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Surgery for varicose veins: use of tourniquet

  1. Kathryn A Rigby1,*,
  2. Simon J Palfreyman2,
  3. Catherine Beverley3,
  4. Jonathan A Michaels4

Editorial Group: Cochrane Vascular Group

Published Online: 10 JUN 2013

Assessed as up-to-date: 9 APR 2013

DOI: 10.1002/14651858.CD001486.pub2


How to Cite

Rigby KA, Palfreyman SJ, Beverley C, Michaels JA. Surgery for varicose veins: use of tourniquet. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD001486. DOI: 10.1002/14651858.CD001486.pub2.

Author Information

  1. 1

    Centre for Population Health Sciences, c/o Cochrane PVD group, Edinburgh, UK

  2. 2

    Sheffield Teaching Hospitals NHS Foundation Trust, Tissue Viability, Sheffield, UK

  3. 3

    Cumbria County Council, Adult Social Care, Carlisle, UK

  4. 4

    University of Sheffield, ScHARR, School of Health and Related Research, Sheffield, UK

*Kathryn A Rigby, c/o Cochrane PVD group, Centre for Population Health Sciences, The Medical School, University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG, UK. Keeley74@btinternet.com.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 10 JUN 2013

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Characteristics of included studies [ordered by study ID]
Corbett 1989

MethodsStudy design: RCT.

Method of randomisation: Coin spun by anaesthetist to decide if tourniquet should be used (for bilateral cases coin spun twice).

Blinding: No blinding of assessors indicated.

Exclusions post-randomisation: None stated.

Losses to follow-up: None stated.


ParticipantsCountry: UK.

Setting: Hospital.

No. of participants: 26
No. of limbs: 40

Age mean (years): 51.

Gender: 9 men, 17 women.

Inclusion criteria: Participants undergoing operation for primary varicose veins.

Exclusion criteria: None stated.


InterventionsTreatment: Tourniquet - Esmarsh bandage (n = 20).

Control: No tourniquet.

Note: in bilateral cases a tourniquet was always applied to one limb.

All patients had SFJ ligation, strip of LSV to below knee and avulsions.


Outcomes1. Mean blood loss:
Treatment: 16 ml (range 0 to 56).
Control: 107 ml (range 16 to 581); P < 0.01.

2. Weight of excised varices
(washed and dried before weighing): no differences between groups.

3. Mean time to complete avulsions (start of avulsing to dressing): no difference between groups.


NotesBlood loss estimated by weighing swabs not gown or drapes.

No significant difference for other outcome measures.


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Low riskA - Adequate

Sykes 2000

MethodsStudy design: RCT.

Method of randomisation: Sealed envelopes on day of operation.

Blinding of assessment: Unclear.

Exclusions post-randomisation: None stated.

Losses to follow-up: None stated.


ParticipantsCountry: UK.

Setting: Hospital.

No. of participants: 50.

Age mean (years): 49 (32 to 65) no tourniquet; 47 (29 to 80) tourniquet.

Gender: M:F 1:4 no tourniquet; 1:2 tourniquet.

Inclusion criteria: Unilateral SFJ ligation strip and avulsions.

Exclusion criteria: History of DVT or deep venous insufficiency, extensive anterior thigh veins, saphenopopliteal reflux.

Groups "similar" for age, sex and VV grade.


InterventionsTreatment: Sterile Loquist (Boazal cuff) inflated to 120 mm Hg.

Control: no Boazal cuff.

All patients had SFJ ligation strip using disposable Astra vasistrip and avulsions. 30° head down tilt. Cotton wool and crepe bandages applied for 48 hrs then TED stockings for 2 weeks.


OutcomesMedian blood loss:
Treatment: 0 ml.
Control: 125 ml (range 20 to 300); P < 0.01.

Mean operative time:
Treatment: 30 mins (range 11 to 47).
Control: 37 mins (range 18 to 50); P < 0.01.

Median area of bruising thigh at 7 days:
Treatment: 77 cm² (range 30 to 429).
Control: 179 cm²; P < 0.01.

Pain (VAS 0 to 10): No significant difference.

Patient activity over first week (VAS 0 to 7): No significant difference.

Cosmetic appearance at 6 weeks: No significant difference.


Notes3 patients had temporary sensory neuralgia - one in treatment group and two in control group.

Two patients had wound complications (one infection and one haematoma - both in I2.


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)Unclear riskB - Unclear

Thompson 1990

MethodsStudy design: RCT.

Method of randomisation: Method not stated but if bilateral then right leg allocated to treatment and left leg to control.

Blinding of assessment: Unclear.

Exclusions post-randomisation: None stated.

Losses to follow-up: None stated.


ParticipantsCountry: UK.

Setting: Hospital.

No. participants: 100 consecutive.
No. limbs: 121 (i.e. 21 bilaterals) only 101 limbs included in analysis.

Age mean (years): Similar for the two groups.

Gender: Male/Female ratio: 68% (37/54) of the non-tourniquet group were female compared to 57% (27/47) in the tourniquet group.

