Endovenous laser ablation therapy (EVLT) is an effective and safe treatment for varicose veins. Most reported complications are self-limiting. Here we report a rare case of a 29-year-old woman who was recently treated with EVLT and had a retained guidewire up to the petrosal sinus causing a severe headache.

Varicose veins are consistent with physically dilated superficial veins ≥3 mm. Physiologically, chronic venous insufficiency is an advanced chronic venous disease with functional abnormalities. Essentially, the shape of the vein is directly influenced by hydrostatic pressure. Ambulatory venous pressure is increased as shunt formation and vein will be dilated by the connection with deep venous refluxes. Hydrostatic parodox in varicose veins is that the ambulatory venous pressure is not directly related with vein diameter but with shunt formation with valve insufficiency. Mean ambulatory venous pressure of 10–30 mmHg is considered as normal, 31–45 mmHg as intermediate and >45 mmHg as severe venous hypertension. Diameter measurement is used in the diagnosis of varicose veins, but treatment need to be more focused to remove hydrostatic pressure rather than diameter of vein in respect to improve symptoms related with varicose veins. Nevertheless, there are some concerns for the treatment of large veins. From the guidelines endothermal ablation is recommended than non-thermal ablation for >10 mm large varicose vein. Large veins might increase the incidence of endothermal heat induced thrombosis. Caprini score more than 7 will be benefited from chemoprophylaxis for large vein. For the compression therapy, inelastic compression is recommended than elastic compression to improve the function of calf muscle pump.

An 82-year-old female was referred from a local clinic due to left leg swelling despite 1 month of direct oral anticoagulant therapy for left iliac deep vein thrombosis. Enhanced computed tomography (CT) revealed a hypoplastic iliac vein with several iliac and popliteal arteriovenous fistulas (AVFs), without significant iliofemoral deep vein thrombosis. First, endovascular balloon angioplasty was performed for iliac vein hypoplasia related to a previous deep vein thrombosis. On postoperative day 4, CT angiography was performed due to persistent left leg edema with circumference discrepancy, which confirmed narrowing of the left common iliac vein with extrinsic compression between the right common iliac artery and vertebral body. Persistent left leg edema required an additional endovascular procedure; more specifically, placement of an iliac vein stent. After restoration of circumference equality in both the thigh and calf, the patient was discharged from hospital on antiplatelet and antithrombotic medications. Three months later, the patient visited again due to recurrent left leg edema, with a circumference discrepancy measuring ＞10 cm. Iliac vein balloon angioplasty was performed, as was additional stent placement for May-Thurner syndrome (MTS) and coil embolization of the iliac AVF. Endovascular embolization resulted in full recovery from MTS with coexisting iliac AVFs. MTS combined with ilio-iliac AVF(s) may be a neglected phenomenon, although it is not very rare. The present report reviews this disease category and raises awareness of possible disease mechanisms(s).

Pelvic vein disorder (PeVD) encompasses symptoms originating from the pelvic veins. It significantly impacts quality of life despite not always being life-threatening, necessitating accurate diagnosis and effective management. PeVD may result from pelvic vein incompetence (PVI), or conditions like left common iliac vein compression or Nutcracker syndrome can contribute to PeVD. Chronic pelvic pain, lasting over six months, is a common symptom, affecting various aspects of health and often linked to lower urinary tract, sexual function, and gynecological issues. Diagnosis involves ultrasound, computed tomography, magnetic resonance venography, and catheter venography. Transvaginal or abdominal ultrasound can identify enlarged veins and reflux, while catheter venography is the gold standard for diagnosing PVI. Treatment options include medical and endovascular treatments. Medications like micronized purified flavonoid fraction, medroxyprogesterone acetate, and goserelin acetate offer symptom relief, though effects are temporary. Endovascular treatment provides favorable outcomes, with coil embolization being effective.

Although varicose veins are known to have a very high prevalence, there are many different treatment methods available. The optimal extent of treatment for the incompetent great saphenous vein has not yet been clearly established. Recent guidelines recommend the proper extent and method of treatment based on expert opinion. Considering complications and subjective data, such as symptoms and quality of life, above-the-knee treatment could be suggested. However, in terms of recurrence and objective data, below-the-knee treatment might be preferred. It would be better to approach treatment on a customized basis for each patient by carefully analyzing the results based on both subjective and objective data.

