varicose vein

(′var·ə′kōs ′vān)

(anatomy) An enlarged tortuous blood vessel that occurs chiefly in the superficial veins and their tributaries in the lower extremities. Also known as varicosity.



Twisted vein distended with blood. Varix also covers arteries and lymphatic vessels ( lymphatic system). Varicose veins occur mostly in the legs, when malfunctioning valves let blood pool in veins near the skin. Causes include hereditary valve and vein wall weakness and internal or external pressure on veins. Varices are common in pregnancy, suggesting that hormone abnormalities play a role. Symptoms include a heavy feeling, with leg cramps and swelling after standing a long time. Complications include skin ulcers and thrombosis. Treatment involves strong support hose, injection therapy, or surgery. Varices in the esophagus, which often occur in liver disease, can ulcerate and bleed. hemorrhoid.

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varices

Veins, commonly in the legs, which have become distended and twisted as a result of weakening of their walls and valves. Because they protrude, they are ruptured relatively easily. Ruptured veins bleed heavily, but the application of firm pressure usually brings the bleeding under control quickly. Obese individuals, pregnant women, those who regularly stand for prolonged periods, and the physically inactive are particularly susceptible. As long as varicose veins are not associated with other symptoms that may indicate a more sinister condition, a controlled programme of physical exercise may improve circulation and benefit sufferers.

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A varix or varicosity is an irregularity or lumpiness. In the body, this means irregularities caused by dilated and distorted veins.

Veins in the legs have valves which normally prevent any backflow of the blood on its way towards the heart. The pressure of the blood tending to distend these veins is greater than in veins elsewhere simply because, for most of most people's waking hours, they are lower than the rest of the body, and vertical. This can put a considerable strain on the valves, each of which supports the column of blood immediately above it, between it and the next valve further up. In ideal normal circumstances the blood is kept moving upwards effectively because of persistent squeezing of veins by actively contracting muscles as we walk about, as well as by other mechanisms which tend continually to draw the blood towards the chest. The superficial veins just under the skin benefit less directly than the deep ones from leg movements — but because they connect to the deep veins, squeezing by the muscles helps to siphon blood from those near the surface, as well as ‘milking’ it up the deep ones.

Thus gravity does not normally cause an accumulation of weighty blood in our lowest parts, as it would in, say, a liquid-filled bicycle inner tube suspended vertically. But there are less than ideal circumstances which cause relative stagnation, particularly in the superficial unsupported veins; blood then leans more heavily on the valves, and in some cases these become damaged and develop leaks. This can occur if there is an obstruction to blood flow up from the legs (such as a heavily pregnant uterus pressing on the veins in the pelvic cavity) and the problem is exacerbated by sitting or standing still. As for many bodily dysfunctions, there is no doubt a combination of innate propensity (weak veins and valves) and risk factors (flow obstruction and immobility). The leakage of valves in turn leads to the irregular bulges on the veins which are known as varicosities, along with enlargement and distortion. The sluggishness imposed on the circulation to the skin and underlying tissues by back pressure from these veins predisposes to discomfort, ulceration, and oedema.

Applying pressure by support stockings to keep the varicose veins from filling is the first line of treatment. But the veins which are affected are fortunately usually dispensible: if they are removed, blood can flow through alternative deeper channels. Effective surgical treatment involves making cuts only at the top and the bottom of the offending vein, which is then removed by using a ‘stripper’. From the top end (say at the knee) a thin flexible rod is passed down the vein to the far end (say at the ankle). The vein is tied around the rod, which has a knob on its end. Pulling from the top then causes the knob to draw the whole length of the vein up before it, ‘crumpling’ it as it comes. Thus the vein is pulled by the stripper from under the skin and out through the upper incision.

A similar problem can occur at other sites. In the lower end of the oesophagus, ‘varices’ may result from back pressure associated with liver disease. In the scrotum a ‘varicocoele’ is a swelling of the veins around the testis. Haemorrhoids represent a comparable condition of the anal veins.

