junction with removal of the initial cm of the AASV as well as the GSV, plus complementary phlebectomy, while leaving intact the rest of the GSV.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">18</span></a> In 2011, Theivacumar used a treatment with endovenous laser in patients with AASV varicose veins with a minimal length of 10<span class="elsevierStyleHsp" style=""></span>cm and a diameter of 3<span class="elsevierStyleHsp" style=""></span>mm, without affecting the GSV, with good results.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">19</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Careful haemodynamic mapping of the AASV varices allowed us to design this treatment in which we disconnect the venovenous shunt and eliminate the varicose network, without the need to operate in the groin with closure of the saphenofemoral junction, thus respecting the GSV. Crossectomy is avoided and the GSV is preserved for future material in case revascularisation bypass were ever needed.</p><p id="par0180" class="elsevierStylePara elsevierViewall">In our series, the GSV was not modified by our actions and was maintained anterograde in all cases. Meanwhile, the AASV remained with anterograde flow in 82% of the cases. Currently, there are no studies about haemodynamic surgery that have described this type of treatment in AASV-related varices.</p><p id="par0185" class="elsevierStylePara elsevierViewall">In our approach, we have assumed the treatment proposed for the GSV by Zamboni more than a decade ago, which support performing haemodynamic surgery in patients with a positive RET test in the GSV after the interruption of the venovenous shunt by compression of the R3. In the first series from 2001, the patients who were treated in this manner presented a GSV with anterograde flow in 85% of cases after 6 months. The second series presented a three-year follow-up with anterograde saphenous vein flow of 18% in the cases that presented incompetence of the ostial valve and 86% in those with competent ostial valves. In 2003, Escribano presented six-month results for anterograde flow of only 12%.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">10,20,21</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">Saphenous vein thrombosis was one of the complications that we feared. We used low-molecular-weight heparin for one month to minimise this risk. One month later, 7 partial AASV thromboses were detected, although they were asymptomatic and did not persist after one year. The clinical complications presented were local haematomas, which resolved spontaneously with no problems. These results coincide with the study about CHIVA surgery complications published by our group some years ago, and they provide evidence about the safety of this therapeutic modality.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">8</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">The clinical results have been favourable in all cases, including patients that have presented recurrence, with very high patient satisfaction. We have not found statistically significant associations between most variables and the presence of recurrence, saphenous vein thrombosis or haemodynamic failure. We have found, however, that excess weight and AASV diameter<span class="elsevierStyleHsp" style=""></span>>7.5<span class="elsevierStyleHsp" style=""></span>mm are associated with poorer haemodynamic results. In these cases and in the future, we would consider other therapeutic options.</p><p id="par0200" class="elsevierStylePara elsevierViewall">The limitations of our study include the small number of cases and a follow-up period that is still short. It is useful to observe that the potential thrombosis of the AASV with extension to the saphenofemoral junction and the common femoral vein, which could be associated with this treatment variation for AASV-related varicose veins, did not occur. Nor did we observe a high number of recurrences. Furthermore, the percentage of complications was low and patient satisfaction high.</p><p id="par0205" class="elsevierStylePara elsevierViewall">It is possible that this technique is not the technique of choice for patients with an anterior saphenous vein larger than 7.5<span class="elsevierStyleHsp" style=""></span>mm or in very obese patients.</p><p id="par0210" class="elsevierStylePara elsevierViewall">This new haemodynamic treatment method for AASV varicose veins presents successful haemodynamic and clinical results 12 months later, with high patient satisfaction. It is safe, and complications are local and benign. It enables us to correct AASV-related varices without having to operate on the saphenofemoral junction or the GSV, which continues to function correctly and is potentially useable for revascularisation surgery.</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Funding</span><p id="par0215" class="elsevierStylePara elsevierViewall">No institutional funding was received for the elaboration of this study.</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Authorship/Collaborators</span><p id="par0220" class="elsevierStylePara elsevierViewall">NMF: design, data collection, analysis, writing, critical review and approval.</p><p id="par0225" class="elsevierStylePara elsevierViewall">JPLP: design, analysis, writing, critical review and approval.</p><p id="par0230" class="elsevierStylePara elsevierViewall">CLE: analysis, writing, critical review and approval.</p><p id="par0235" class="elsevierStylePara elsevierViewall">FJMG: design, data collection and approval.</p><p id="par0240" class="elsevierStylePara elsevierViewall">ERD: writing critical review and approval.</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conflict of Interests</span><p id="par0245" class="elsevierStylePara elsevierViewall">The authors declare having no conflict of interests.