47  Endoluminal Ablation of Varicose Veins	495

C.  It increases the efficacy of treatment by compressing the vein and causing vasospasm. D.  It is associated with a small increase in nerve injury because of the increase in tissue

pressure.

Question 8

Which of the following is/are characteristic of EVLT?

A.  EVLT is more effective than high ligation and stripping for treatment of VV.

B.  The ideal position of the catheter tip should be right at the SFJ to accomplish complete thrombosis of the dilated GSV and prevent recurrence.

C.  here is no significant difference in the effectiveness of the different laser wavelengths (810, 980, 1,320, and 1,470 nm) used.

D.  DVT can occur from extension of thrombosis into the deep system. Most clots resolve within 3 months and do not lead to pulmonary embolization (PE).

Question 9

The statement(s) that is/are correct about RFA is (are):

A.  RFA relies on direct contact of the catheter with vessel wall.

B.  Most studies on RFA were performed using the VNUS Closure device with a continuous catheter pullback technique.

C.  Body Mass Index (BMI) and catheter pullback rate are predictors of failure of RFA. D.  The RFA probe typically heats the vein wall to a temperature of 250°C for successful

obliteration.

The patient presents for follow up one week after the procedure. DU shows obliteration of the GSV and a competent proximal GSV (Fig. 47.3). There is no evidence of DVT. The large dilated vessels did not show however complete resolution externally. He returns 3 months later asking for removal of the residual varices. You proceed with stab avulsions in the operating room resulting in complete resolution of the VV.

Fig. 47.3  DU showing complete obliteration of the treated segment (white arrow). The proximal GSV is patent (red arrow) and there is no extension of the thrombosis into the deep system

496	C.I.N.O. Chaar and J. Indes

47.1  Commentary

VV are visible dilatation involving predominantly the two major superficial veins of the lower extremities: the GSV and the SSV. It is a common disease in adults affecting 15% of men and 25% of women.1 [Q 2-A: F] Incidence increases with age and with positive family history. The ratio of progesterone to estrogen seems to affect venous insufficiency. Most women have increase in symptoms during pregnancy. [Q 2-B: T] Patient with varicose veins seek treatment mostly for cosmetic reasons. [Q 2-C: F] Some patients present with pain especially at the end of the day after standing for long periods of time and causing excess engorgement of their varicosities. They may also complain of leg cramping and a sensation of heaviness. Lower extremity swelling is sometimes associated with VV. Overlying skin changes may occur and consist of brown discoloration, lipodermatosclerosis, or frank ulceration. Venous ulcers are typically located over the malleoli while arterial ulcers arise on the toes and the metatarsal heads. [Q 2-D: F]

Compression stocking is the first line treatment for VV despite the lack of level 1 evidence as recently reviewed by Palfreyman and Michaels.2 [Q 3-E: F] Stocking increase veno-muscular efficiency, and reduce venous reflux and leg edema. [Q 3-A: T] The classification of stockings is based on the level of compression applied. Class 1 has the lowest sub-bandage pressure between 14 and 21 mmHg. [Q 3-B: T] The classification is not standardized and varies between different countries. [Q 3-C: F] In the United States, Class 1, 2, and 3 stockings exert 15–20, 20–30, and 30–40 mmHg respectively. There is no consensus whether thigh or knee length is better. The class prescribed depends on the size and shape of the leg as well as the level of activity of the patient. Poorly fitted stockings can cause tissue necrosis and potentially amputation especially in patients with arterial insufficiency. [Q 3-D: F] It is safer to measure an ABI on elderly patients before prescribing stockings.2

Surgical treatment of VV underwent a dramatic evolution with the introduction of endoluminal therapy. The traditional procedure is ligation and stripping of the involved vein that has been practiced for over 100 years.3 Newer technology using laser or radiofrequency ablation can achieve the same goal using often a single small incision. The shortterm effectiveness of endoluminal therapy seems to be comparable to open ligation and stripping. However, long term results and safety profile are still under investigation.

