Duplex ultrasound changes in the great saphenous vein after endosaphenous laser occlusion with 808-nm wavelength Leonardo Corcos, MD, Sergio Dini, MD,

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Duplex ultrasound changes in the great saphenous vein after endosaphenous laser occlusion with 808-nm wavelength Leonardo Corcos, MD, Sergio Dini, MD, Giampiero Peruzzi, MD, Daniele Pontello, MD, Mario Dini, MD, Dino De Anna, MD Journal of Vascular Surgery Volume 48, Issue 5, Pages 1262-1271 (November 2008) DOI: 10.1016/j.jvs.2008.06.004 Copyright © 2008 The Society for Vascular Surgery Terms and Conditions

Fig 1 A cross section of a great saphenous vein distal stump taken 7 cm below the groin immediately after surgical interruption and endosaphenous laser ablation shows clumped erythrocytes and necrotic fragments visible in the vein lumen. Circular necrotic thermal damage to the intima and inner media can be seen in correspondence with a necrotic fragment (black arrow). Hematoxylin and eosin staining; original magnification ×100. Journal of Vascular Surgery 2008 48, 1262-1271DOI: (10.1016/j.jvs.2008.06.004) Copyright © 2008 The Society for Vascular Surgery Terms and Conditions

Fig 2 A cross section of a great saphenous vein distal stump taken 7 cm below the groin immediately after surgical interruption and endosaphenous laser ablation shows blood transformation into amorphous substance, with necrotic tissue residues and large empty areas corresponding to thermal blood vaporization. Circular necrosis of the intima and thermal damage to the inner media is shown (black arrow) along with asymmetric thinning and thickening of the venous wall, with sclerosis of the media. Hematoxylin and eosin staining; original magnification ×25. Journal of Vascular Surgery 2008 48, 1262-1271DOI: (10.1016/j.jvs.2008.06.004) Copyright © 2008 The Society for Vascular Surgery Terms and Conditions

Fig 3 A cross section of a great saphenous vein distal stump taken 7 mm below the groin 30 days after surgical interruption and endosaphenous laser ablation shows symmetric thinning of the venous wall, with sclerosis of the media. Thrombus is attached to the venous wall, with more advanced fibrous organization in the peripheral circumference than in the center. Two patent peripheral areas probably corresponding to a partial occlusion or early recanalization (black arrows) are visible, as is early hypotrophy of the venous wall. (Compare with the duplex ultrasound imaging of the same sample in Fig 6.) Hematoxylin and eosin staining; original magnification ×30. Journal of Vascular Surgery 2008 48, 1262-1271DOI: (10.1016/j.jvs.2008.06.004) Copyright © 2008 The Society for Vascular Surgery Terms and Conditions

Fig 4 Detail from Fig 3 of a patent peripheral area in the thrombus covered with endothelium shows a peripheral organization process of the thrombus and small new vessels in the thrombus structure (black arrow). Hematoxylin and eosin staining; original magnification ×30. Journal of Vascular Surgery 2008 48, 1262-1271DOI: (10.1016/j.jvs.2008.06.004) Copyright © 2008 The Society for Vascular Surgery Terms and Conditions

Fig 5 Cross section of a great saphenous vein distal stump taken 7 cm below the groin 60 days after surgical interruption and endosaphenous laser ablation (ELA) shows more advanced hypotrophic thinning of the venous wall, with marked sclerosis of the media. Thrombus is partially attached to the venous wall, with fibrotic organization more advanced in the middle section and necrotic inclusions (black arrows). Inflammatory cells are visible in the peripheral section due to post-ELA phlebitis (white arrow). (Compare with Fig 8, which shows the duplex ultrasound imaging of the same sample.) Phosphotungstic acid-hematoxylin staining; original magnification ×25. Journal of Vascular Surgery 2008 48, 1262-1271DOI: (10.1016/j.jvs.2008.06.004) Copyright © 2008 The Society for Vascular Surgery Terms and Conditions

