Superficial Venous Disease of the Legs and Treatment
Robert R. Attaran, MD, FACC, FASE, FSCAI, RPVI
Key Points
Reflux of the great saphenous veins is the leading cause of superficial venous insufficiency in the lower extremity.
Edema, restless legs, hyperpigmentation, pain, and venous ulcers are among the symptoms of venous reflux.
Radiofrequency ablation, laser ablation, mechanochemical ablation (MOCA), and sclerotherapy are undertaken for closure of refluxing veins not responding to traditional therapies such as compression.
I. Introduction
Venous insufficiency and varicose veins are very common, affecting more than 40% of men and 70% of women in their 60s.1 In addition to being unsightly, in many cases they can lead to aching, edema, pruritis, stasis dermatitis, lipodermatosclerosis, and even ulceration.2,3 They can affect quality of life and be disabling.4 The leading cause of superficial venous insufficiency in the legs is great saphenous vein (GSV) reflux.5 For centuries, compression therapy has been used as the mainstay of venous disease therapy. In addition, numerous surgical techniques have been adopted. These include avulsion (phlebectomy) of varicosities, saphenous vein stripping, and ligation of the saphenofemoral junction (SFJ).6 Over recent years many surgical options have been replaced by minimally invasive techniques with lower complications, faster recovery, and comparable success rates. These include thermal ablation, for example, laser and radiofrequency, and nonthermal ablation, for example, nontumescent nonthermal (NTNT) techniques (foam sclerotherapy, mechanochemical ablation, and cyanoacrylate glue). The current US and UK guidelines (American Venous Forum/Society of Vascular Surgery and the National Institute for Health and Care Excellence) recommend endovenous thermal ablation in preference to surgical treatment for saphenous vein incompetence.7,8 These nonsurgical techniques are less invasive, safer, and require less convalescence time. There are few strong contraindications to venous ablation, but they include pregnancy and femoral/popliteal vein occlusion.9 In this chapter, we review the contemporary endovascular and approaches to treat superficial venous disease.
II. Compression Therapy
A. Compression Stockings
1. Regardless of the pathophysiology, reflux or obstruction, the mainstay of therapy in venous disease remains compression.10 Compression stockings are utilized as they are thought to compensate for increased ambulatory venous pressure, for prevention of deep and superficial vein thrombosis, reduction in inflammation, swelling and pain. In addition to various forms of stocking, compression can be provided with bandages as well as pneumatic devices.
2. Conrad Jobst made the observation that hydrostatic pressures in a pool relieved venous insufficiency symptoms. The applied pressure was greater with depth, and in the 1950s he developed compression stockings to emulate them.11
The ankle venous pressure represents the weight of the column of blood leading up to the right atrium. While low in the supine position, ankle venous pressures rise closer to 80-100 mm Hg upon standing. When venous valves are healthy, the use of the calf pump dramatically reduces this pressure.
B. C5/C6 Disease
1. For C5/C6 disease (healed or active venous ulcer) two Cochrane reviews have reported lower ulcer recurrence with compression therapy. Compression noncompliance is associated with lower ulcer healing and greater recurrence.10,15 Higher pressure compression may work better than medium compression to prevent recurrence.15
2. El-Sheika’s16 systematic review of randomized control trials on posttreatment compression found seven suitable for analysis. Three studies were surgical, two used sclerotherapy, and two endovenous laser ablation (EVLA). Heterogeneity in study quality and duration of compression made meta-analysis difficult. No specific conclusions could be drawn about efficacy or optimal duration of compression therapy.
Two studies suggested that longer compression resulted in less postprocedural pain. Bakker et al17 randomized patients undergoing EVLA of the GSV to 2 versus 7 days of compression stockings (35 mm Hg). At 1-week follow-up, the 7-day compression group reported less pain and better physical function. Another similarly designed prospective study noted a small but significant reduction in pain scores when compression was worn after EVLA.18 These studies did not demonstrate any difference in procedural success or ablative efficacy.