— Sheila Jennett

See also blood circulation; blood vessels.


varices

Veins, commonly in the legs, which have become abnormally distended and twisted as a result of incompetence of internal valves. Varicose veins may bleed heavily if ruptured, in which case the application of firm pressure easily controls the bleeding. As long as varicose veins are not associated with other symptoms, a controlled programme of physical exercise may improve circulation and benefit sufferers.

varicose vein, superficial vessel that is abnormally lengthened, twisted, or dilated, seen most often on the legs and thighs. Varicose veins develop spontaneously, and are usually attributed to a hereditary weakness of the vein; the valves in the vein that keep the blood circulating upward toward the heart are usually incompetent. Increased pressure from long standing or exertion, or internal factors such as pregnancy, or lessened support by the tissues surrounding the veins that occurs with aging and obesity causes the weakened veins to dilate. Mild varicosities often cause no discomfort. Persons with more severe cases may develop swelling of the legs, ankles, and feet, and local eczema or ulcers. Mild varicosities may be treated with rest, elevation of the legs, and the use of elastic bandages or stockings. In severe cases surgical treatment may be necessary. Traditional surgery involves tying off and removing a vein segment. Varicose veins may now also be treated without removing them through an endoscopic surgical procedure that uses the heat produced by radio waves or a laser to seal off the veins. Varicose veins that occur around the rectum are called hemorrhoids, and those that form in the scrotum are called varicoceles.


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categories related to 'varicose veins'

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Random House Word Menu by Stephen Glazier
For a list of words related to varicose veins, see:
  • Afflictions and Conditions - varicose veins: bulging, distended, sometimes painful veins in legs, rectum, or scrotum due to obstruction of blood flow


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Varicose veins
Classification and external resources

A person affected by varicose veins.
ICD-10 I83, I84, I85, I86
ICD-9 454-456, 671
OMIM 192200
DiseasesDB 13734
MedlinePlus 001109
eMedicine med/2788
MeSH D014648

Varicose veins are veins that have become enlarged and tortuous. The term commonly refers to the veins on the leg,[1] although varicose veins can occur elsewhere. Veins have leaflet valves to prevent blood from flowing backwards (retrograde flow or reflux). Leg muscles pump the veins to return blood to the heart (the calf muscle pump mechanism), against the effects of gravity. When veins become varicose, the leaflets of the valves no longer meet properly, and the valves do not work (valvular incompetence). This allows blood to flow backwards and they enlarge even more. Varicose veins are most common in the superficial veins of the legs, which are subject to high pressure when standing. Besides being a cosmetic problem, varicose veins can be painful, especially when standing. Severe long-standing varicose veins can lead to leg swelling, venous eczema, skin thickening (lipodermatosclerosis) and ulceration. Life-threatening complications are uncommon.

Non-surgical treatments include sclerotherapy, elastic stockings, elevating the legs, and exercise. The traditional surgical treatment has been vein stripping to remove the affected veins. Newer, less invasive treatments which seal the main leaking vein are available. Alternative techniques, such as ultrasound-guided foam sclerotherapy, radiofrequency ablation and endovenous laser treatment, are available as well. Because most of the blood in the legs is returned by the deep veins, the superficial veins, which return only about 10 per cent of the total blood of the legs, can usually be removed or ablated without serious harm.[2][3]

Secondary varicose veins are those developing as collateral pathways, typically after stenosis or occlusion of the deep veins, a common sequel of extensive deep venous thrombosis (DVT). Treatment options are usually support stockings, occasionally sclerotherapy, and rarely limited surgery.

Varicose veins are distinguished from reticular veins (blue veins) and telangiectasias (spider veins), which also involve valvular insufficiency,[4] by the size and location of the veins. Many patients who suffer with varicose veins seek out the assistance of physicians who specialize in vein care or peripheral vascular disease. These physicians are called vascular surgeons, phlebologists or interventional radiologists.

Contents

Signs and symptoms

  • Aching, heavy legs (often worse at night and after exercise).
  • Appearance of spider veins (telangiectasia) in the affected leg.
  • Ankle swelling, especially in evening.
  • A brownish-yellow shiny skin discoloration near the affected veins.
  • Redness, dryness, and itchiness of areas of skin, termed stasis dermatitis or venous eczema, because of waste products building up in the leg.
  • Cramps may develop especially when making a sudden move as standing up.
  • Minor injuries to the area may bleed more than normal or take a long time to heal.
  • In some people the skin above the ankle may shrink (lipodermatosclerosis) because the fat underneath the skin becomes hard.
  • Restless legs syndrome appears to be a common overlapping clinical syndrome in patients with varicose veins and other chronic venous insufficiency.
  • Whitened, irregular scar-like patches can appear at the ankles. This is known as atrophie blanche.