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres621287" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec635536" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres621286" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec635535" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Selected Patients" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Surgical Procedure" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Follow-up" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Study Variables and Statistical Analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0035" "titulo" => "Results" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Demographic Data" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Haemodynamic Results" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Clinical Results" ] 3 => array:2 [ "identificador" => "sec0055" "titulo" => "Complications" ] 4 => array:2 [ "identificador" => "sec0060" "titulo" => "Analysis of the Results" ] ] ] 7 => array:2 [ "identificador" => "sec0065" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0070" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0075" "titulo" => "Authorship/Collaborators" ] 10 => array:2 [ "identificador" => "sec0080" "titulo" => "Conflict of Interests" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-09-27" "fechaAceptado" => "2015-10-31" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec635536" "palabras" => array:4 [ 0 => "Anterior accessory great saphenous vein" 1 => "Haemodynamic venous surgery" 2 => "CHIVA technique" 3 => "Varicose veins surgery" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec635535" "palabras" => array:4 [ 0 => "Vena safena magna accesoria anterior" 1 => "Cirugía hemodinámica venosa" 2 => "Técnica CHIVA" 3 => "Cirugía de varices" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Traditionally, anterior accessory great saphenous vein insufficiency was managed by crossectomy and resection of varicose veins. The aim of this paper is to show the safety and efficacy of a new therapeutic strategy for anterior accessory great saphenous varicose veins.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This non-randomised prospective study included 65 patients with varicose veins from the anterior accessory great saphenous vein. The novelty of the technique is to avoid the great saphenous vein crossectomy and perform just flebectomy of the visible veins. Venous duplex studies were performed preoperatively, a month and a year postoperatively. The clinical assessment was done by the Fligelstone scale.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The baseline CEAP clinical classification was: 58% C2, 26% C3 and 15% C4–6. The new strategy was applied to all cases. Complications: 3 haematomas, 7 cases of asymptomatic partial anterior saphenous thrombosis. Reduction of the initial average diameter was from 6.4<span class="elsevierStyleHsp" style=""></span>mm anterior saphenous to 3.4<span class="elsevierStyleHsp" style=""></span>mm by one year (<span class="elsevierStyleItalic">P</span><.001). At twelve months a forward flow is maintained in 82% of cases. Recurrence of varicose veins was 8%. All patients improved their clinical status based on the Fligelstone scale. Cases with saphenous diameter bigger than 7.5<span class="elsevierStyleHsp" style=""></span>mm and obesity were identified as predictors of worse clinical and haemodynamic outcome.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">This modified surgical strategy for anterior saphenous varicose veins results in better clinical outcomes at one year postoperatively.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Tradicionalmente la insuficiencia de safena anterior se trataba mediante crosectomía y resección de los paquetes varicosos. El objetivo del trabajo es mostrar la seguridad y eficacia de una nueva estrategia terapéutica en las varices dependientes de la vena safena magna accesoria anterior.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio prospectivo no ramdomizado que incluyó 65 pacientes con varices dependientes de la safena anterior con safena interna anterógrada. La modificación en la técnica consiste en hacer solamente flebectomía de los paquetes varicosos, sin ligar el cayado de la safena. Se realizó un estudio hemodinámico venoso preoperatorio, al mes y al año, y para la valoración clínica se utilizó la escala de Fligelstone.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Clasificación clínica basal CEAP: C2 58%, C3 26% y C4–6 15%. Complicaciones: 3 hematomas, 7 casos de trombosis parciales asintomáticas de safena anterior. Se observó una reducción del diámetro medio inicial de safena anterior de 6,4<span class="elsevierStyleHsp" style=""></span>mm a 3,4<span class="elsevierStyleHsp" style=""></span>mm al año (p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,001). A los doce meses mantenían un flujo anterógrado el 82% de los casos. Hubo una recidiva de varices visibles en el 8% de los casos. Todos los pacientes han reflejado una mejoría clínica en la escala de Fligelstone. El diámetro de safena anterior mayor de 7,5<span class="elsevierStyleHsp" style=""></span>mm y la obesidad se identifican como predictores de un peor resultado clínico y hemodinámico.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La modificación de la estrategia quirúrgica sobre las varices dependientes de la safena anterior presenta un resultado clínico favourable al año de la intervención.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">The content of this article is original and has not been submitted for consideration at any other publication, either in its entirety or partially. Preliminary results of this study were presented at the 30th Conference of the Andalusian Society of Angiology and Vascular Surgery in 2013 and included in the supplement of the scientific journal <span class="elsevierStyleItalic">Actualidad Médica</span> that was published in relation to the conference: Actual Med 2013; 98: (789). Supl. 13–16.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as: Maldonado-Fernández N, Linares-Palomino JP, López-Espada C, Martínez-Gámez FJ, Ros-Díe E. Resultados clínicos de una nueva estrategia quirúrgica (CHIVA modificado) en el tratamiento de las varices dependientes de la vena safena magna accesoria anterior. Cir Esp. 2016;94:144–150.