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

Modern Treatment of Branch Varicosities

Just as ablative catheter techniques have made open ligation and stripping a historic procedure, new techniques in the removal of varicose veins are challenging traditional stab phlebectomy. In the past 10 years, a more contemporary approach for the treatment of varicosities, known as transilluminated powered phlebectomy (TIPP), has evolved. While TIPP offers a relatively new technique for varicose vein removal, traditional ambulatory phlebectomy is the gold standard for varicose vein removal and does not require the use of special equipment other than a scalpel and vein hook. Varicose veins are marked preoperatively and small incisions are made along the course of the vein. A small hook is placed under the skin and the varicose vein is pulled from the subcutaneous tissues. In a sequential fashion, the vein is removed through a series of small incisions. Commercial transillumination devices exist to assist in locating the vein; however, this is not necessary in most cases. Once the proximal and distal ends of the varicose vein are reached, the vein can be ligated and allowed to retract back into the subcutaneous tissues. These small incisions are rarely closed by sutures but routinely left open or, more often, closed with steri-strips. With adequate local anesthesia, ambulatory phlebectomy can be performed in an office-based setting with or without conscious sedation.

TIPP (Trivex™, Inavein, MA, USA) is an alternative technique for the removal of varicose veins and may be especially useful for removal of larger clusters of varicosities. Theoretical advantages of TIPP include a decrease in the number of incisions, removal of veins under direct visualization and a perceived faster technique for removal of varicose veins, especially large clusters. The Trivex system is made of a central tower with controls for xenon light source, irrigation pump and resection oscillation speeds. The tower provides two handpieces, an illuminator handpiece, which is also capable of hydrodissecting surrounding tissues with tumescence irrigation, and a resectorhandpiece, which is available in a two sizes, 4.5 and 5.5 mm. During a TIPP procedure, the handpieces are introduced through small incisions placed circumferentially around clusters of varicosities (Figure 2A). Proper transillumination is achieved by passing the illuminator handpiece into the subcutaneous tissues beneath varicose veins, allowing for transillumination and visualization of these veins onto the surface of the skin (Figure 2B & C). Placement of the illuminated handpiece into the deep or superficial tissues limits transillumination. Constant administration of tumescence from the illuminator hand piece hydrodissects the vein, which also complements removal (Figure 2D). Resection is done in line with the course of the vein, resecting the varicosities furthest away first and then working towards oneself (Figure 2E). Counter tension is applied to bring the vein taught, aiding in removal. Care is taken during vein resection to avoid passing the resector hand piece too superficially, which can lead to skin tears. Conversely, placing the resector too deeply may increase postoperative paresthesias, as well as limit the ability for proper vein resection. Small 1.5-mm punch incisions are made to allow for drainage of blood and tumescence that collects in the vein tract, limiting postoperative hematoma and bruising.[25,26]

Figure 2.

Transilluminated powered phlebectomy technique. (A) Clusters of varicosities are encircled prior to placing the patient supine. Stab incisions are then made circumferentially. (B) The illuminator hand piece is passed under the skin to allow for transillumination of the underlying varicose veins. (C) Operative pictures demonstrating transillumination. (D) The illuminator hand piece dispenses tumescence anesthesia, which hydrodissects the veins, as well as causes venoconstriction, decreasing bleeding during resection. (E) The resector hand piece avulses varicosities under constant aspiration.
Courtesy of Inavein (MA, USA).

Following resection, the leg is repetitively compressed removing all blood and tumescence. Stab incisions are closed with steri-strips. We advocate for multiple layers of compression along the entire course of the ablated GSV and areas of phlebectomy comprised of heavy absorbent pads, followed by short stretch bandages and finally, an elastic stretch bandage, which is applied from the foot to the groin.

Patients are seen back in the clinic within 6–10 days. Duplex ultrasound is used to confirm ablation of the GSV as well as identify subclinical hematomas or fluid collections. At this visit, bruising is expected as it has not resolved in greater than 60% of people by this time. One must be careful in examining the patient's bruising at this stage as fading ecchymoses are often mistaken for cellulits. However, true infectious complications are quite rare and reoperation for abscess or infected fluid collection occurs in far less than 1% the population. Patients are transitioned from their compression bandages to a compression stocking of 30–40 mmHg.

Although supporters of TIPP credit shorter operative times and fewer incisions as primary benefits over ambulatory phlebectomy, opponents site a higher incidence of postoperative bruising and hematoma, paresthesias and cost without a difference in cosmetic appearance or clinical outcome. Early criticisms of TIPP centered around a high learning curve in order to avoid skin tears and excessive ecchymosis. Since first entering clinical use in 2000, there have been a limited number of studies, either prospective or retrospective, regarding the outcome of TIPP.[27] Included are three small randomized trials comparing TIPP with ambulatory phlebectomy.[28–30] All three trials documented fewer incisions with TIPP; however, the benefits of a shorter operative time were overshadowed by a steep learning curve.[31] Only one of these studies attempted to compare the impact that either procedure had on the quality of life postoperatively.[30] In this small trial, quality of life assessment was conducted during short-term follow-up at 1 and 6 weeks. Although patients in the TIPP cohort demonstrated a reduction in early quality of life, this trial was small, with only 29 patients included in the TIPP cohort.

