34. Great Saphenous Vein Endovenous Treatment

Bernadette Aulivola¹

(1)

Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Loyola University Health System, Stritch School of Medicine, Maywood, IL, USA

Bernadette Aulivola

Email: baulivola@lumc.edu

Keywords

Great saphenous veinGSVSaphenous insufficiencyVenous refluxEndovenous ablationEndovenous laser ablationEVLARadiofrequency ablationRFAAdhesive closureMechanicochemical ablation

General Principles

Treatment methods for addressing great saphenous venous insufficiency have evolved over the past several decades. The standard treatment technique for saphenous insufficiency for many years involved surgical ligation at the saphenofemoral junction (SFJ) and stripping of the great saphenous vein (GSV). This approach was noted to be associated with prolonged recovery time and high recurrence rates of 25% at 5 years [1]. Endovenous ablation is now the primary mode of treatment for symptomatic insufficiency of the great saphenous vein; saphenous vein ligation and stripping are rarely performed.

Multiple modalities are available for saphenous ablation. Endovenous techniques have been available since the late 1990s and have undergone multiple improvements since that time. Earlier endovenous ablation techniques included endovenous laser ablation (EVLA) and radiofrequency ablation (RFA), both of which use thermal energy sources to cause venous fibrosis, sclerosis, and thrombosis of the treated vein. EVLA and RFA are equally effective and safe in treating GSV reflux. As compared with GSV stripping, thermal ablation is associated with reduced recovery time and less periprocedural pain, discomfort, and morbidity. Other techniques used for saphenous ablation that avoid the need for tumescent anesthesia are adhesive closure using n-butyl cyanoacrylate (VenaSeal™ closure system, Medtronic, Minneapolis MN) and mechanicochemical ablation (ClariVein®, Merit Medical, South Jordan, UT). Such non-thermal ablation techniques accomplish venous ablation quickly with minimal patient discomfort and quick recovery time. All techniques have certain advantages and indications, with significant overlap in the roles that they play in treatment. Sclerotherapy alone has not been demonstrated to be as efficacious as endothermal ablation for GSV treatment and is not discussed further here.

The method of venous ablation often depends on physician preference, as several techniques have been demonstrated to have acceptable outcomes with respect to technical success and incidence of complications such as deep venous thrombosis [2–4]. Patient-related and anatomic factors may play a role in the recommendation for one ablation technique over another, and insurance coverage is not uniform for all ablation techniques. The practicalities of decision-making on ablation technique should take into consideration many factors. Optimal management of GSV insufficiency requires a comprehensive understanding of the venous anatomy of the lower extremity, appropriate diagnostic evaluation, and proper patient selection.

Evaluation of Venous Insufficiency

Duplex ultrasound of the lower extremities is essential in the evaluation and diagnosis of venous insufficiency and thrombosis. Standard venous reflux imaging protocols include assessment of the deep, superficial, perforating, and tributary venous systems for reflux or obstruction. In the evaluation of the superficial venous system, the presence or absence of reflux is identified in the great saphenous and small saphenous veins, as well as in tributary and accessory veins. Diagnostic criteria for the presence of significant reflux within the superficial venous system of the lower extremities includes reversal of flow for greater than 500 ms (Fig. 34.1). In the deep veins, reversal of flow for greater than 1000 ms is diagnostic of significant reflux. Treatment algorithms for venous insufficiency are tailored to the patient, taking into consideration clinical symptoms and the location of reflux. Typically, the approach involves addressing the most proximal extent of the superficial venous reflux, which often entails treatment of the great saphenous vein.

../images/60971_2_En_34_Chapter/60971_2_En_34_Fig1_HTML.jpg — Fig. 34.1

Venous duplex ultrasound demonstrating significant reflux in the great saphenous vein (GSV)

Indications for Endovenous Treatment

It is essential to adopt a standard system for evaluation in the clinical assessment of venous insufficiency. Many use the CEAP classification (clinical, etiologic, anatomic, pathophysiologic). This chapter does not comprehensively cover the indications for saphenous ablation, but rather covers the techniques available to effect saphenous ablation. One should consider the risks and benefits of ablation of the saphenous vein. Known risks of saphenous ablation include deep venous thrombosis, pain and discomfort, saphenous and sural neuropathy, ecchymosis, and symptoms associated with superficial thrombophlebitis.

Relative contraindications to saphenous ablation include the presence of concomitant peripheral artery disease or coronary artery disease, given the destruction of a potential future autogenous vein conduit for bypass. However, it is also helpful to take into consideration in this patient population that tortuous, enlarged saphenous veins may not serve as a suitable conduit for autogenous vein use anyway. A discussion with the patient regarding the risk/benefit ratio is warranted prior to treatment planning. Deep venous reflux is not a contraindication to saphenous ablation, but deep vein obstruction is a relative contraindication.

