Endovenous Laser Treatment of Varicose Veins

A Single-Center Experience of Anterior Accessory Saphenous Vein Endothermal Ablation Demonstrates Safety and Efficacy

OBJECTIVE

Endothermal ablation is well established for the treatment of the great and small saphenous veins. Data are lacking for treatment of the Anterior Accessory Saphenous Vein (AASV). The purpose of this study is to evaluate the safety and efficacy of AASV treatment using endothermal ablation.

METHODS

This was a retrospective review of 314 limbs at a single academic institution from 2016-2018 using the institutional Vascular Quality Initiative database. All limbs had documented AASV reflux. Baseline characteristics were evaluated including age, sex, ethnicity, CEAP (clinical, etiology, anatomy, pathophysiology) classification, Venous Clinical Severity Score (VCSS), and vein diameter. Outcomes relating to procedure safety and efficacy included treatment modality and length, successful ablation on post-operative imaging, post-procedural clinical outcomes, incidence of endothermal heat induced thrombosis (EHIT), and any post-procedural complication.

RESULTS

A total of 314 consecutive limbs were identified from 2016-2018. Pre-procedure VCSS scores were available for 312 limbs and averaged 6.13 ± 3.33. History of varicose veins were reported in all limbs with 49.4% (n=155) having previously undergone a procedure. The most common presenting symptom was mild edema in 52.5% (n=165). Vein diameter and assessment of reflux were obtained by venous duplex ultrasound (DUS). The largest AASV diameter was available for 304 limbs, averaging 7.93 ± 2.69 mm. Treatment modalities included radiofrequency ablation (RFA) in 59.2% (n=186), endovenous laser ablation (EVLA) in 37.9% (n=119), and isolated microphlebectomy in 2.9% (n=9). 38.5% (N=121) of limbs underwent concomitant microphlebectomy at the time of EVLA. Total treatment length was obtained in 297 limbs, averaging 23.0 cm ± 12.0. Post-operatively, 94.6% (n=297) of limbs were prescribed compression stockings. Post-operative DUS was performed in 312 limbs, revealing successful ablation in 96.5% (n=303) with 2 limbs (0.6%) developing an EHIT, both treated with therapeutic enoxaparin for one week. Repeat DUS revealed thrombus resolution in one limb, while the other patient was lost to follow-up. VCSS scores post-procedure were available for 145 limbs and averaged 4.45 ± 2.31. This was a statistically significant decrease from pre-procedure VCSS scores (p<0.01). Average duration of follow-up was 2.2 years, with two limbs lost to follow-up. Of the 9 limbs (3.5%) whose initial procedure failed, 5 (56%) were treated using RFA and 4 (44%) were treated using EVLA. There were no other post-operative complications.

CONCLUSION

Our experience over a three-year period for treating the AASV shows it to be safe and effective in a broad range of disease severity with an improvement in VCSS and a low incidence of EHIT. Additionally, RFA and EVLA exhibit similar treatment efficacy. Long-term follow-up data are needed.

Evaluation of the efficacy of foam sclerosant after addition of glycerine on human great saphenous vein: histological and immunohistochemical study

INTRODUCTION

Several treatment modalities have been postulated to improve the efficacy of varicose vein treatment. Addition of glycerine to the sclerosing material has been documented to increase its viscosity and subsequently prolong the duration of stability, in addition to the direct sclerosing effect of glycerine. This histological and immunohistochemical study investigated the efficacy of addition of glycerine 72% to sclerotherapy on the human varicose vein.

METHODS

After surgical stripping of great saphenous veins, three equal segments were resected between two clamps. Specimen 1 was injected with saline only, specimen 2 was exposed to foam sclerosant 2%, and specimen 3 was exposed to a mixture of foam sclerosant 2% and glycerine 72%. All segments were left for 5min. Vein segments were then processed for histological and immunohistochemical study.

RESULTS

Microscopically, haematoxylin and eosin-stained specimen 1 showed endothelial swelling, cytoplasmic eosinophilia and pyknotic nuclei. The media showed sarcoplasm vacuolisation and necrosis. Specimen 3 showed hypereosinophilic sarcoplasm of the smooth muscle fibres. Oedema was less evident, with a relative decrease in the thickness of the wall compared with specimen 2. Immunohistochemically, the expression of smooth muscle actin was weak in specimen 3 compared with specimens 1 and 2. Expression of CD31 antibody was much reduced in specimen 2 which showed conserved islands of endothelial cells. By contrast, there was a complete loss of endothelial cells in specimen 3.

CONCLUSION

Addition of glycerine 72% to foam sclerosant has a more damaging effect on human vein wall.

Venous Ablation

Chronic venous insufficiency is a common and a highly prevalent vascular disorder, that occurs as a result of venous reflux owing to defective venous valves, which in turn causes venous hypertension with significant symptom burden that can interfere with quality of life. Therapeutic strategy involves lowering the venous pressure by lifestyle changes, compression therapy, and conventional catheter-based thermal ablation and novel nonthermal, nontumescent techniques of ablating the affected veins.