Investigations

Traditionally, varicose veins were only investigated using imaging techniques if there was a clinical suspicion of deep venous insufficiency, if they were recurrent, or if they involved the sapheno-popliteal junction. This practice is not now widely accepted. All patients with varicose veins should now be investigated using Duplex doppler ultrasound scanning. The results from a randomised controlled trial (RCT) on the follow up of patients with and without routine Duplex scan has shown a significant difference in recurrence rate and reoperation rate at 2 and 7 years of follow up. .[5]

Complications

Most varicose veins are relatively benign, but severe varicosities can lead to major complications, due to the poor circulation through the affected limb.

  • Pain, heaviness, inability to walk or stand for long hours, thus hindering work
  • Skin conditions / Dermatitis which could predispose skin loss
  • Skin ulcers especially near the ankle, usually referred to as venous ulcers.
  • Development of carcinoma or sarcoma in longstanding venous ulcers. There have been over 100 reported cases of malignant transformation and the rate is reported as 0.4% to 1%.[6]
  • Severe bleeding from minor trauma, of particular concern in the elderly.
  • Blood clotting within affected veins. Termed superficial thrombophlebitis. These are frequently isolated to the superficial veins, but can extend into deep veins becoming a more serious problem.
  • Acute fat necrosis can occur, especially at the ankle of overweight patients with varicose veins. Females are more frequently affected than males.
  • The afflicted person suffers tenderness in that region

Stages

  • C0 no visible or palpable signs of venous disease
  • C1 telangectasia or reticular veins
  • C2 varicose veins
  • C3 edema
  • C4a skin changes due to venous disorders: pigmentation, eczema
  • C4b skin changes due to venous disorders: lipodermatosclerosis, atrophie blanche
  • C5 as C4 but with healed ulcers
  • C6 skin changes with active ulcers (venous insufficiency ulceration)

Causes

The illustration shows how a varicose vein forms in a leg. Figure A shows a normal vein with a working valve and normal blood flow. Figure B shows a varicose vein with a deformed valve, abnormal blood flow, and thin, stretched walls. The middle image shows where varicose veins might appear in a leg.

Varicose veins are more common in women than in men, and are linked with heredity.[7] Other related factors are pregnancy, obesity, menopause, aging, prolonged standing, leg injury, abdominal straining, and crossing legs at the knees or ankles. Less commonly, but not exceptionally, varicose veins can be due to other causes, as post phlebitic obstruction or incontinence, venous and arteriovenous malformations[8] See also for differential diagnosis- 1. Klippel-Trenaunay syndrome, 2. Parkes-Weber syndrome

Treatment

Conservative

The symptoms of varicose veins can be controlled to an extent with the following:

  • Elevating the legs often provides temporary symptomatic relief.
  • Advice about regular exercise sounds sensible but is not supported by any evidence.[9]
  • The wearing of graduated compression stockings with variable pressure gradients (Class II or III) has been shown to correct the swelling, nutritional exchange, and improve the microcirculation in legs affected by varicose veins.[10] They also often provide relief from the discomfort associated with this disease. Caution should be exercised in their use in patients with concurrent arterial disease.
  • The wearing of intermittent pneumatic compression devices have been shown to reduce swelling and increase circulation[medical citation needed]
  • Diosmin/Hesperidine and other flavonoids.
  • anti-inflammatory medication such as ibuprofen or aspirin can be used as part of treatment for superficial thrombophlebitis along with graduated compression hosiery – but there is a risk of intestinal bleeding. In extensive superficial thrombophlebitis, consideration should be given to anti-coagulation, thrombectomy or sclerotherapy of the involved vein.
  • Topical gel application, helps in managing symptoms related to varicose veins such as inflammation, pain, swelling, itching and dryness. Topical application-Non invasive and has patient compliance.

Active

Active medical intervention in varicose veins can be divided into surgical and non-surgical treatments. Some doctors favor traditional open surgery, while others prefer the newer methods. Newer methods for treating varicose veins such as Endovenous Thermal Ablation (endovenous laser treatment or radiofrequency ablation), and foam sclerotherapy are not as well studied, especially in the longer term.[11][12]

Surgical

Several techniques have been performed for over a century, from the more invasive saphenous stripping, to less invasive procedures like ambulatory phlebectomy and CHIVA.