There exists some controversy as to whether adjunctive treatments such as stab phlebectomy or reticular, spider, or varicose vein sclerotherapy should be performed at the same time as saphenous ablation or in a staged manner. In patients undergoing concomitant saphenous laser ablation and phlebectomy, 94% avoided additional ambulatory phlebectomy procedures [5]. In a study of patients undergoing saphenous RFA first, 75% required additional treatment with ambulatory phlebectomy [6]. A systematic review of the literature on this topic identified three prospective randomized trials, two prospective trials, and three retrospective reviews. Based on these data, Quality of Life scores improved more quickly with a combined approach; 30% to 60% of patients who underwent ablation required subsequent treatment of varicosities. Few complications were seen with either sequential or staged procedures. This review concluded that combined treatment of saphenous reflux and symptomatic varicose veins results in better short-term results and better to equivalent long-term patient outcomes [7].

General Ablation Techniques

Patient Preparation

GSV ablation may be safely and comfortably performed in the office setting. Patient preparation should include assessment for the need for intravenous sedation or an oral anxiolytic medication such as diazepam prior to the procedure. Our practice rarely uses these; our patients tolerate the procedure quite well using local anesthetic only. The application of EMLA cream (lidocaine 2.5%, prilocaine 2.5%) to the skin along the course of the vein to be ablated may help to avoid some of the discomfort related to the injection of tumescent anesthesia required for thermal ablation procedures. If used, EMLA is applied to the anteromedial thigh and calf 1 hour prior to the intervention. The area is covered with an occlusive dressing to allow enough time for it to take effect.

Given the risk of deep venous thrombosis associated with saphenous ablation procedures, individualized thromboembolism prophylaxis is considered. We routinely administer a prophylactic dose of 5000 units of subcutaneous heparin prior to the ablation procedure in any patient with an elevated risk of venous thromboembolism, such as those with a known hypercoagulable state, obesity, recent cancer diagnosis, or history of venous thromboembolic event, if they are not already on therapeutic anticoagulation. It is unnecessary to discontinue antiplatelet agents or anticoagulants for saphenous ablation procedures.

Procedure Room Setup

Venous ablation procedures may be safely and comfortably performed in the clinic or procedure room setting. The typical table setup is shown in Fig. 34.2 for EVLA and Fig. 34.3 for adhesive ablation. Room setup typically includes the following:

Tilt table.
Sterile field and drapes.
Ultrasound machine with sterile probe cover (Fig. 34.4).
Local anesthetic (1% plain lidocaine) in 10 cc syringe.
Injectable normal saline.
Micropuncture access kit.
- Echogenic-tipped 18-gauge needle, 0.018″ guidewire, 4 or 5 French sheath.
Long guidewire.
Ablation sheath and catheter.
Ablation device.
Tumescent pump for thermal ablation.
Laser safety goggles for patient and staff (for laser ablation).
Sclerosing agent (for mechanicochemical ablation).
Skin prep sticks.

../images/60971_2_En_34_Chapter/60971_2_En_34_Fig2_HTML.jpg — Fig. 34.2

Table setup for endovenous laser ablation (EVLA)

../images/60971_2_En_34_Chapter/60971_2_En_34_Fig3_HTML.png — Fig. 34.3

Table setup for adhesive ablation (VenaSeal)

../images/60971_2_En_34_Chapter/60971_2_En_34_Fig4_HTML.jpg — Fig. 34.4

Ultrasound machine setup

Additional items that should be available:

Torque device.
Angled hydrophilic guidewire.

Patient Setup and Venous Access

Patients presenting for great saphenous vein ablation typically have undergone a full venous reflux imaging protocol, but real-time imaging from the SFJ distally is essential to clarify the anatomy. The ipsilateral lower extremity is prepped and draped using standard sterile technique. The groin should be included in the prepped area, as imaging of the SFJ at the groin crease is necessary. In patients with venous ulceration, care should be taken to keep wounds remote from the procedural field, assuming that vein access need not involve this area. Placement of a roll of towels under the bent knee and external rotation at the hip facilitates imaging of the great saphenous vein. Great saphenous vein puncture may be facilitated by placing the patient in the reverse Trendelenburg position to dilate the incompetent vein, if a tilt table is available. This is not necessary but is helpful, especially if the diameter of the vein is small. Use of an ultrasound technologist for intraprocedural imaging is an option but is not our routine.

Once the patient is positioned properly, ultrasound imaging is performed starting at the groin crease (Fig. 34.5). The common femoral vein and SFJ are identified first, following the great saphenous vein distally. The great saphenous vein is typically located within the saphenous sheath, but it may be located more superficially if it exits the sheath. Endothermal ablation may be performed even if the saphenous vein exits the sheath, as long as its depth after tumescent solution infiltration is more than 1.0 cm from the surface of the skin. When performing thermal ablation, the decision about access location should consider the risks of heat-induced nerve injury when the vein is treated below the knee. Typically, access of the great saphenous vein is achieved at or just below the knee for this reason when EVLA or RFA is being performed. When adhesive or mechanicochemical ablation is being used, the vein may be accessed at the ankle for treatment of the entire length, without concern about nerve injury.

../images/60971_2_En_34_Chapter/60971_2_En_34_Fig5_HTML.jpg

Tags: Vascular Reconstructions Anatomy Exposures and Techniques

Jul 25, 2021 | Posted by admin in CARDIOLOGY | Comments Off

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Saphenous Vein Endovenous Treatment

34. Great Saphenous Vein Endovenous Treatment

General Principles

Evaluation of Venous Insufficiency

Indications for Endovenous Treatment