Superficial Veins: Treatment Options and Techniques for Saphenous Veins, Perforators, and Tributary Veins Ronald S. Winokur, MD, and Neil M. Khilnani, MD Superficial venous insufficiency is a common cause of lower-extremity symptoms of pain and swelling. A thorough understanding of the superficial venous anatomy, as well as gaining knowledge of treatment approaches, can direct one’s approach to providing an appropriate treatment for desired and durable outcomes. This article reviews the details of anatomy and treatment of the saphenous veins, perforator veins, and tributary veins. Tech Vasc Interventional Rad 17:82-89 C 2014 Elsevier Inc. All rights reserved.
Saphenous Veins Clinical Evaluation of the Patient Before performing any treatment, a directed history and physical examination of the pelvis and lower extremities should be obtained and documented.1 This should include the patient’s age, gender, medications, prior vein treatment, as well as medical, surgical, family, and pregnancy history. Other historic factors that may be important to elicit are occupations requiring prolonged sitting or standing, obesity, physical activity requiring heavy straining, neuromuscular disorders causing foot muscle pump dysfunction, history of leg trauma, clotting disorders, deep vein thrombosis (DVT) and superficial vein thrombosis, congenital vascular malformations, and connective tissue laxity.2 One should also assess for symptoms of venous disease, which include aching, tiredness or heaviness in legs, pain, throbbing, cramping, swelling, itching, or restless legs. Venous insufficiency symptoms are frequently relieved by leg elevation, activity, graduated compression stockings (GCSs), or cold compresses. Bursting pain with activity may be a symptom of iliac vein obstruction. A targeted physical examination of the legs and in some cases the pelvis should be performed, which includes
Division of Interventional Radiology, Department of Radiology, Weill Cornell Vascular, New York-Presbyterian Hospital/Weill Cornell Medical College, New York, NY. Address reprint requests to Neil M. Khilnani, MD, Division of Interventional Radiology, Department of Radiology, Weill Cornell Vascular, New York-Presbyterian Hospital/Weill Cornell Medical College, 2315 Broadway, 4th Floor, New York, NY 10024. E-mail: nmkhilna@med. cornell.edu
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visual inspection and selective use of transillumination. Physical examination findings include tortuous or dilated reticular veins; varicose veins; edema; skin changes such as discoloration, rash, eczema, or induration; and healed or active ulcerations. It is important to distinguish venous edema (aka phleboedema, which is brawny nonpitting edema) from other common causes of lower-extremity swelling, such as heart disease, renal dysfunction, and liver dysfunction as well as lymphedema. It is also important to recognize lipedema, which consists of symmetric enlargement of the lower extremities with soft fatty tissue and minimal edema sparing the feet.3 A carefully performed Doppler ultrasound (DUS) focused on the superficial venous system will elucidate underlying causes of varicose veins to adequately remove the source of venous hypertension in patients who are candidates for treatment.4 Guidelines from the American College of Phlebology and Intersocietal Accreditation Commission exist for a complete examination of the superficial venous system. DUS is typically performed with a high-frequency linear transducer (7.5-15 MHz). Standing and reverse Trendelenburg positions improve the ability to detect reflux and increase the caliber of refluxing veins compared with supine positioning. Color Doppler is used to rapidly determine the direction of blood flow. Spectral (pulsed wave) Doppler should be used to demonstrate the magnitude, duration, and direction of flow in refluxing veins. The criteria for retrograde flow in superficial veins and perforator veins are 0.5 seconds and 0.3 seconds, respectively. However, much longer periods of retrograde flow or reflux are commonly seen, extending for several seconds.