C. Evidence The evidence for compression therapy is discussed in more detail in a review by this chapter’s author.19
III. Laser Ablation
A. Endovenous Laser Ablation Endovenous laser ablation (EVLA) was initially described by Boné and Navarro20,21 using an 810 nm diode laser. Using ultrasound guidance, a laser fiber (with or without a sheath) is inserted into the GSV at typically the knee level and advanced toward the SFJ. Local anesthetic was initially used but has now been superseded by tumescent anesthesia (saline, lidocaine, bicarbonate, and epinephrine). The activated laser fiber heats the vein and generates steam bubbles. It is withdrawn at a steady rate along the vein. In animal models, fiber temperatures in excess of 1000°C have been recorded.22
B. Endovenous Laser Ablation Treatment The treatment results in the thrombosis, gradual necrosis, and shrinkage of the treated vein.23 Postprocedure compression is recommended. Successful closure rates, based mostly on observational studies, have been in the range of 90%-98%.24,25
Various laser fiber wavelengths have been developed, which typically focus energy for absorption by either red blood cells or water. A 1470 nm wavelength laser, for example, targets water. The 810 and 980 nm wavelengths target hemoglobin. The water-focused higher wavelength lasers may result in less discomfort and bruising.26
C. Endovenous Laser Ablation Complications Complications of EVLA, similar to radiofrequency ablation (RFA), include ecchymosis, hematoma, skin burns, nerve injury (the saphenous nerve courses close to the GSV below the mid-calf and the sural nerve courses close to the small saphenous vein (SSV) distally), and endothermal heat-induced thrombosis (EHIT).27
IV. Radiofrequency Ablation
A. VNUS Closure System Use of heat from radiofrequency energy to ablate the GSV was first described by Goldman28 using the VNUS Closure System (Sunnyvale, CA). A sheath was inserted into the saphenous vein in the knee region, through which the radiofrequency fiber was advanced more proximally to the saphenofemoral junction. The electrode tip element generated local heat (85°C) which burned the vein wall. The original protocol involved slow steady pullback of the catheter. To facilitate vein emptying and occlusion, the procedure was performed in reverse Trendelenburg and compression bandaging was applied.29
B. Medtronic ClosureFast Device
1. The current iteration is the Medtronic ClosureFast device (Minneapolis, MN) (Fig. 24.1). For saphenous vein ablation it comes with a 3- or 7-cm heating element, reaching 120°C. Each vein segment is treated for 20 seconds before the fiber is repositioned to the adjacent segment. The procedure is performed with tumescent anesthesia, administered around the vein and typically within the saphenous fascia. Our usual practice is to add 250 mg (25 mL) 1% lidocaine with epinephrine (1:100,000) plus 2.5 mL of 8.4% sodium bicarbonate to a bag of 500 mL saline (after discarding approximately 25 mL of saline). This creates a 500 mL bag of 0.05% lidocaine solution. The tumescent anesthetic is typically refrigerated before administration. The net effect is to create local anesthesia, a heat sink as well as vasoconstriction, improving contact of the heating element with the vein. In our experience, bicarbonate reduces the discomfort of the injections. The tumescent anesthesia can also be used to ensure the saphenous vein is at least 1 cm deep to the dermis, to prevent skin burns with thermal ablation. It can also help create separation from nerves in certain locations.
2. Patients are recommended to wear compression stockings for up to 2 weeks postablation. There is no strong evidence that compression improves the efficacy of thermal ablation, but it may lower discomfort.16,17,30
FIGURE 24.1: The Medtronic ClosureFast radiofrequency ablation device (fiber and generator). Used with permission by Medtronic© 2019.
3. Five-year follow-up data for radiofrequency ablation of the GSV (295 GSVs in 225 patients) found occlusion rates of 92%, with 95% free of reflux and only six patients reporting ongoing symptoms.31 Symptoms and quality of life scores improve dramatically after ablation.32,33,34
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