Endovenous Management of Varicose Veins

Varicose veins are a very common condition and have been the subject of a recent proliferation of treatment modalities. The advent of the endovenous treatment era has led to a confusing array of different techniques that can be daunting when making the transition from traditional surgery. All modalities offer excellent results in the right situation, and each has its own treatment profile. Thermal ablation techniques have matured and have a reassuring and reliable outcome, but the arrival of nonthermal techniques has delivered further options for both patient and surgeon. This article provides an overview of the different treatment devices and modalities available to the modern superficial vein surgeon and details the currently available evidence and summation analysis to help surgeons to make an appropriate treatment choice for their patients.

The advent of non-thermal, non-tumescent techniques for treatment of varicose veins

Varicose veins are common and their management has undergone a number of changes over the years. Surgery has been the traditional treatment option, but towards the 21st century, new endovenous thermal ablation techniques, namely, radiofrequency ablation and endovenous laser ablation, were introduced which have revolutionised the way varicose veins are treated. These minimally invasive techniques are associated with earlier return to normal activity and less pain, as well as enabling procedures to be carried out as day cases. They are, however, also known to cause a number of side-effects and involve infiltration of tumescent fluid which can cause discomfort. Non-thermal, non-tumescent methods are believed to be the answer to these unwelcome effects. Ultrasound-guided foam sclerotherapy is one such non-thermal, non-tumescent method and, despite a possible lower occlusion, has been shown to improve the quality of life of patients. The early results of two recently launched non-thermal, non-tumescent methods, mechanochemical ablation and cyanoacrylate glue, are promising and are discussed.

Endovenous laser treatment (EVLT) for the saphenous reflux and varicose veins: a follow-up study

PURPOSE

The aim of this study is to report our experience about endovenous laser treatment (EVLT) for lower extremity varices in our centre which was followed by ultrasonography during the 6-month period.

METHODS

During a 1-year period, 46 patients who were treated by EVLT with the 940-nm diode laser for venous insufficiency enrolled in the study. The diagnosis of greater saphenous vein (GSV) incompetence with reflux was made by clinical evaluation and duplex Doppler examinations. Clinical outcomes, complications and duplex ultrasound of the GSV were assessed within 1 week, 1 month, 3 months and 6 months, after the endovascular laser treatment.

RESULTS

The mean age of our patients was 44 ± 11 years (24-70), and among them, 23 (50%) were male. Improvement in visible varicosity was seen in 39 (84.8%) patients after 6 months (P value = 0.011). The baseline mean diameter of GSV was 4.9 ± 1.6 mm and it dropped to 3.5 ± 1.3 after 6 months (P < 0.0001). After 6 months, 95.7% of our patients were satisfied and recommended this procedure to others.

CONCLUSIONS

Endovascular laser ablation seems to be a safe and effective method for the treatment of lower limb varices.

Treatment of primary varicose veins has changed with the introduction of new techniques

New technologies have produced a revolution in primary varicose vein treatments. Duplex ultrasound is now used for preoperative diagnosis, postoperative surveillance, and during many procedures. Ultrasound has also altered our understanding of the pathophysiology of chronic venous disease. Laser and radiofrequency saphenous ablations are common. Classic techniques, such as sclerotherapy, high ligation, stripping, and phlebectomy, have been improved. Magnetic resonance venography, computed tomographic venography, and intravascular ultrasound have improved diagnostic capabilities. New strategies like ambulatory selective varices ablation under local anesthesia (ASVAL) and conservative hemodynamic treatment for chronic venous insufficiency (CHIVA) raise important questions about how to manage these patients.

The surgical anatomy of the small saphenous vein and adjacent nerves in relation to endovenous thermal ablation

BACKGROUND

Thermal damage to peripheral nerves is a known complication of endovenous thermal ablation (EVA) of the small saphenous vein (SSV). Therefore, the main objective of this anatomic study was to define a safe zone in the lower leg where EVA of the SSV can be performed safely.

METHODS

The anatomy of the SSV and adjacent nerves was studied in 20 embalmed human specimens. The absolute distances between the SSV and the sural nerve (SN) (closest/nearest branch) were measured over the complete length of the leg (>120 data points per leg), and the presence of the interlaying deep fascia was mapped. The distance between the SSV and the tibial nerve (TN) and the common peroneal nerve was assessed. A new analysis method, computer-assisted surgical anatomy mapping, was used to visualize the gathered data.

RESULTS

The distance between the SSV and the SN was highly variable. In the proximal one-third of the lower leg, the distance between the vein and the nerve was <5 mm in 70% of the legs. In 95%, the deep fascia was present between the SSV and the SN. In the distal two-thirds of the lower leg, the distance between the vein and the nerve was <5 mm in 90% of the legs. The deep fascia was present between both structures in 15%. In 19 legs, the SN partially ran beneath the deep fascia. In the saphenopopliteal region, the average shortest distance between the SSV and the TN was 4.4 mm. In 20%, the distance was <1 mm. The average, shortest distance between the SSV and the common peroneal nerve was 14.2 mm. The distance was <1 mm in one leg.

