JAMA Surg. 2022 May 1;157(5):395-404. doi: 10.1001/ jamasurg.2022.0298.
Pain outcomes following mechanochemical ablation vs. cyanoacrylate adhesive for the treatment of primary truncal saphenous vein incompetence: The MOCCA randomized clinical trial
Belramman A, Bootun R, Tang TY, Lane TRA, Davies AH
Importance: Endovenous thermal ablations (ETAs) are recommended as first-line treatment for truncal vein reflux, have a short recovery time and are cost-effective. However, ETAs are associated with discomfort during tumescent anesthesia infiltration. To minimize discomfort, nonthermal, nontumescent ablation techniques had emerged in the form of mechanochemical ablation (MOCA) and cyanoacrylate adhesive injection (CAE).
Objective: To assess pain scores immediately after truncal ablation using a 100-mm visual analog scale and 10-point number scale to compare pain-related outcomes following mechanochemical ablation vs. cyanoacrylate adhesive treatment.
Design, setting and participants: The Multicenter Randomized II Clinical Trial Comparing Mechanochemical Ablation vs. Cyanoacrylate Adhesive for the Treatment of Primary Truncal Saphenous Veins Incompetence study was a prospective multicenter randomized clinical trial conducted at three sites between November 2017 and January 2020. Inclusion criteria were primary great or small saphenous varicose veins; exclusion criteria included recurrent varicose veins, current deep venous thrombosis or serious arterial disease. There were 392 participants screened, 225 were excluded and 167 participants underwent randomization. Four participants did not receive allocated intervention and were included in the intention-to-treat analysis. Follow-up took place at 2 weeks and 3, 6, and 12 months.
Interventions: Patients with primary truncal vein incompetence were randomized to receive either MOCA or CAE.
Main outcomes and measures: The primary outcome measure was pain score immediately after completing truncal ablation using a 100-mm visual analog scale (VAS) and a 10-point number scale. Secondary outcome measures included degree of ecchymosis, occlusion rates, clinical severity, and generic and disease-specific quality of life (QoL) scores.
Results: Of 167 study participants, 99 (59.3%) were women, and the mean (SD) age was 56 (15.8) years. Overall, 155 truncal veins treated (92.8%) were great saphenous veins. Demographic data and baseline status were comparable between treatment groups. A total of 73 patients (47%) underwent adjunctive treatment of varicosities. Overall median (IQR) maximum pain score after truncal treatment was 23 mm (10–44) on the VAS and 3 (2–5) on the number scale, showing no significant difference in median (IQR) pain measured by VAS (MOCA, 24 [11.5–44.7] mm vs. CAE, 20 [9.0–42.0] mm; P = .23) or by number scale (MOCA, 4 [2–5] vs. CAE, 3 [2–4]; P = .18). Both groups demonstrated significant and comparable improvement in clinical severity, generic and disease-specific QoL scores, and complete occlusion rates.
32 IRQ | SUMMER 2022
J Urol. 2022 May;207(5):1077-1085. doi: 10.1097/ JU.0000000000002424. Epub 2022 Jan 4.
Utility and outcome of angioembolization for high- grade renal trauma management in a large hospital- based trauma registry
Hakam N, Amend GM, Nabavizadeh B, Allen IE, Shaw NM, Cuschieri J, Wilson MW, Stein DM, Breyer BN
Purpose: We evaluated angioembolization (AE) use for high- grade renal trauma (HGRT) management and compared AE vs. surgical repair (SR) in requiring nephrectomy.
Materials and methods: Using National Trauma Data Bank® 2013–2018, we identified patients with HGRT who underwent AE or SR as initial management. Therapy failure was defined as performing subsequent nephrectomy, partial nephrectomy, SR or AE. Logistic regression was performed to assess the association between intervention type (AE vs. SR) and nephrectomy. Analysis was repeated in a propensity score-matched cohort constructed by matching AE to SR patients on American Association for the Surgery of Trauma (AAST) grade, injury mechanism (blunt vs. penetrating) and hemodynamic instability (systolic blood pressure <90 mmHg).
Results: There were 266 patients in the AE group and 215 in the SR group. Median age was 29.5 years and 212 patients (44.1%) had penetrating injuries. AE was successful in 94.2% and 85.3% of grade IV and V injuries, respectively, whereas SR was successful in 82.1% and 56%, respectively. Grade V injury was associated with AE failure in the adjusted analysis (OR 3.55, 95% CI 1.22–10.2, p=0.02). Nephrectomy was less likely to be performed after AE vs. after SR in HGRT (6.4% vs. 17.2%, p=0.01), AAST grade IV (4.2% vs. 13.7%, p=0.001) and AAST grade V (12% vs. 44%, p=0.001). The matched cohort comprised 528 patients. In post-match regression, AE, compared to SR, was associated with lower odds of nephrectomy (OR 0.18, 95% CI 0.04–0.70, p=0.013).
Conclusions: AE achieved superior kidney salvage compared to SR in this observational cohort. These results inform both clinical practice and future prospective trials.
Four patients treated with CAE developed minor complications (superficial thrombophlebitis and thrombus extensions).
Conclusions and relevance: To our knowledge, this was the first randomized clinical trial directly comparing nontumescent ablation techniques. The study demonstrated that the MOCA and CAE techniques have a similar periprocedural pain score.
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