Although current data do not establish superiority of TIPP over ambulatory phlebectomy, one must consider that these trials evaluated a new technology in its infancy. Most published literature uses a device and operative technique hindered by higher oscillation frequency (800–1200 rpm) and an approach of minimal tumescence irrigation secondary to not using a punch drainage technique. Newer generation TIPP systems and technical modifications have incorporated a lower oscillation frequency (300–500 rpm), dermal punch drainage technique, smaller and serrated resector head and a recommendation of copious administration of tumescence irrigation. With these adjustments TIPP has become less traumatic, decreasing potential complications and improving outcomes previously reported. Furthermore, it must be highlighted that all early trials treated concomitant superficial venous incompetence with an open saphenofemoral ligation and vein stripping. In performing simultaneous procedures, it is difficult to ascertain the effect of one procedure on the outcome of the other, especially when referring to postoperative pain and quality of life. As catheter-based ablation of the great saphenous vein is now recommended and the modified TIPP technique has not been evaluated in a contemporary trial, previous literature regarding the outcomes of TIPP is outdated. The decision to offer stab phlebectomy or TIPP lies within patient selection. Anecdotally, we feel patients with large clusters of varicosities are better served by TIPP, while those patients with few isolated varicosities may be best served by stab phlebectomy. In choosing either procedure, one must consider the venue in which the procedure will be performed, in an operating room or in an office-based procedure room. This decision is strongly influenced on the type of anesthesia, which will be required to provide adequate sedation and analgesia during the procedure. Traditionally, we have advocated for general anesthesia during a combined GSV ablation and extensive (greater than 20 stab incisions) phlebectomy. However, performing phlebectomy in an ambulatory setting using just local tumescence anesthesia is acceptable. Long procedural time and patient discomfort may limit the extent of phlebectomy that can be done using just tumescence anesthesia in the office setting. Therefore, when an extensive phlebectomy is anticipated in the office setting, multiple phlebectomy procedure sessions may be required to achieve acceptable results. In select patients who have required extensive phlebectomy, but the risk of general anesthesia is high, we have found success in conscious sedation and local tumescence anesthesia.

When performing TIPP for extensive varicosities, we use a similar strategy with regards to anesthesia; the majority of patients undergo general or spinal anesthesia. Unlike stab phlebectomy, consideration must be given to the discomfort of passing the illuminator and resector hand pieces through the subcutaneous tissues. In the select patient, we have found that conscious sedation with copious amounts of tumescence anesthesia is possible. The applicability of office-based TIPP procedures has been recently demonstrated by Spitz who published his single-center office-based TIPP experience.[32] This small series highlights 36 patients who underwent a TIPP procedure in the office setting using only tumescence anesthesia. Patients in this series were thin (mean BMI: 25 kg/m2) and young (mean age: 58.8 years), with the majority having only CEAP-2 disease severity (64%). Furthermore, the majority of the cohort only had one cluster of veins to remove. At 3 months there was no reportable hematoma, deep venous thrombosis or extended paresthesias. Although ambulatory TIPP may not be possible for all patients, Spitz has demonstrated that with careful patient selection, the future of TIPP includes the office venue.

To date, the largest published TIPP experience includes 339 patients, of which 88% required just 20 or fewer incisions.[33] At 12 weeks, there were no significant hematomas and no recurrent varicose veins. Patient satisfaction with clinical outcome was stated at 99.7%. Despite good reported subjective outcomes, this large case series did not address postoperative paresthesias of the operative leg, which is often cited as one of the largest disadvantages of TIPP. The incidence of cutaneous nerve injury causing paresthesias with TIPP has been reported as high as 38%.[26,27] However, it is important to consider that stab phlebectomy can also cause postoperative paresthesias, with an incidence as high as 25% in one series.[29] Furthermore, as TIPP is often performed simultaneously with GSV ablation, one must consider the paresthesias that result from the ablative catheter, independent of phlebectomy. Estimated rates of paresthesias following RFA of the GSV range from 2.8 to 33%.[34] In our practice, patients who have undergone an RFA treatment of the GSV in the past 12 months report a 12.3% incidence in paresthesias postoperatively (14 out of 114). This is most likely, in part, secondary to transfer of energy from the ablative catheter to the saphenous and sural nerves. In our experience with TIPP during the same time period, we report a 26% incidence of postoperative paresthesias (34 out of 131). However, as most of these patients also underwent a simultaneous RFA procedure, it is difficult to accurately ascertain the incidence of paresthesias attributable to the TIPP procedure. In addition, in our experience, the incidence is lower using the smaller 4.5-mm head rather than the larger 5.5-mm head (21 vs 31%). Nonetheless, in those patients who maintained regular postoperative follow-up or who were compliant with a telephone interview, resolution of paresthesias occurred in 30% of the cases, usually within 6 months. Furthermore, only one patient thought the paresthesias were bothersome to the point of regretting surgery. Importantly, using the TIPP approach rather than traditional stab phlebectomy, the number of incisions per procedure has decreased in our practice from 31 to eight.