Current surgical options include high ligation and stripping of the refluxing vein, as well as ablation with RFA or EVLT. [Q 6-C: F] High ligation alone is not sufficient and predisposes patients to recurrence as shown by the group from Gloucestershire. [Q 6-A: T] They followed100patientsthatunderwenthighligationwithandwithoutroutinestrippingofthe GSV. Patients undergoing high ligation only had significantly higher rates of recurrence at 5 years4 and 11 years.5 O’Hare etal. examined surgical treatment of SSV varicosities in 234 legs in 219 patients. Patients that had stripping in addition to SPJ ligation had significantly lower incidence of SPJ reflux at 1 year (13%) as compared to patients who had isolated SPJ ligation (32%). The complication rate was comparable between the two groups.6 [Q 6-B: F] High ligation and stripping is very effective for the treatment of VV. The improvement in quality of life is remarkable and comparable to the improvement in quality of life of patients with billiary colic who undergo laparoscopic cholecystectomy.7 [Q 6-D: T]

47  Endoluminal Ablation of Varicose Veins	497

Tumescent anesthesia is the injection of a solution of local anesthetic around the VV to be treated with an endoluminal modality. [Q7-A: F] The injection is done under DU guidance to avoid inadvertent injection into the vein or injury to adjacent nerves or arteries. Large volume of fluid should be used especially with the SSV to separate it from the sural nerve. The injection facilitates the dissection of the vein from the surrounding soft tissue. It also protects neighboring structures and overlying skin from thermal injury by acting as a heat sink. [Q7-B: T; 7-D: F] In addition to providing prolonged analgesia lasting to the postoperative period, tumescence compresses the vein and causes it to spasm making the delivery of thermal energy more effective.8 [Q7-C: T]

EVLT relies on the introduction of a catheter into the dilated vein under DU guidance. The tip of the catheter is a laser fiber placed 1.5–2.0 cm distal to the junction of the superficial vein with the deep venous system. [Q8-B: F] After confirmation of the location of the tip, energy is delivered to denature collagen in the vessel wall and denude the endothelium. Eventually, the vessel contracts and gets obliterated by fibrosis. The optimal wavelengthofthelaserusedisasubjectofongoingresearch.Kabnickcomparedthewavelength of 810 nm and 980 nm in 51 patients. His results showed less pain using the 980 nm wavelength.9 More recent reports have looked at a higher wavelength (1,470 nm) that is preferentially absorbed by water as opposed to hemoglobin. It may better target the vessel wall and allow closure of the veins with less total energy delivered and consequently less pain and ecchymosis.10 [Q8-C: F]

Rasmussen et al. conducted a randomized trial comparing EVLT of GSV with high ligation and stripping. Both procedures were performed in an office setting with tumescent anesthesia. The success rates and the complication rates for the two procedures were comparable. The only difference was that patients undergoing high ligation and stripping had increased postoperative pain and bruising.11 Darwood et al. showed similar results in 118 patients. EVLT with SFJ ligation and stripping had comparable efficacy in abolishing reflux and had comparable safety profile. [Q8-A: F] Patients returned to normal activity and resumed work earlier after EVLT. The authors did not do a cost analysis but postulated that earlier return to normal activity (5 days earlier) and work (13 days earlier) might confer a socioeconomic advantage to EVLT.12

Endovenous techniques for treatment of VV can be complicated by DVT and occasionally PE. Thus, most specialists recommend follow up DU within a week of the procedure. The imaging can document success of the procedure and detect the presence of DVT resulting from clot extension into the deep system. To avoid this complication, most vascular surgeonsleave the proximal 1.5–2.0cmof the GSVuntreated.Theincidence of DVT is less than 1% in most series with occasional PEs.13 [Q8-D: T] The use of perioperative DVT prophylaxis with heparin products may help decrease the incidence of thrombosis.