Objective To determine whether variations in the termination of the small saphenous vein predict small saphenous vein incompetence.
Methods We conducted a prospective observational study, evaluating 133 patients diagnosed with either an isolated small saphenous vein incompetence (study group, n=47) or an isolated great saphenous vein incompetence (control group, n=86) between December 2014 and June 2015. The variations in the termination of the small saphenous vein were assessed using color Doppler ultrasound and classified according to the modified Kosinski’s classification. Data were compared between two groups.
Results Type 1 variation was more common (41/47, 87%) in patients with small saphenous vein incompetence compared to those with isolated great saphenous vein incompetence (54/86, 63%). No patients had Type 3 variation. Although not statistically significant, small saphenous vein incompetence was less common in patients with type 2 variation in the termination of small saphenous vein (16% vs. 43%; p=0.055).
Conclusion While awareness of small saphenous vein termination variations cannot predict saphenous vein incompetence, since we encounter these variations frequently, it is important to determine the type of variation before surgical treatment in order to prevent recurrence.

Flebogrif^® is a new modality of mechanochemical ablation for incompetent saphenous vein treatment. With our experiences, it offers advantages such as reduced sclerosant dosage, shorter procedure times, lower catheter costs and in terms of closure rate as well. However, the potential for increased pain and thrombophlebitis due to more potent mechanical injury is apparent.

Objective This study aims to evaluate the effect of treatment for great saphenous vein incompetence with a fourth-generation 1940 nm laser with radial fiber and catheter directed foam sclerotherapy (CDFS) without a tumescent simultaneously. The procedure was termed laser assisted sclerotherapy (LAST). It is a kind of thermochemical ablation.
Methods From January 1 to June 30, 2023, 86 GSV cases from 50 patients who underwent LAST at Cheongmac hospital were enrolled in this retrospective study. Endogenous laser ablation (EVLA) was performed in the order of accessary vein, tributaries and truncal vein and then followed by CDFS which was performed with a 3% sodium tetradecyl sulfate (STS) mixed with CO₂ gas at a ratio of 1:4. The degree of pain was measured after procedure at 2 hours after the procedure. Follow-up was conducted at 1 week, 1 month, and 6 months.
Results Three of the 86 GSV observed for >6 months showed mild reflux. According to size and number of ablated vessels, various energy level was needed. Three percent STS was used 4.5±0.4 cc and operation time per GSV was about 8±2 minutes. The VAS score was 2.5±0.6 at 2 hours after surgery. The closure rate was 100% at 6 months. Symptoms improved after 6 months in all patients (6.2±1.2 to 0.9±0.2).
Conclusion LAST showed a good closure rate in the early midterm follow up period. Ablation was possible with less energy compared with EVLA and the pain index was lower at the second hour after procedure.

Objective To determine hemodynamic changes after surgical treatment for great saphenous vein (GSV) incompetence.
Methods According to clinical, etiological, anatomical, and pathophysiological classification, all patients were classified as C2EpAsPr. A total of 976 limbs of 900 patients with primary varicose veins who underwent surgical treatment at the Samsung Medical Center were retrospectively reviewed. Surgical modalities were high ligation (HL) with stripping, endovenous laser ablation (EVLA), and radiofrequency ablation (RFA) of GSV. Hemodynamic changes were measured using air plethysmography preoperatively and 1 and 6 months postoperatively. Duplex scans were performed to evaluate the GSV status after surgery.
Results Of the 900 patients, 250, 139, and 511 underwent EVLA, RFA, and HL with stripping, respectively. All groups showed a significant increase in the ejection fraction (EF) and a decrease in the venous volume (VV), venous filling index (VFI), and residual volume fraction (RVF) at 1 month postoperatively, compared with the corresponding preoperative values. When the rate of reduction was compared between the treatment modalities, the 1-month postoperative rate of reduction in the VV was higher in the RFA group and those of the VFI, EF, and RVF were higher in the HL with stripping group, compared with the other groups (p<0.05). The GSV occlusion rates at 1 and 6 months were 85.6% and 97.5% in the EVLA group and 95.7% and 99.4% in the RFA group, respectively.
Conclusion All three surgical modalities improved the hemodynamic parameters after treatment for GSV incompetence. Thus, appropriate surgical methods can be selected according to the patient’s condition and physician’s preference.

Left-sided inferior vena cava (IVC) is a congenital venous anomaly variant with an incidence of 0.2%–0.5%. Furthermore case of abdominal aortic aneurysm with left-sided IVC is very rare. We reported our experience with two cases of left-sided IVC during open repair of the abdominal aortic aneurysm.