Stripping

Stripping consists of removal of all or part the saphenous vein (great/long or lesser/short) main trunk. The complications include deep vein thrombosis (5.3%),[13] pulmonary embolism (0.06%), and wound complications including infection (2.2%). For traditional surgery, reported recurrence rates, which have been tracked for 10 years, range from 5-60%. In addition, since stripping removes the saphenous main trunks, they are no longer available for use as venous bypass grafts in the future (coronary or leg artery vital disease)[14]

Other

Other surgical treatments are:

  • Ambulatory phlebectomy
  • Vein ligation
  • Cryosurgery- A cryoprobe is passed down the long saphenous vein following saphenofemoral ligation. Then the probe is cooled with NO2 or CO2 to a temperature of -85o. The vein freezes to the probe and can be retrogradely stripped after 5 second of freezing. It is a variant of Stripping. The only point of this technique is to avoid a distal incision to remove the stripper.[15]

Non-surgical treatment

Sclerotherapy

A commonly performed non-surgical treatment for varicose and "spider" leg veins is sclerotherapy in which medicine (sclerosant) is injected into the veins to make them shrink. The medicines that are commonly used as sclerosants are polidocanol (POL), sodium tetradecyl sulphate (STS), Sclerodex (Canada), Hypertonic Saline, Glycerin and Chromated Glycerin. STS (branded Fibrovein in Australia) and Polidocanol (branded Asclera in the United States, Aethoxysklerol in Australia) liquids can be mixed at varying concentrations of sclerosant and varying sclerosant/gas proportions, with air or CO2 or O2 to create foams. Foams may allow more veins to be treated per session with comparable efficacy. Their use in contrast to liquid sclerosant is still somewhat controversial. Sclerotherapy has been used in the treatment of varicose veins for over 150 years.[16] Sclerotherapy is often used for telangiectasias (spider veins) and varicose veins that persist or recur after vein stripping.[17][18] Sclerotherapy can also be performed using foamed sclerosants under ultrasound guidance to treat larger varicose veins, including the great saphenous and small saphenous veins.[19][20] A study by Kanter and Thibault in 1996 reported a 76% success rate at 24 months in treating saphenofemoral junction and great saphenous vein incompetence with STS 3% solution.[21] A Cochrane Collaboration review[22] concluded sclerotherapy was better than surgery in the short term (1 year) for its treatment success, complication rate and cost, but surgery was better after 5 years, although the research is weak.[23] A Health Technology Assessment found that sclerotherapy provided less benefit than surgery, but is likely to provide a small benefit in varicose veins without reflux.[24] This Health Technology Assessment monograph includes reviews of the epidemiology, assessment, and treatment of varicose veins, as well as a study on clinical and cost effectiveness of surgery and sclerotherapy. Complications of sclerotherapy are rare but can include blood clots and ulceration. Anaphylactic reactions are "extraordinarily rare but can be life-threatening," and doctors should have resuscitation equipment ready.[25][26] There has been one reported case of stroke after ultrasound guided sclerotherapy when an unusually large dose of sclerosant foam was injected.

Endovenous thermal ablation

The Australian Medical Services Advisory Committee (MSAC) in 2008 has determined that endovenous laser treatment/ablation (ELA) for varicose veins "appears to be more effective in the short term, and at least as effective overall, as the comparative procedure of junction ligation and vein stripping for the treatment of varicose veins."[27] It also found in its assessment of available literature, that "occurrence rates of more severe complications such as DVT, nerve injury and paraesthesia, post-operative infections and haematomas, appears to be greater after ligation and stripping than after EVLT". Complications for ELA include minor skin burns (0.4%)[28] and temporary paraesthesia (2.1%). The longest study of endovenous laser ablation is 39 months.

Two prospective randomized trials found speedier recovery and fewer complications after radiofrequency ablation (ERA) compared to open surgery.[29][30] Myers[31] wrote that open surgery for small saphenous vein reflux is obsolete. Myers said these veins should be treated with endovenous techniques, citing high recurrence rates after surgical management, and risk of nerve damage up to 15%. In comparison, ERA has been shown to control 80% of cases of small saphenous vein reflux at 4 years, said Myers. Complications for ERA include burns, paraesthesia, clinical phlebitis, and slightly higher rates of deep vein thrombosis (0.57%) and pulmonary embolism (0.17%).One 3-year study compared ERA, with a recurrence rate of 33%, to open surgery, which had a recurrence rate of 23%.