1089-2516/13/$ - see front matter & 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1053/j.tvir.2014.02.004
Superficial veins: Treatment options and techniques Multiple scoring systems exist for the physician to assess the patient’s clinical status and for the patient to report the severity of their symptoms. These include the Clinical, Etiologic, Anatomic, Pathophysiologic (CEAP) classification; the revised venous clinical severity score (VCSS); and several patient-reported metrics, including generic instruments such as the 36-Item Short Form Health Survey and several disease-specific instruments such as the Aberdeen Varicose Vein Questionnaire, Chronic Venous Insuficiency quality of life Questionnaire, Venous Insufficiency Epidemiological and Economic Study, and VVsymQ (the latter being the only instrument meeting Food and Drug Administration guidelines for use in device and drug trials). The CEAP classification is a common descriptive platform for reporting patient status in chronic venous disease.5 The classification scheme is detailed in the Table. CEAP is physician generated and relatively static; once a patient has had an ulcer they can never be better than a C5, despite treatment. As a result, it is less useful as a tool to follow disease severity after therapy. VCSS is another physician-generated scale assessing disease severity. It includes assessments of the typical signs and symptoms of venous disease rated on a scale of 0-3, including pain, varicose veins, venous edema, skin pigmentation, inflammation, induration, number of active ulcers, size of active ulcers, ulcer duration, and compression therapy.6 VCSS poorly delineates the lower end of the disease spectrum. A thorough understanding of superficial venous anatomy and anatomical variations of the lower extremities is critical to performing an accurate examination and guiding future treatment.4 The great saphenous vein (GSV) is the most commonly involved superficial vein in reflux and varicose veins. The anterior accessory GSV is a common channel within the saphenous space that can be responsible for anterior thigh varicose veins, which are present in 14% of patients with varicose veins.7 The small saphenous vein (SSV) begins on the lateral aspect of the foot and ascends posteriorly between the heads of the gastrocnemius muscle. The cephalad or thigh extension of the SSV is variable in its connection to the deep venous system and anatomy at the saphenopopliteal junction (SPJ), but it is present in 95% of patients7 (Fig. 1). Common femoral vein waveforms should be assessed bilaterally to identify evidence for an iliac vein stenosis or occlusion. An evaluation of the deep venous system for thrombosis or insufficiency in the common femoral, femoral, and popliteal veins should also be included in the DUS examination.4 Table CEAP Classification C0 C1 C2 C3 C4a C4b C5 C6
No visible or palpable signs of venous disease Telangiectasias or reticular veins Varicose veins Edema Pigmentation or eczema Lipodermatosclerosis or atrophie blanche Healed venous ulcer Active venous ulcer
83 It is important to understand the patient’s goals of treatment before initiating any therapy as managing expectations to achieve the desired outcome will lead to the perception of much better results by the patient.
Indications and Contraindications for the Treatment of Saphenous Veins Indications for treatment include clinically significant symptoms of venous insufficiency and current or prior venous ulceration as well as DUS showing axial reflux greater than 0.5 seconds in duration and a patent deep venous system. Absolute contraindications include restricted mobility and deep venous obstruction with the superficial system vital to allow venous return. Ablation can be performed to treat veins causing venous ulceration in the setting of DVT if the deep system is adequate to return blood. Relative contraindications include allergy and severe coagulopathy or thrombophilia. If a patient has an allergy to lidocaine, an amide local anesthetic, use of an ester local anesthetic such as benzocaine is suggested. Methylparaben antiseptic preservative can cause an allergy when using lidocaine in a multiuse vial, and epinephrine can cause an adverse reaction such as palpitations. Patients with a history of thrombophlebitis, DVT, known thrombophilia, or obesity are candidates for treatment with DVT prophylaxis.8 Prophylaxis is most commonly performed with low-molecular-weight heparin before or at the beginning of the procedure, although no evidence is available to support this practice. A risk assessment scale such as the Caprini Assessment tool may make this assessment more objective. A score of greater than 8 has been suggested as a valid indication for prophylaxis.9
Venous Ablation Equipment Saphenous vein ablation consists of using either a radiofrequency ablation (RFA) system or endovenous laser ablation (EVLA) system. ClosureFast (Covidien, Mansfield, MA) is the most commonly used RFA system. EVLA can be performed with multiple different laser fiber designs (ie, bare tip fibers, jacket tip fibers, and radial fibers) and diameters available from a variety of vendors. Laser generators exist with multiple different wavelengths including lower wavelengths that are considered hemoglobin specific and include 810, 940, 980, and 1064 nm. Higher wavelengths are considered water specific and include 1320 and 1470 nm. Although it is still not definitively established in the literature, some authors suggest that the higher wavelength lasers are considered to produce similar efficacy at lower power settings with less postprocedure symptoms.10
Procedural Steps Treatment of the GSV, anterior accessory GSV, and SSV is performed in a similar fashion (Fig. 2). These procedures are typically performed in an outpatient office setting without the need for oral or intravenous sedation. However,
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Figure 1 Schematic diagram of the (A) GSV and (B) SSV. (Color version of figure is available online.)
