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Percutaneous Management of Varicose Veins
Epidemiology
Chronic venous disease (CVD), which includes varicose and spider veins, is extraordinarily common: approximately 22%–29% of the adult Western population has varicose veins and 5% has more advanced CVD findings. Many patients with CVD have symptoms that may interfere with daily living such as heaviness, aching, swelling, throbbing, and itching (often referred to as HASTI symptoms). More advanced venous disease is associated with skin damage resulting from chronic venous hypertension such as eczema, edema, hyperpigmentation, lipodermatosclerosis, and venous leg ulcers, with at least 20,000 new ulcers developing in the United States each year. Venous disease is the most common cause of lower extremity ulceration with a prevalence of about 1% in the United States, with an increased frequency in the elderly.
Evaluation
The initial examination of patients suspected of having CVD should include visual and tactile inspection of the legs, pedal pulse evaluation, and duplex ultrasound (DUS). The goal of DUS evaluation is to map out all the incompetent superficial and deep venous pathways responsible for the patient’s condition, as well as assessing the adequacy of the deep venous system including assessment for postthrombotic and nonthrombotic obstruction. Such a map is necessary to determine the best treatment plan. Discussing the goals of treatment with the patient to establish expectations is crucial in venous disease because many patients with CVD also seek to rid their legs of spider and varicose veins for aesthetic reasons.
Treatment Strategies
Initial treatment includes graduated compression and wound care, but long-term control is best accomplished with treatment of the underlying venous disease. Saphenous vein ablation is indicated for elimination of saphenous reflux in patients where this reflux is demonstrated to be causally related to varicose veins, pain, advanced skin injury (lipodermatosclerosis), and prior or current venous leg ulceration. Evidence has demonstrated the value of ablation in improving patient’s quality of life over graduated compression stockings for patients with C2 disease (CEAP classification based on Clinical, Etiology, Anatomy, Pathophysiology). It has also demonstrated to result in lengthening the time to recurrent ulceration in patients with venous leg ulcers and more recently in facilitating venous leg ulcer healing.
Treatment of tributaries is generally selected on the basis of vein size and physician preference because only a limited amount of high quality evidence exists to guide choices. For small veins, (spider, reticular, and small varicose veins) sclerotherapy using liquid and foamed sclerosants is typically used. For larger varicose veins, visual and ultrasound guided sclerotherapy and microphlebectomy (also known as stab or ambulatory phlebectomy, and requiring only tumescent anesthetic) are typically employed. A transilluminated powered phlebectomy device using a subcutaneous light, irrigation, and a rotating resector is available (TRIVEX, LeMaitre Vascular, Burlington, MA), but requires a regional or general anesthetic and is not widely used.
Saphenous vein ablation and phlebectomy are often performed together for convenience and based on patient preference. Concurrent ablation and phlebectomy has been associated with increased quality of life as compared with ablation alone or ablation with delayed phlebectomy. However, there is a low increase in the risk of deep venous thrombosis (DVT) with concurrent phlebectomy or sclerotherapy and some patients may not require subsequent tributary treatment.
Saphenous Ablation
Ablation using either endovenous laser treatment (EVLT) or radiofrequency ablation (RFA) quickly became the standard approach to ablate the great, small, or anterior accessory saphenous veins (GSV, SSV, and AA-GSV), replacing junctional ligation and stripping in the United States after their introduction. Both forms of thermal ablation result in high rates of successful ablation and low complication rates, with similar outcomes using patient important measures in randomized studies. A first-generation RFA tool for saphenous ablation was introduced in 1999 and a second-generation device, ClosureFast RF (Medtronic, Minneapolis, MN) in 2007. The ClosureFast RF system induces thermal injury to the vein wall over fixed 7-cm segments while the catheter is withdrawn through the target vein. Dr. Boné first reported on delivery of endoluminal laser energy in 1999. Subsequently, a method for treating the entire incompetent vein segment was described by Min and Navarro. Currently laser generators utilizing various wavelengths including 810, 940, 980, 1064, 1320, and 1470 nm are used with a variety of fiber types including bare, radial emitting, and jacketed tips. Although the mechanism of action of ablation using laser energy delivered by catheters is debated, permanent occlusion is almost universal utilizing any of the approaches, with the 810–1064-nm wavelength laser considered to be hemoglobin specific, and the 1320–1470-nm lasers more water specific. The laser effect is most likely a combination of direct heat injury to the vein wall, resulting in destruction of the endothelium; collagen denaturation of the media; and fibrotic and thrombotic occlusions of the vein; as well as direct heat injury to the blood, leading to steam bubbles and secondary injury to the intima. Low-quality evidence suggests an ability to use a lower amount of energy to successfully close a vein with fewer side effects when using water-specific wavelengths. Additional low-quality evidence supports that the use of radial finders (outside the United States) and jacketed fibers when compared with bare fibers is associated with less pain and bruising.
Although thermal ablation has resulted in high degrees of successful vein closure and patient symptom improvement, nonthermal nontumescent (NTNT) options for vein closure have been developed to reduce the mild intra- and postprocedure-related pain and theoretical thermal risk to perivenous nerves associated with thermal approaches. These recently approved techniques include cyanoacrylate glue ablation (VenaSeal, Medtronic, Minneapolis, MN [approved by the US Food and Drug Administration {FDA}] and VariClose, Biolas, Ankara, Turkey [not FDA approved]), mechanochemical ablation (ClariVein, Vascular Insights, Quincy, MA [FDA approved for infusion of an intravascular drug]), and polidocanol injectable foam (Varithena, BTG, West Conshohocken, PA [FDA approved]). Each of the NTNT procedures have demonstrated technical success and quality of life improvement similar to that seen with thermal ablation. Physician-compounded foam is widely used internationally as a saphenous ablation method. However, this is off-label use in the United States. Investigational devices not extensively evaluated and not FDA approved include steam ablation (CermaVein, Archamps, France), balloon occlusion sclerotherapy (KAVS, Tel Aviv, Israel) and V-Block, a combined mechanical ligation device combined with catheter sclerotherapy (VVT Medical Ltd., Kfar Saba, Israel).
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