ELA and ERA require specialized training for doctors and expensive equipment. ELA is performed as an outpatient procedure and does not require the use of an operating theatre, nor does the patient need a general anaesthetic. Doctors must use high frequency ultrasound during the procedure to visualize the anatomical relationships between the saphenous structures. Some practitioners also perform phlebectomy or ultrasound guided sclerotherapy at the time of endovenous treatment. Follow-up treatment to smaller branch varicose veins is often needed in the weeks or months after the initial procedure.

See also

References

Notes

  1. ^ "Varicose Veins". 2010-07-06. http://www.webcitation.org/5r1PRrJul. Mount Sinai Hospital, New York
  2. ^ Merck Manual Home Edition, 2nd ed.
  3. ^ [1][dead link]
  4. ^ Weiss RA, Weiss MA (1993). "Doppler ultrasound findings in reticular veins of the thigh subdermic lateral venous system and implications for sclerotherapy". J Dermatol Surg Oncol 19 (10): 947–51. PMID 8408914.
  5. ^ Blomgren L, Johansson G, Emanuelsson L, Dahlberg-Åkerman A, Thermaenius P, Bergqvist D. Late follow-up of a randomized trial of routine duplex imaging before varicose vein surgery. Br J Surg. 2011 Aug;98(8):1112-6. doi:10.1002/bjs.7579.
  6. ^ Goldman M. Sclerotherapy, Treatment of Varicose and Telangiectatic Leg Veins. Hardcover Text, 2nd Ed, 1995
  7. ^ Ng M, Andrew T, Spector T, Jeffery S (2005). "Linkage to the FOXC2 region of chromosome 16 for varicose veins in otherwise healthy, unselected sibling pairs.". J Med Genet 42 (3): 235–9. doi:10.1136/jmg.2004.024075. PMC 1736007. PMID 15744037. //www.ncbi.nlm.nih.gov/pmc/articles/PMC1736007/.
  8. ^ Claude Franceschi Physiopathologie Hémodynamique de l'Insuffisance veineuse in Chirurgie des veines des Membres Inférieurs, p. 49, 1996, AERCV editions 23 rue Royale 75008 Paris France. Varicose veins could also be caused by elevated levels of homocysteine in the body can degrade and inhibit the formation of the three main structural components of the artery, collagen, elastin and the proteoglycans. Homocysteine permanently degrades cysteine disulfide bridges and lysine amino acid residues in proteins, gradually affecting function and structure. Simply put, homocysteine is a 'corrosive' of long-living proteins, i.e. collagen or elastin, or life-long proteins, i.e. fibrillin. These long-term effects are difficult to establish in clinical trials focusing on groups with existing artery decline.
  9. ^ Campbell B (2006). "Varicose veins and their management". BMJ 333 (7562): 287–92. doi:10.1136/bmj.333.7562.287. PMC 1526945. PMID 16888305. //www.ncbi.nlm.nih.gov/pmc/articles/PMC1526945/.
  10. ^ Curri SB et al. Changes of cutaneous microcirculation from elasto-compression in chronic venous insufficiency. In Davy A and Stemmer R, editors: Phlebology '89, Montrouge, France, 1989, John Libbey Eurotext.
  11. ^ "Open Surgery Is Still The Best Technique To Ablate The Great Saphenous Vein Vascular, Vol. 14 (November 2006), Suppl. 1, p. S. 25
  12. ^ Jia, X; Mowatt, G; Burr, JM; Cassar, K; Cook, J; Fraser, C (2007). "Systematic review of foam sclerotherapy for varicose veins". The British journal of surgery 94 (8): 925–36. doi:10.1002/bjs.5891. PMID 17636511.
  13. ^ van Rij AM, Chai J, Hill GB, Christie RA (December 2004). "Incidence of deep vein thrombosis after varicose vein surgery". Br J Surg 91 (12): 1582–5. doi:10.1002/bjs.4701. PMID 15386324.
  14. ^ Hammarsten J, Pedersen P, Cederlund CG, Campanello M (1990). "Long saphenous vein saving surgery for varicose veins. A long-term follow-up". Eur J Vasc Surg 4 (4): 361–4. doi:10.1016/S0950-821X(05)80867-9. PMID 2204548.
