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Endovenous Ablation for the Treatment of Varicose Veins and Lower Extremity Venous Insufficiency

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Abstract

Lower extremity venous insufficiency is a common condition with a variety of clinical presentations, the most cited of which is varicose veins. Venous insufficiency and varicose veins tend to progress over time because of worsening of venous valvular insufficiency. There are a number of treatment options ranging from conservative therapy with compression stockings to the most invasive option of surgical stripping and/or ligation. Endovenous ablation (EVA) is a relatively new treatment, which has revolutionized the treatment of venous insufficiency and its secondary manifestations, such as varicose veins, over the last 20 years. EVA is an outpatient, low-risk procedure with minimal recovery time. Attentive procedural technique and detailed procedural instructions are essential for good results and patient satisfaction.

Introduction

Lower extremity venous insufficiency is one of the most common vascular conditions encountered in the population at large. The prevalence of this condition varies widely, but is estimated to be in the range of 30% to 35% in women and 10% to 15% of men in Western society (Callam, 1994, Sisto et al., 1995). Varicose veins are the most common presentation of lower extremity venous insufficiency. Lower extremity venous insufficiency is most commonly rooted in reflux in the great saphenous vein secondary to an incompetent saphenofemoral junction.

The treatment of varicose veins may be for either cosmetic or symptomatic reasons. Historically, the traditional treatment was surgical stripping and ligation with ancillary phlebectomy of tributary varicose veins (Beale & Gough, 2005). However, treatment of lower extremity venous insufficiency has significantly evolved over the last 20 years, namely through the innovation of ultrasound guided endovenous ablation (EVA) for the treatment of axial vein insufficiency (Muller, 1966). More recently, there has been considerable refinement of the EVA technique and the treatment of branch varicose veins with adjunctive sclerotherapy or microphlebectomy (Bartholomew, King, Sahgal, & Vidimos, 2005). This review article is intended to provide an overview of the clinical presentation, diagnosis, and treatment of lower extremity venous insufficiency using EVA and such adjunctive techniques.

Section snippets

Clinical presentation

Lower extremity venous insufficiency can present in its most mild form as mere surface reticular veins and spider veins with no associated symptoms. Reticular veins are usually small green or blue nonbulging veins, measuring approximately 1 to 4 mm in diameter and identified by their distinctive flat and nontortuous appearance. Spider veins are the smallest veins, measuring less than 1 mm and identified by their reddish, purple, or dark blue appearance (Bartholomew et al., 2005). In these

Diagnosis and investigation

The clinical exam should begin with a very careful history focused on venous symptoms, ensuring to elicit symptoms that the patient may not be aware of, or even associate with varicose veins. A general medical and surgical history is also important to determine previous venous treatments or surgery and risk factors for thrombophilia and pigmentation. A directed physical examination is critical in detecting the presence and extent of varicose veins, sites of swelling, discoloration,

Treatment options

The primary goals of treating varicose veins and venous insufficiency are to improve the cosmetic appearance, reduce venous hypertension, prevent complications of varicose veins, and prevent the progression of venous insufficiency. The treatment options are divided into conservative noninvasive treatments, surgical treatments, and image-guided EVA procedures.

Conservative treatments

Conservative treatment options for varicose veins and venous insufficiency include lifestyle modification, compression therapy, and/or pharmacotherapy. Patients with varicose veins are advised to avoid prolonged periods of standing or sitting, as this promotes the development and progression of venous valvular insufficiency (Rathbun & Kirkpatrick, 2007). When standing or sitting for prolonged periods, it is recommended to either change the standing or sitting position every 5 min or wear

Surgical treatments

Surgical treatment options include saphenous vein stripping, ligation of the saphenofemoral junction, or ambulatory phelebectomy. Saphenous vein stripping was the historical gold standard treatment for varicose veins and venous insufficiency for over three decades (Yao, 1997). Saphenous vein stripping is performed under general anesthesia, and the procedure involves making an incision at the groin and ligating the great saphenous vein and its major tributaries (Beale and Gough, 2005, Belcaro et

Endovenous ablation

EVA for the treatment of main superficial truncal vein reflux including the great and small saphenous veins may be divided into chemical or thermal ablation procedures. Thermal ablation procedures may be further subdivided into endovenous laser ablation (EVLT) or endovenous radiofrequency ablation.

Endovenous chemical ablation

Endovenous chemical ablation involves the use of ultrasound to localize the most superficial accessible segment of the varicose vein or incompetent truncal vein. After localization, the target vein is accessed using ultrasound guidance followed by catheter insertion. A chemical sclerosant (polidocanol, sodium morrhuate, or sodium teradecyl sulfate [STDS]) is then combined with air or carbon dioxide to produce a foam solution. The solution is then injected through the endovenous catheter under

Endovenous radiofrequency ablation

Endovenous radiofrequency ablation acts by delivering controlled thermal energy to the vein wall using radiofrequency energy passed through an endovenous electrode. The procedure is performed under ultrasound imaging guidance. The endovenous catheter is placed under dynamic ultrasound imaging into the great or small saphenous vein. The endovenous catheter is advanced to the saphenofemoral or saphenopopliteal junction. Tumescent anesthesia under ultrasound guidance is instilled around the target

Endovenous laser ablation

The first application of endoluminal laser was described by Dr. Bone in 1999 (Bone, 1999). A technique for treating the entire incompetent great saphenous vein and eliminate venous reflux was first reported by Dr. Min and Dr. Navarro in 2001 (Min et al., 2003b, Min et al., 2001, Navarro et al., 2001). EVLT received Food and Drug Administration approval in January 2002, and acts through a mechanism of nonthombotic venous occlusion of the target vein through the delivery of laser energy into the

Conclusion

Lower extremity venous insufficiency with secondary varicose veins and associated symptoms is a common but unrecognized problem throughout the population at large. With the refinement of imaging technology and the evolution of new treatment techniques, there has been dramatic advancements in the treatment of lower extremity venous insufficiency. Minimally invasive image-guided thermal ablative treatments are now the first line of therapy for this difficult but common problem. Educating the

Sanjoy Kundu, MD, BSc, RVT, RPVI, FRCPC, DABR, FASA, FCIRSE, FSIR, is the Medical Director of The Vein Institute of Toronto, Ontario, Canada.

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    Sanjoy Kundu, MD, BSc, RVT, RPVI, FRCPC, DABR, FASA, FCIRSE, FSIR, is the Medical Director of The Vein Institute of Toronto, Ontario, Canada.

    Milad Modabber, MSc, is affiliated with The Vein Institute of Toronto, Ontario, Canada.

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