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1210 "Ancho" => 1400 "Tamanyo" => 201840 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Patient mapping with varicose tributaries of the saphenous vein: (A) baseline situation of AASV-related varicose veins; (B) CHIVA cure 1<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>2 (traditional), non-haemodynamic approach: crossectomy of the saphenofemoral junction and disconnection of the varicose veins from the AASV and extensive phlebectomy; (C) haemodynamic CHIVA cure (innovative procedure): disconnection of the varices from the AASV and extensive phlebectomy.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1560 "Ancho" => 950 "Tamanyo" => 194754 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">One-year results after surgery: image showing varicose tributaries of the AASV; the left image shows the preoperative mapping, and situation 12 months after surgery is on the right.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Evolution of saphenous diameters (mm)</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Initial \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">12 months \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">AASV diameter \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.49±1.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.41±1.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">GSV diameter \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.73±0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.70±0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.258 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1018705.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Results of the Variation in Diameters of the Internal and Anterior Saphenous Veins One Year After Surgery.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Patient assessment of symptoms (Fligelstone scale)</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>1. - Asymptomatic, no discomfort \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37 (57%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>2. - Quite improved, but occasional mild discomfort \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 (40%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>3. - Improved, but with frequent mild symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>4. - Same: no improvement; same symptoms as before \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>5. - Worse: symptoms have worsened \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Patient assessment of aesthetics (Fligelstone score)</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>1. - Excellent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27 (42%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>2. - Very good: very satisfied with the results \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29 (46%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>3. - Good: satisfied with the results \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (14%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>4. - Same: poor result; the improvement was not important \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>5. - Worse: aesthetic improvement has been minimal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Aesthetic assessment by an independent observer (Fligelstone score)</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>1. - No visible varicosities \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">52 (80%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>2. - Superficial varicosities<span class="elsevierStyleHsp" style=""></span><5<span class="elsevierStyleHsp" style=""></span>mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (12%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>3. - Superficial varicosities<span class="elsevierStyleHsp" style=""></span>>5<span class="elsevierStyleHsp" style=""></span>mm on the thigh or calf \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>4. - Superficial varicosities<span class="elsevierStyleHsp" style=""></span>>5<span class="elsevierStyleHsp" style=""></span>mm on the thigh and calf \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>5. - Varicose vein complications: eczema, ulcers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1018708.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Symptomatic and Aesthetic Assessment 12 Months After Surgery of the 65 Patients in Follow-up.</p>" ] ] 4 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Recurrent varices</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">>5</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">mm</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>No new varices \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60 (92%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Appearance of new varices \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Haemodynamic results</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Normal anterograde flow \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53 (82%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Persistent retrograde flow \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (18%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Clinical results (Fligelstone score)</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Improved (CEAP 1,2,3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">65 (100%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Worsened (CEAP 4,5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1018707.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Clinical Results After 12 Months.</p>" ] ] 5 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">This table shows the different factors that have been studied with regards to recurrence variables after 12 months and poor haemodynamic results (according to the criteria established in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). The percentages represent the presence of each factor. The univariate analysis was done with the chi squared or Fisher text, and the <span class="elsevierStyleItalic">P</span> reached for each test is shown. For the multivariate analysis, a nominal logistic regression model was followed, and <span class="elsevierStyleItalic">P</span> values are also included.