some physicians elect to prescribe an oral or intravenous sedative before the procedure. After obtaining informed consent from the patient, an ultrasound is performed to map the course of the GSV or SSV from the intended puncture site to the saphenofemoral junction (SFJ) or SPJ. The patient is placed on the procedure table in the reverse Trendelenburg position to improve dilatation of the target vein and enhance success of cannulation. The patient’s leg is prepped and draped in standard sterile fashion from the groin to the insertion site. The saphenous vein is accessed with an 18-21 gauge needle using ultrasound guidance. Following exchange over a 0.018-in wire if a 21 gauge needle is used, an angled tip 0.035-in guidewire is advanced to the SFJ (the 0.035-in wire can be placed directly through an 18-gauge or thin-walled 19-gauge needle). For some ablation tools, a vascular sheath is inserted over the guidewire near the SFJ, just peripheral to the site of the superficial epigastric vein confluence or 2 cm below the SFJ. For others, a short sheath can be used with the laser or radiofrequency (RF) tool positioned as previously stated. In the SSV, the catheter tip or laser fiber is positioned peripheral to the thigh extension of the SSV or just below the point that the vein angulates deep to join the popliteal vein. The patient’s position is usually changed to the Trendelenburg position. Dilute tumescent anesthetic is injected in the perivenous saphenous space along the entire course of the desired treatment length. The mixture for tumescent anesthetic at our institution consists of 440-mL 0.9% normal saline, 50-mL 1% Lidocaine, and 10-mL 8.4% sodium bicarbonate. The maximum patient dose of lidocaine in such a dilution for tumescent anesthetic is 35 mg/kg based on extrapolations made in the plastic surgical literature.11
Ablation is performed with the desired system. Withdrawal of the ClosureFast system is performed in 6.5-cm segments after each 7-cm section has been treated. A double cycle of the first 7 cm is performed. The RFITT system withdrawal rate is reportedly 1 cm/s. Withdrawal rate of the laser systems varies depending on the wavelength and power settings of each system. The rate using the 810-nm laser should be titrated to maintain energy transfer of 80-100 J/cm.12 Lower linear energy deposition amount have been suggested to be as effective with the more water-specific lasers. Manual compression is held over the puncture site for hemostasis and a sterile dressing is applied. A class II (30-40 mm Hg) GCS is placed on the patient immediately following the procedure and is recommended for at least one week by most practitioners. Following the procedure, the patient is encouraged to walk, and our practice is to instruct patients to take a 1-hour walk following the procedure and then 2 hours per day for 2 weeks.
Overcoming Technical Challenges Excellent ultrasound skill is essential for successful venous puncture. Nitropaste can be placed over the site of a planned venous puncture for vessel dilation and improved success of cannulation. Keeping the procedure room warm helps as well. A second puncture site that is more central can be used at times of access failure, but this is at the expense of treating segments of abnormal saphenous vein. Occasionally, the saphenous vein is tortuous, and it is difficult to advance the standard 0.035-in guidewire through the entire course of the vein. External compression can be utilized to direct the wire tip through areas of
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Figure 2 Images of the procedural steps involved in saphenous ablation. (A) Ultrasound image depicting the location of the laser fiber tip (small arrow) in relation to the SFJ (arrowhead) and the SEV (large arrow). (B) Axial ultrasound image of the laser fiber within the GSV (arrow). (C) Axial ultrasound image of the laser fiber (small arrow) with a surrounding halo of tumescent anesthesia (large arrow). A 25-gauge needle utilized for delivery of tumescent is seen in the saphenous space (arrowhead). (D) Ultrasound image at 4 weeks postablation with a typical “target” appearance of the saphenous vein (arrow). SEV, superficial epigastric vein. (Color version of figure is available online.)
tortuosity. A 0.035-in angled hydrophilic guidewire can also be used to navigate through tortuous segments or segments with synechia and scarring from prior superficial thrombophlebitis. In some cases of tortuosity, prior ablated segments with segmental remnant sections of GSV or after prior GSV phlebitis, multiple puncture sites and sheaths may be required to treat all refluxing segments. In extreme cases, fluoroscopy, if available, can be used to direct the wire.