The application of RFA is analogous to EVLT. A catheter is introduced in the dilated veins with an electrode extending from the tip. A generator delivers the radiofrequency energy necessary to keep the vein wall heated to 85–120°C. [Q9-D: F] The catheter contains a feedback mechanism that evaluates vein wall impedance and adjusts the energy delivered to keep the temperature at a set target. Heat causes contraction of the vessel wall and complete obliteration. [Q9-A: T] Emptying the vein from blood by putting the patient in Trendelenburg and compression are crucial since the effectiveness of the treatment relies on the contact with the vein wall. The first catheter used for RFA is the VNUS closure

498	C.I.N.O. Chaar and J. Indes

system (VNUS Medical Technologies Inc., San Jose, CA, USA). It requires a continuous pullback technique and it is the catheter used in most published papers. [Q9-B: T] In 2006, VNUS introduced the ClosureFast segmental ablation catheter. The new catheter allows RFAofa7cmsegmentofsuperficialveinin20swithoutcontinuouspull-back.Theadvan- tage is a faster and more consistent ablation.14 Merchant et al. reported the largest series of patients undergoing RFA. They followed 1,006 patients (1,222 limbs) up to 5 years and reported occlusion rate of 87.2% at the end of the follow up period. Linear regression showed that BMI and speed of catheter pullback were predictors of failure.15 [Q9-C: T]

References

 1. Callam MJ. Epidemiology of varicose veins. Br J Surg. 1994;81(2):167-173.

 2. Palfreyman SJ, Michaels JA. A systematic review of compression hosiery for uncomplicated varicose veins. Phlebology. 2009;24(Suppl 1):13-33.

 3. Perkins JM. Standard varicose vein surgery. Phlebology. 2009;24(Suppl 1):34-41.

 4. Dwerryhouse S, Davies B, Harradine K, Earnshaw JJ. Stripping the long saphenous vein reduces the rate of reoperation for recurrent varicose veins: five-year results of a randomized trial. J Vasc Surg. 1999;29(4):589-592.

 5. Winterborn RJ, Foy C, Earnshaw JJ. Causes of varicose vein recurrence: late results of a randomized controlled trial of stripping the long saphenous vein. J Vasc Surg. 2004;40(4):634639.

 6. O’Hare JL, Vandenbroeck CP, Whitman B, et al. A prospective evaluation of the outcome after small saphenous varicose vein surgery with one-year follow-up. J Vasc Surg. 2008;48(3):669-673. discussion 674.

 7. Sam RC, Darvall KA, Adam DJ, Silverman SH, Bradbury AW. A comparison of the changes in generic quality of life after superficial venous surgery with those after laparoscopic cholecystectomy. J Vasc Surg. 2006;44(3):606-610.

 8. Bhayani R, Lippitz J. Varicose veins. Dis Mon. 2009;55(4):212-222.

 9. Kabnick LS. Outcome of different endovenous laser wavelengths for great saphenous vein ablation. J Vasc Surg. 2006;43(1):88-93.

10.Almeida J, Mackay E, Javier J, Mauriello J, Raines J. Saphenous laser ablation at 1470 nm targets the vein wall, not blood. Vasc Endovascular Surg. 2009;43(5):467-472.

11.Rasmussen LH, Bjoern L, Lawaetz M, Blemings A, Lawaetz B, Eklof B. Randomized trial comparing endovenous laser ablation of the great saphenous vein with high ligation and stripping in patients with varicose veins: Short-term results. J Vasc Surg. 2007;46(2):308-315.

12.Darwood RJ, Theivacumar N, Dellagrammaticas D, Mavor AI, Gough MJ. Randomized clinical trial comparing endovenous laser ablation with surgery for the treatment of primary great saphenous varicose veins. Br J Surg. 2008;95(3):294-301.

13.Mozes G, Kalra M, Carmo M, Swenson L, Gloviczki P. Extension of saphenous thrombus into the femoral vein: A potential complication of new endovenous ablation techniques. J Vasc Surg. 2005;41(1):130-135.

14.GohelMS,DaviesAH.Radiofrequencyablationforuncomplicatedvaricoseveins.Phlebology. 2009;24(Suppl 1):42-49.

15.Merchant RF, Pichot O, Closure Study Group. Long-term outcomes of endovenous radiofrequency obliteration of saphenous reflux as a treatment for superficial venous insufficiency. J Vasc Surg. 2005;42(3):502-509. discussion 509.