</p><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">AASV: anterior accessory saphenous vein.</p><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">HD: haemodynamic.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Factor \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Recurrence</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Poor HD results</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Univar \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Multvar \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Univar \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Multvar \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Female sex \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.821 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Overweight \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.07 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.218 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.044 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Reoperation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.04 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.121 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.04 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.178 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">AASV length<span class="elsevierStyleHsp" style=""></span>>10<span class="elsevierStyleHsp" style=""></span>cm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.339 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.38 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Shunt 3/shunt 5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10-0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.03 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24-0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.263 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.067 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Initial diameter AASV<span class="elsevierStyleHsp" style=""></span>>7.5<span class="elsevierStyleHsp" style=""></span>mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.04 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.030 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.02 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1018706.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Analysis of Factors Related With the Results of Recurrence and Poor Haemodynamic Results After 12 Months.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:21 [ 0 => array:3 [ "identificador" => "bib0110" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "La insuficiencia venosa crónica en el Sistema Nacional de Salud. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 3 | 9 |
| 2024 October | 56 | 11 | 67 |
| 2024 September | 54 | 7 | 61 |
| 2024 August | 62 | 13 | 75 |
| 2024 July | 41 | 7 | 48 |
| 2024 June | 64 | 7 | 71 |
| 2024 May | 60 | 5 | 65 |
| 2024 April | 45 | 7 | 52 |
| 2024 March | 67 | 3 | 70 |
| 2024 February | 49 | 5 | 54 |
| 2024 January | 70 | 5 | 75 |
| 2023 December | 69 | 5 | 74 |
| 2023 November | 73 | 8 | 81 |
| 2023 October | 102 | 12 | 114 |
| 2023 September | 60 | 1 | 61 |
| 2023 August | 64 | 7 | 71 |
| 2023 July | 77 | 4 | 81 |
| 2023 June | 70 | 3 | 73 |
| 2023 May | 120 | 4 | 124 |
| 2023 April | 107 | 3 | 110 |
| 2023 March | 94 | 11 | 105 |
| 2023 February | 117 | 2 | 119 |
| 2023 January | 70 | 12 | 82 |
| 2022 December | 77 | 2 | 79 |
| 2022 November | 86 | 8 | 94 |
| 2022 October | 68 | 9 | 77 |
| 2022 September | 109 | 25 | 134 |
| 2022 August | 75 | 22 | 97 |
| 2022 July | 47 | 10 | 57 |
| 2022 June | 43 | 6 | 49 |
| 2022 May | 38 | 19 | 57 |
| 2022 April | 58 | 11 | 69 |
| 2022 March | 79 | 13 | 92 |
| 2022 February | 57 | 6 | 63 |
| 2022 January | 107 | 8 | 115 |
| 2021 December | 51 | 10 | 61 |
| 2021 November | 87 | 14 | 101 |
| 2021 October | 67 | 15 | 82 |
| 2021 September | 33 | 13 | 46 |
| 2021 August | 51 | 7 | 58 |
| 2021 July | 48 | 13 | 61 |
| 2021 June | 46 | 11 | 57 |
| 2021 May | 44 | 10 | 54 |
| 2021 April | 86 | 23 | 109 |
| 2021 March | 50 | 11 | 61 |
| 2021 February | 45 | 17 | 62 |
| 2021 January | 61 | 21 | 82 |
| 2020 December | 43 | 5 | 48 |
| 2020 November | 47 | 10 | 57 |
| 2020 October | 42 | 8 | 50 |
| 2020 September | 27 | 12 | 39 |
| 2020 August | 79 | 10 | 89 |
| 2020 July | 24 | 9 | 33 |
| 2020 June | 38 | 12 | 50 |
| 2020 May | 38 | 8 | 46 |
| 2020 April | 27 | 2 | 29 |
| 2020 March | 26 | 3 | 29 |
| 2020 February | 42 | 6 | 48 |
| 2020 January | 46 | 11 | 57 |
| 2019 December | 39 | 17 | 56 |
| 2019 November | 49 | 12 | 61 |
| 2019 October | 51 | 17 | 68 |
| 2019 September | 43 | 14 | 57 |
| 2019 August | 42 | 11 | 53 |
| 2019 July | 34 | 23 | 57 |
| 2019 June | 78 | 21 | 99 |
| 2019 May | 188 | 38 | 226 |
| 2019 April | 78 | 14 | 92 |
| 2019 March | 14 | 7 | 21 |
| 2019 February | 15 | 6 | 21 |
| 2019 January | 14 | 6 | 20 |
| 2018 December | 13 | 11 | 24 |
| 2018 November | 25 | 13 | 38 |
| 2018 October | 50 | 10 | 60 |
| 2018 September | 35 | 3 | 38 |
| 2018 August | 13 | 0 | 13 |
| 2018 July | 19 | 4 | 23 |
| 2018 June | 15 | 1 | 16 |
| 2018 May | 10 | 1 | 11 |
| 2018 April | 20 | 2 | 22 |
| 2018 March | 10 | 1 | 11 |
| 2018 February | 17 | 1 | 18 |
| 2018 January | 15 | 1 | 16 |
| 2017 December | 18 | 0 | 18 |
| 2017 November | 18 | 2 | 20 |
| 2017 October | 27 | 3 | 30 |
| 2017 September | 16 | 14 | 30 |
| 2017 August | 15 | 8 | 23 |
| 2017 July | 17 | 1 | 18 |
| 2017 June | 23 | 1 | 24 |
| 2017 May | 37 | 5 | 42 |
| 2017 April | 17 | 6 | 23 |
| 2017 March | 34 | 21 | 55 |
| 2017 February | 51 | 4 | 55 |
| 2017 January | 45 | 5 | 50 |
| 2016 December | 27 | 10 | 37 |
| 2016 November | 59 | 7 | 66 |
| 2016 October | 66 | 14 | 80 |
| 2016 September | 59 | 10 | 69 |
| 2016 August | 51 | 11 | 62 |
| 2016 July | 35 | 5 | 40 |
| 2016 June | 16 | 8 | 24 |
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