Recognizing and Treating Complications Most complications of saphenous vein ablation are minor and typically most notable during the first 2 weeks following treatment.13,14 Commonly reported side effects include soreness, bruising, tenderness, and induration. Most complaints can be relieved with over-the-counter anti-inflammatory medications and GCSs. With GSV ablation, patients frequently will report tightness in the medial thigh due to the evolving fibrosis of the vein, which improves with stretching and time. Arteriovenous fistula creation is extremely rare with only 11 cases reported in the literature.14,15 The majority of them are asymptomatic, and avoidance of embolization or surgery
is recommended if possible. Skin burns are a rare complication of the procedure occurring in 0.14%-1.32% of EVLA procedures, which can be avoided with appropriate tumescent anesthetic.14 DVT occurs from propagation of thrombus from the superficial venous system to the deep venous system at the SFJ or SPJ, occurring in 0%-5.7% of patients after EVLA.16-18 The risk of venous thromboembolism is higher in patients with a history of prior DVT or phlebitis, CEAP 3 or greater, and male gender.17 Endothermal heatinduced thrombosis (EHIT) defines the extent of superficial thrombosis and its extension into the deep venous system as proposed by Rhee.17 Ultrasounds performed at 1.7 days postprocedure revealed a 4% incidence of EHIT 1 (venous thrombosis to the deep/superficial junction but not extending into the deep system) and EHIT 2, (nonocclusive thrombosis extending into the deep veins of o50% crosssectional area). However, EHIT 3 and EHIT 4 (450% femoral vein diameter and complete occlusion of the femoral vein) were not seen.17 Anticoagulation is not recommended for EHIT 1, and it is at the provider’s discretion for EHIT 2. It would be suggested for EHIT 3 and 4 to perform frequent monitoring with DUS to determine the duration of therapy. Catheter-directed thrombus elimination could be considered for EHIT
R.S. Winokur and N.M. Khilnani
86 4 and possibly EHIT 3. Parasthesias and nerve injury can occur due to the location of several nerves in close proximity to the saphenous vein. The great saphenous nerve approximates the GSV and is in closest proximity to the vein from the midcalf down to the ankle. Injury most commonly causes parasthesias that are typically transient but occasionally permanent. The sural nerve originates in the posterior calf and is alongside the SSV beginning near the inferior aspect of the gastrocnemius muscle down to the lateral malleolus. Sural nerve injury after thermal ablation occurs in 1.3%-11% of patients following SSV ablation, with 1 of 2 patients recovering sensation.19
Clinical Follow-Up Clinical follow-up in the office and with DUS varies among physicians performing this procedure. Although, many will see the patient 2 days to 1 week following ablation, our practice is to see most patients after a month and reserve early follow-up for patients in whom we are concerned about a postprocedure DVT. Further clinical follow-up after the initial postprocedure period is largely based on the needs of the patient and requirement for follow-up sclerotherapy or ambulatory phlebectomy (AP) to control symptoms or for esthetic enhancement. Once the patient’s quality of life affecting symptoms are resolved or you have achieved the desired cosmetic result or both, the patient can return as needed for recurrence of symptoms or cosmetic improvement.
Expected Outcomes EVLA and RFA result in high long-term success rates of obliterating the saphenous vein of 93% and 87.5%, respectively.18 GSV success rates range from 88%-100% and SSV success rates range from 88%-96%.18 Surgical ligation and stripping and ultrasound-guided foam sclerotherapy achieve poorer anatomical success (disappearance of the vein). In a meta-analysis by van den Bos et al,18 it is likely that the long-term recurrence rate after surgery is higher than that of EVLA because of neovascularization.
Perforating Veins Clinical Evaluation of the Patient Clinical evaluation of the patient is the same as stated earlier for saphenous veins involving a complete history and physical examination, transillumination, and DUS. There are approximately 60 perforating veins (PVs) in the thigh, 8 in the popliteal fossa, 55 in the calf, and 28 in the foot.20 The number of incompetent PVs per limb increases with worsening chronic venous disease (CEAP 4-6), and there is also an increasing incidence of incompetent PVs when they measure more than 4 mm.20
Indications for the Treatment of PVs Treatment of pathologic PV should be reserved for patients who have exhausted other methods of treating venous
hypertension and eliminating other sources of reflux. Although the evidence is not strong, the American Venous Forum and Society of Vascular Surgery define pathologic perforators and recommend treatment of perforators when their size is greater than 3.5 mm, when the reflux is greater than 0.5 seconds, and when they are located in close proximity to an active ulcer that persists after all superficial venous reflux is eliminated and inelastic compression bandaging used.21
Equipment Needed Percutaneous ablation of perforators (PAPS) can be performed with either the EVLA kit or RFA kit. Sclerotherapy is performed with 25-, 27-, or 30-gauge needles. Sodium tetradecyl sulfate or polidocanol detergent sclerosant is most commonly utilized as a foam created by the Tessari method, which consists of a 1:4 liquid-to-air or gas ratio.
Procedural Steps Percutaneous Ablation of Perforators (Endovenous Laser Ablation or Radiofrequency) The PV is accessed with a 21-gauge needle or a 16-gauge angiocatheter with the patient in the reverse Trendelenburg position.22 The 21-gauge needle would need to be exchanged for a micropuncture access set. The ClosureRFS stylet (Covidien, Mansfield, MA) or the laser fiber is then inserted and positioned at or just below the level of the fascia. Tumescent anesthesia is administered after placing the patient in Trendelenburg position. Ablation is performed with RF by treating all 4 quadrants of the vein wall for 1 minute each and then withdrawing the device 12 mm for a second ablation. When using laser, a pulsed technique is recommended by Elias et al21 using 15 watts and a 4-second pulse interval. Each segment of the vein is treated twice for a total delivery of 120 J to each segment for an average of 3 segments.