CONCLUSIONS

At the saphenopopliteal region, the TN is at risk during EVA. In the distal two-thirds of the lower leg, the SN is at risk for (thermal) damage due to the small distance to the SSV and the absence of the deep fascia between both structures. The proximal one-third of the lower leg is the optimal region for EVA of the SSV to avoid nerve damage; the fascia between the SSV and the SN is a natural barrier in this region that could preclude (thermal) damage to the nerve.

Evolution of an Endovenous Laser Ablation Practice for Varicose Veins

Objective:

We aimed to assess the evolution of an endovenous laser ablation (EVLA) practice in the management of varicose veins in a university teaching hospital vascular surgical unit, over five years.

Methods:

This was a retrospective review of a prospectively collected database of patients undergoing EVLA for great saphenous vein incompetence and followed up for a year. For inter- and intragroup comparison, patients were divided into three groups: group A: endovenous access generally established at the perigenicular level ( n = 105); group B: when practice changed to gain access at lowest point of demonstrable reflux ( n = 70); and group C: when tumescence delivery changed from manual injections to delivery via peristaltic pump ( n = 49). Outcomes including pain scores, time taken to return to normal functioning, quality of life (QoL), venous clinical severity scores (VCSS) and complication rates were evaluated.

Results:

Intergroup analysis: increase in the length of vein treated and laser density delivered was observed over time, even as median procedure duration decreased ( P < 0.001). An increase in sensory disturbance was noticed in group C ( P = 0.047) while better Aberdeen Varicose Vein Questionnaire (AVVQ) ( P = 0.004), SF-36® physical domains ( P < 0.05) and patient satisfaction with treatment ( P = 0.025) were recorded in the same group at 52 weeks. No significant difference was observed in technical failure, pain scores, return to normal functioning, VCSS and recurrence rates post-intervention. Intragroup analysis: QoL measures (AVVQ, SF-36®, EQ-5D) and VCSS scores demonstrated significant improvement at 12 and 52 weeks compared with baseline ( P < 0.05).

Conclusions:

Increase in length of vein treated and energy delivery seems to improve short-term outcomes; however, operators need to be wary of a possible concurrent increase in paraesthetic complications.

Endovenous laser ablation with 980-nm diode laser: early and midterm results

OBJECTIVE

Endovenous laser ablation (EVLA) is an efficient method to treat incompetent great saphenous veins (GSV) with high occlusion rates. The aim of this prospective study is to demonstrate the treatment outcomes of EVLA of incompetent GSV with a 980-nm diode laser in an ambulatory setting.

BACKGROUND DATA

EVLA of the incompetent GSV with a 980-nm diode laser appears to be an extremely safe technique. There are several treatment alternatives available. Among the emerging techniques, EVLA is one of the most promising.

METHODS

Ninety eight patients (103 limbs) with symptomatic varicose veins secondary to GSV insufficiency treated with 980-nm EVLA were prospectively studied. In all patients, laser energy was administered with constant pullback of fiberoptic laser catheter under tumescent anesthesia. The patients were assessed and followed by clinical examination and venous duplex ultrasonography. Pain scores of the patients from discharge to their first follow-up visit (7 days) were recorded by using visual analog scale (VAS). Patient satisfaction was assessed and recorded at 6 month follow-up.

RESULTS

All patients tolerated EVLA procedure well, and were discharged from hospital on the same day with ablation procedure. The overall success rate was 97.5% in 98 patients. Mean length of measured treated vein segment was 29.93±6.36 cm. Mean applied total energy was 2006.24±480.16 J. Major complications such as deep vein thrombosis and skin burns were not seen. Most of the complications were minor and improved quickly. All patients returned to daily activities within 2 days.

CONCLUSIONS

EVLA of the GSV insufficiency using 980-nm diode laser is an effective and safe technique with a high patient satisfaction rate. The advantages of the procedure are that it is performed as an outpatient procedure, provides early mobilization, causes minimal cessation of daily activities, and avoids classic surgical complications.

Combination technique of tumescent anesthesia during endovenous laser therapy of saphenous vein insufficiency

OBJECTIVE

This study aimed at evaluating the efficiency of applying tumescent anesthesia before an ablation procedure and continuously during endovenous laser treatment (EVLT) (combined tumescent technique) of saphenous vein insufficiency to reduce the patients pain and discomfort.

METHODS

Twenty-five patients with 31 duplex-confirmed great saphenous vein insufficiency underwent endovenous laser (940 nm) varicose vein treatment between December 2009 and April 2010. The patients were randomized in two groups. In group A (15 patients) tumescent anesthesia was used before the ablation procedure and in group B (10 patients) tumescent anesthesia was used before and continuously during the procedure. Patients were scheduled for a three-day examination after EVLT to assess the level of pain experienced.

RESULTS

According to the statistic analysis we observed that the mean level of pain score for the patients given classical tumescent anesthesia showed a higher level (P=0.003) compared with the patients given tumescent anesthesia in the combined procedure.

CONCLUSION

Combination technique of administering tumescent anesthesia before ablation and continuously during the EVLT procedure may be an alternative way to reduce the patient's peroperative pain and discomfort.