Varicose Veins: Evaluating Modern Treatments, With Emphasis on Powered Phlebectomy for Branch Varicosities

Frank Vandy; Thomas W Wakefield


Interv Cardiol. 2012;4(5):527-536. 

In This Article

Treatment Options for Superficial Vein Reflux

As described above, the underlying pathologic process behind the formation of varicose veins lies within both deep and superficial reflux. Conventional teaching suggests that the underlying truncal or axial reflux must be treated in order to achieve success with superficial varicosities. Currently, treatment of deep axial reflux is limited to compression therapy with stockings, good exercise (e.g., walking, biking or swimming) and intermittent leg elevation. Although techniques of autologous valve transplant, autologous valve creation and surgical bypass have been described as therapeutic options for deep system reflux, no randomized trial has shown them to be more beneficial that compression. However, in the setting of superficial GSV and SSV or perforator reflux, surgical options exist.

Historically, treatment of superficial system reflux centered on surgical disconnection of the GSV or SSV from its respective insertion into the common femoral or popliteal vein. This was followed by stripping the vein from its surrounding subcutaneous tissues to allow for removal. However, endovenous catheter treatment has made surgical stripping a procedure of the past. Endovenous ablation of the saphenous vein has become so successful that it has been assigned a grade 1B recommendation by the Society of Vascular Surgery.[15] In a large meta-analysis, both endovenous ablation and surgical stripping are statistically equivalent at 3 months with regard to efficacy and recurrence.[16–18] However, the less invasive endovascular ablation technique is less painful and allows for a quicker return to baseline function, making it superior to open surgery.[16] In a similar fashion, treatment of incompetent perforators can also be performed using endovascular catheter-based techniques.

Once a decision has been made to treat the superficial axial reflux, the timing of when to treat the associated varicose veins is controversial. Treatment of the varicosities may be done concomitantly at the time of superficial venous ablation, or alternatively, the procedure may be staged and varicosities can be removed at a later date. The primary advantage of performing a staged procedure is that treating the axial reflux of the superficial system may be sufficient in the select patient to cause regression of the smaller varicosities and resolution of all symptoms. However, in those patients who do not experience resolution, they will incur the need for an additional procedure. By contrast, performing both ablation and varicose vein phlebectomy concomitantly reduces the risk of residual varicosities,[19] but may subject some patients to a more extensive procedure than they actually need.

Currently, superficial ablation can be achieved using either a radiofrequency ablation catheter (RFA) or an endovenous laser catheter (EVLT). Randomized controlled trials have attempted to demonstrate a difference and establish superiority between the two therapies. EVLT may be more efficacious at ablating the GSV, although, with the exception of one trial by Gale et al., this has been an insignificant observational trend.[20–22] Additionally, most studies have used the first-generation RFA technology, rather than the new improved second-generation RFA catheter system. There is strong evidence that RFA is superior to EVLT in regards to postoperative pain and bruising.[23,24] However, these trials were done with earlier laser technology using an 810nm or 980nm wavelength laser. Newer catheters that use a 1470nm wavelength laser have a theoretical benefit of causing less bruising.[25] Regardless, all studies listed above show that in long-term follow-up, the immediate postoperative advantages of RFA over EVLT are not continuous, with both procedures offering equal cosmesis by 3 months.

At our institution we often use the second-generation ClosureFAST™ radiofrequency ablation catheter (VNUS ClosureFAST; VNUS Medical Technologies, CA, USA) in order to achieve great saphenous vein closure. Prior to sterile prepping the course of the great saphenous vein in visualized in real time with ultrasound and marked with permanent ink. This guides the surgeon in both insertion of the ablation catheter, as well as focal administration of tumescence anesthesia. The great saphenous vein is accessed using a Seldinger technique at the level of, or just below, the knee. A 7-French sheath is placed into the vein over a guide wire. Through this sheath, the catheter is introduced into the great saphenous vein. The catheter is 60 or 100 cm long; however the active ablation tip is 7 cm long. Under ultrasound guidance, the catheter is advanced towards the saphenofemoral junction. The tip of the catheter is highly echogenic allowing for easy visualization. To prevent inappropriate transfer of energy to the common femoral vein, the catheter is pulled back at least 2 cm from the saphenofemoral junction. Under ultrasound guidance, tumescent anesthesia is then rapidly delivered via a pump to the perivenous tissue surrounding the great saphenous vein. Liberal use of tumescence decreases pain, hydrodissects the vein away from surrounding tissues and allows an efficient transfer of energy during vein ablation. After the patient is placed in the Trendelenburg position, the vein is ablated by delivering a 20 s RFA treatment to the vein wall and then pulling the catheter back in stages. The first ablation is repeated twice due to the large diameter of the proximal great saphenous vein. At the completion of vein closure, ultrasonography is used to confirm both ablation as well as patency of the common femoral vein. A similar procedure is performed for the small saphenous vein, taking care to be at least 2 cm from the saphenopopliteal junction.