Inclusion criteria:
Referral for varicose vein surgery.

Exclusion criteria:
Vascular insufficiency, cardiovascular disease or previous DVT.

Baseline characteristics

Indications for surgery: there were no differences between the groups in terms of the main presenting complaints for surgery (cosmetic, pain, swelling or eczema, ulceration and bleeding).


InterventionsTreatment: Rhys-Davies cuff to exsanguinate leg inflated to 500 mmHg and ischaemia maintained with a pneumatic tourniquet (n = 47).

Control: no tourniquet. (n = 54).

All patients had:
SFJ ligation flush with the femoral vein and avulsions, dressed with gauze, crepe and tubigrip, overnight stay and dressings removed after three weeks.


OutcomesMean blood loss:
Treatment: 13.5 ml (range 1 to 56).
Control: 133 ml (range 5 to 430); P < 0.01

Operative time (entered theatre to completion of dressings): No significant difference.

Cosmesis (Linear Analogue Score): Improved cosmetic result in the tourniquet group assessed by both the patient and blinded observer
(P < 0.01).

Bruising (Linear Analogue Score): No significant difference.


NotesAuthors acknowledge the lack of formal cosmetic assessment of the severity of the varicose veins but felt the large numbers balanced this out.


Risk of bias

BiasAuthors' judgementSupport for judgement

Allocation concealment (selection bias)High riskC - Inadequate

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Farrands 1987Letter; not enough information.

Fischer 1991Review article.

Fischer 1994Non-randomised retrospective study.

Klenerman 1977Cohort study examining use of tourniquet in prophylactic treatment of DVT.

Lahl 2000Non-randomised study.

Lofqvist 1988Non-randomised study.

Meyer 1997Non-randomised study.

Mildner 2000Non-randomised study.

Robinson 2000Non-randomised study.

Royle 1984Non-randomised study.

Sachs 1994Non-randomised study. Description of surgical technique.

Streichenberger 1991Non-randomised study.

Tsavellas 2000Non-randomised study.

Tsavellas 2000bPostal questionnaire.

Wigger 1998Review article.

 
Table 1. Electronic bibliographic databases searched

Sources searched

1. AMED
2. Best Evidence
3. Biological Abstracts
4. CCTR (Cochrane Controlled Trials Register) ( last searched Issue 3, 2001)
5. CDSR (Cochrane Database of Systematic Reviews)
6. EMBASE
7. HMIC (Health Information Management Consortium - comprising DH-Data, the King's Fund Database, and Helmis)
8. Medline
9. NHS DARE (Database of Assessments of Reviews of Effectiveness)
10. NHS EED (Economic Evaluations Database)
11. NHS HTA (Health Technology Assessment)
12. PubMed (last 180 days)
13. Science Citation Index

 
Table 2. Other sources searched

Other sources

1. AHRQ (Agency for Healthcare Research and Quality)
2. ARIF (Aggressive Research Intelligence Facility)
3. Bandolier
4. CCOHTA (Canadian Co-ordinating Centre for Health Technology Assessment)
5. CCT (Current Controlled Trials)
6. CenterWatch Trials Register
7. ClinicalTrials.gov, NIH Clinical Trials Database
8. COIN (Department of Health Circulars)
9. CRiB (Current Research in Britain)
10. CRW (Current Research Worldwide)
11. Department of Health
12. eMC(Electronic Medicines Compendium)
13. Health Care Needs Assessment
14. Health Evidence Bulletins, Wales
15. HSTAT (Health Services/Technology Assessment Text, US National Library of Medicine)
16. INAHTA (International Network of Agencies for Health Technology Assessment) Clearinghouse
17. Index to Theses
18. ISTP (Index to Scientific and Technical Proceedings)
19. MRC (Medical Research Council) Funded Projects Database
20. National Guideline Clearinghouse
21. National Research Register
22. NCCHTA (National Co-ordinating Centre for Health Technology Assessment)
23. NHS CRD (Centre for Reviews and Dissemination), University of York
24. NHS R&D Programmes
25. OMNI (Organising Medical Networked Information)
26. POINT (Department of Health publications)
27. ReFeR (Research Findings Register)
28. ScHARR Library Catalogue
29. SIGN (Scottish Intercollegiate Guidelines Network)
30. SumSearch
31. Trent Working Group on Acute Purchasing
32. TRIP (Turning Research into Practice) Database
33. UK Official Publications
34. Uncover
35. Wessex DEC (Development and Evaluation Committee) Reports
36. West Midlands DES (Development and Evaluation Services) Reports

 
Table 3. Results - blood loss

Study IDTourniquet typeTourniquetNo tourniquet

Corbett 1989Esmarch bandage16 (range 0 to 136 ml)107 (range 16 to 581 ml)

Sykes 2000Lofquist Cuff (Boazal)0Median 125 ml (range 20 to 300 ml)

Thompson 1990Rhys-Davies Cuff13.5 (range 1 to 56 ml)133 (range 5 to 430 ml)