Endoluminal Treatment of Varicose Veins

Introduction

Chronic venous insufficiency treatment options have changed dramatically over the last 10 years. Rapid endorsement of minimally invasive techniques has led to a proliferation of vein centers and growth in the number of venous procedures. Traditional treatment of venous insufficiency with high ligation and stripping is a time-tested and successful procedure that has been used worldwide. The transition to minimally invasive techniques, however, has progressively changed the treatment for this disease. Patients who previously would have had surgery in the hospital operating room under general anesthesia now commonly have a clinic-based procedure with local anesthetics only. The techniques that have enabled this transition utilized ablation of the vein with endoluminal techniques rather than physical removal of the diseased veins.

The various ablative techniques share a common mechanism — injury to the vessel wall with an energy source — that results in progressive fibrosis of the vessel and occlusion.1 The commonly used techniques are radiofrequency ablation, laser ablation, and sclerotherapy. In the case of radio-frequency and laser therapy, the energy delivered is converted to heat as opposed to the direct chemical injury utilized in sclerotherapy.

Additional techniques that enable this ambulatory approach are ultrasound guidance and tumescent anesthesia. Ultrasound imaging is paramount to the success of these techniques: accurate diagnosis is established in most cases based exclusively on ultrasound findings, and procedural guidance to maximize success and avoid complications is directly related to its use. Following the procedure, ultrasound is again used to evaluate the success of the treatment and rule out any thrombotic complications. Tumescent anesthesia is critical in the performance of radiofrequency and laser ablation procedures. The benefits are multiple. Anesthesia of the perivenous tissue is the most obvious effect, but equally important are the compression of the vein by the infused fluid, which allows better treatment efficacy, and the displacement of other tissues to avoid injury to skin and nerves during treatment. The minimal level of patient discomfort associated with tumescent anesthesia enables the procedure to be performed in the clinic setting.2 Additionally, multiple adjunctive phlebectomies can be performed in the clinic setting with this type of anesthetic, which previously would not have been possible.

Endoluminal vein treatments are performed for both the superficial venous system of greater and small saphenous veins and the perforator veins.