  15. ^ Shouten R, Mollen RM, Kuijpers HC (2006). "A comparison between cryosurgery and conventional stripping in varicose vein surgery: perioperative features and complications". Annals of vascular surgery 20 (3): 306–11. doi:10.1007/s10016-006-9051-x. PMID 16779510.
  16. ^ Goldman M, Sclerotherapy Treatment of varicose and telangiectatic leg vein, Hardcover Text, 2nd Ed, 1995
  17. ^ "Veins & Lymphatics," L. K. Pak et al., in Lange's Current Surgical Diagnosis & Treatment, 11th ed., McGraw-Hill,
  18. ^ Tisi PV, Beverley C, Rees A (2006). Tisi, Paul V. ed. "Injection sclerotherapy for varicose veins". Cochrane Database Syst Rev (4): CD001732. doi:10.1002/14651858.CD001732.pub2. PMID 17054141.
  19. ^ Paul Thibault, Sclerotherapy and Ultrasound-Guided Sclerotherapy, The Vein Book / editor, John J. Bergan, 2007.
  20. ^ Padbury A, Benveniste G L, Foam echosclerotherapy of the small saphenous vein, Australian and New Zealand Journal of Phlebology Vol 8, Number 1 (December 2004)
  21. ^ Kanter A, Thibault P (July 1996). "Saphenofemoral incompetence treated by ultrasound-guided sclerotherapy". Dermatol Surg 22 (7): 648–52. doi:10.1016/1076-0512(96)00173-2. PMID 8680788.
  22. ^ Tisi, Paul V; Beverley, Catherine; Rees, Angie (2006). Injection sclerotherapy for varicose veins. In Tisi, Paul V. "Cochrane Database of Systematic Reviews". Cochrane Database Syst Rev (4): CD001732. doi:10.1002/14651858.CD001732.pub2. PMID 17054141.
  23. ^ Rigby KA, Palfreyman SJ, Beverley C, Michaels JA (2004). Rigby, Kathryn A. ed. "Surgery versus sclerotherapy for the treatment of varicose veins". Cochrane Database Syst Rev (4): CD004980. doi:10.1002/14651858.CD004980. PMID 15495134.
  24. ^ Michaels JA, Campbell WB, Brazier JE et al. (April 2006). "Randomised clinical trial, observational study and assessment of cost-effectiveness of the treatment of varicose veins (REACTIV trial)". Health Technol Assess 10 (13): 1–196, iii–iv. PMID 16707070. http://www.hta.ac.uk/execsumm/summ1013.htm.
  25. ^ William R. Finkelmeier, Sclerotherapy, Ch. 12, ACS Surgery: Principles & Practice, 2004, WebMD (hardcover book)
  26. ^ Scurr JR, Fisher RK, Wallace SB (2007). "Anaphylaxis Following Foam Sclerotherapy: A Life Threatening Complication of Non Invasive Treatment For Varicose Veins". EJVES Extra 13 (6): 87–89. doi:10.1016/j.ejvsextra.2007.02.005.
  27. ^ Medical Services Advisory Committee, ELA for varicose veins. MSAC application 1113, Dept of Health and Ageing, Commonwealth of Australia, 2008.
  28. ^ Elmore FA, Lackey D (2008). "Effectiveness of ELA in eliminating superficial venous reflux". Phlebology 23 (1): 21–31. doi:10.1258/phleb.2007.007019. PMID 18361266.
  29. ^ Rautio TT, Perälä JM, Wiik HT, Juvonen TS, Haukipuro KA (June 2002). "Endovenous obliteration with radiofrequency-resistive heating for greater saphenous vein insufficiency: a feasibility study". J Vasc Interv Radiol 13 (6): 569–75. doi:10.1016/S1051-0443(07)61649-2. PMID 12050296.
  30. ^ Lurie F, Creton D, Eklof B et al. (January 2005). "Prospective randomised study of endovenous radiofrequency obliteration (closure) versus ligation and vein stripping (EVOLVeS): two-year follow-up". Eur J Vasc Endovasc Surg 29 (1): 67–73. doi:10.1016/j.ejvs.2004.09.019. PMID 15570274.
  31. ^ Kenneth Myers, An opinion —surgery for small saphenous reflux is obsolete!" Australian and New Zealand Journal of Phlebology, Vol 8, Number 1 (December 2004)

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