Fig 6 Duplex ultrasound cross-scanning (7.5-MHz probe) of a great saphenous vein distal stump performed 7 cm below the groin 30 days after surgical interruption and endosaphenous laser ablation immediately before histologic observation (Figs 3 and 4) shows thinning of the venous wall (hypoechogenic peripheral circle). In 52% of the cases, the thrombus is represented by a hyperechogenic circle, corresponding to a peripheral fibrosis, with a hypoechogenic middle section corresponding to early organization (mixed thrombus). No flow was detected in the patent luminal area. Journal of Vascular Surgery 2008 48, 1262-1271DOI: (10.1016/j.jvs.2008.06.004) Copyright © 2008 The Society for Vascular Surgery Terms and Conditions

Fig 7 Duplex ultrasound cross-scanning (7.5-MHz probe) of a great saphenous vein distal stump performed 7 cm below the groin, 30 days after surgical interruption and endosaphenous laser ablation, shows thinning of the venous wall (hypoechogenic peripheral circle). In 43% of the cases, the thrombus is entirely hyperechogenic. The image corresponds to a complete early fibrotic organization. Journal of Vascular Surgery 2008 48, 1262-1271DOI: (10.1016/j.jvs.2008.06.004) Copyright © 2008 The Society for Vascular Surgery Terms and Conditions

Fig 8 Duplex ultrasound cross-scanning (7.5-MHz probe) of a great saphenous vein distal stump performed 7 cm below the groin 60 days after surgical interruption, and endosaphenous laser ablation immediately before histologic observation (Fig 5), shows persistence of the venous wall imaging (hypoechogenic peripheral circle). In 75% of the limbs at 6 months (P < .00001), the venous content appeared to be entirely hyperechogenic (fibrotic thrombus). Journal of Vascular Surgery 2008 48, 1262-1271DOI: (10.1016/j.jvs.2008.06.004) Copyright © 2008 The Society for Vascular Surgery Terms and Conditions

Fig 9 Duplex ultrasound cross-scanning (7.5-MHz probe) of a great saphenous vein 12 months after surgical interruption and endosaphenous ablation shows the end of the atrophic process: the great saphenous vein is not detected in the normal anatomic site. Journal of Vascular Surgery 2008 48, 1262-1271DOI: (10.1016/j.jvs.2008.06.004) Copyright © 2008 The Society for Vascular Surgery Terms and Conditions

Fig 10 Diagram of the progressive mean decrease of the great saphenous vein (GSV) diameter after surgical interruption and endosaphenous laser ablation during a 12-month follow-up. The duplex ultrasound examination used a 7.5-MHz probe. (Level of statistical significance, P < .01; χ2 test). Mean diameter decrease: at 1 week, 3.07 mm (range, 2.3-12 mm; P < .00001); at 1 month, 3.73 mm (range 2-11 mm; P < .00001); at 2 months, 4.54 mm (range, 2-10 mm; P < .00001; at 6 months, 5.83 mm (range, 1.7-7 mm; P < .00001), and at 12 months in nine persistent GSVs, 7.45 mm (range, 1.5-4.2 mm; P < .05). At 12 months, 35 of 44 GSV (77%) had disappeared (P < .00001). Journal of Vascular Surgery 2008 48, 1262-1271DOI: (10.1016/j.jvs.2008.06.004) Copyright © 2008 The Society for Vascular Surgery Terms and Conditions

Fig 11 Diagram of the great saphenous vein thrombi transformation after surgical interruption and endosaphenous laser ablation during a 12-month follow-up by duplex ultrasound examination (7.5-MHz probe). At 7 days after endosaphenous laser ablation, there was 100% hypoechogenic (fresh) thrombi (triangles). The difference in the presence of mixed (squares) and hyperechogenic (fibrous) thrombi (circles) at 30 and 60 days was not significant. Prevalence of fresh thrombi at 1 week was P < .00001 and at 6 months was P < .00001. At 12 months, 35 of 44 great saphenous veins disappeared vs nine persisting (100% fibrous; P < .00001). (Student t test with 1 degree of freedom; level of statistical significance, 0.05; standard deviation, 13.991; 95% confidence interval, 4.1339. Journal of Vascular Surgery 2008 48, 1262-1271DOI: (10.1016/j.jvs.2008.06.004) Copyright © 2008 The Society for Vascular Surgery Terms and Conditions