Sclerotherapy Ultrasound-guided injection of foam sclerotherapy is typically performed with the leg in the supine position and a volume of 0.5-1 mL. The targeted vein is usually a tributary varix connected to the incompetent perforator vein and not the incompetent perforator vein itself. The end point is filling of the incompetent perforator vein; the injection is terminated just before or after the deep vein is filled. Muscle pump activation is initiated as soon as the injection is completed.
Overcoming PAPS Technical Challenges The perforating vein has a paired artery, and careful attention during ultrasound-guided access is required to avoid puncture and injury or injection of the neighboring artery.
Superficial veins: Treatment options and techniques
Recognizing and Treating Complications The North American subfascial endoscopic perforator surgery registry had no patients with DVT within 30 days of subfascial endoscopic perforator surgery procedure. PAPS procedural complications are extremely rare with a few reported cases of tibial vein thrombosis, foot drop, and skin burn.23 Sclerotherapy also has rare thrombotic complications with a reported 0% incidence of DVT in a study by Masuda et al24 and 1 out of 80 patients who developed skin necrosis.
Clinical Follow-Up
87 veins. In addition to treating underlying axial reflux, treatment of the “varicose reservoir” can remove the low pressure sump caused by varicosities potentially resulting in a more durable removal of unwanted or painful varicose veins.30 Treatment options for elimination of varicose tributaries include AP and chemical ablation (aka sclerotherapy). Light-based therapies have limited value and only in the treatment of telangiectasia.
Indications for the Treatment of Tributary Veins
The patient should continue with compression therapy until ulcer healing. It may be prudent to see the patient weekly to track the progression of ulcer healing over time and participate in wound care.
Indications for treatment include esthetic concerns of eliminating varicose veins, discomfort over the varicose veins due to venous hypertension and vessel dilatation, and adjunctive treatment to saphenous ablation to remove the “varicose reservoir.”
Expected Outcomes
Equipment Needed
Surgery Treatment of perforator veins is controversial with several studies showing no symptomatic benefit in C2 patients or improved ulcer healing in C5 or C6 patients.25-27 Although many limitations exist in these studies, elimination of saphenous reflux may hasten ulcer healing.
For AP, incisions or punctures can be made with an 18gauge needle, an 11-blade scalpel, a 151 ophthalmic blade, or a punch biopsy device. The most widely known vein hooks used for grasping the vein include Muller, Oesch, Tretbar, Ramelet, Verady, Dortu-Mortimbeau, and KabnickGoldman. Three to 5 fine-tip curved clamps (ie, mosquito clamp) are usually used to grab and tease out the vein.31 Chemical ablation is performed in a similar fashion to previously described sclerotherapy for perforator veins using 27- or 30-gauge needles.32 Polidocanol and sodium tetradecyl sulfate are most commonly employed and are typically used in the liquid form for this purpose. A transillumination device can be useful for guidance. Common devices include the Veinlite (TransLite, LLC, Sugar Land, TX) and the VeinViewer (Christie Digital Systems, Cypress, CA). Ultrasound is sometimes necessary to visualize veins that cannot be seen visually or with transillumination.
Percutaneous Ablation of Perforators Although several studies have been performed looking at the feasibility of perforator ablation, very few studies have evaluated for ulcer healing and recurrence. One study evaluated patients with nonhealing ulcers following conservative management with compression therapy and saphenous ablation and found a greater than 90% success rate of complete ulcer healing after perforator ablation with RF.28 However, there is a prolonged learning curve to the procedure, and its use should be reserved for patients with recalcitrant venous ulcers. In a study of patients with CEAP 5 disease, healed venous ulcers, and progressive lipodermatoscleros is, ablation of at least one incompetent perforator resulted in an ulcer recurrence rate of 4.8% in another study.29 Sclerotherapy In a study by Masuda et al,24 80 limbs were treated with perforator sclerotherapy for perforator incompetence alone. The study demonstrated a significant improvement in VCSS scores and rapid ulcer healing in 86.5% of patients with a mean time of healing of 36 days.
Tributary Veins Clinical Evaluation of the Patient Clinical evaluation, as with previous patients with venous insufficiency, involves a complete history and physical examination, transillumination, and DUS. It is extremely important to have a clear understanding of the superficial venous anatomy and pattern of flow resulting in varicose
Procedural Steps Ambulatory Phlebectomy Use transillumination to identify the varicose veins and outline them with a surgical marker while the patient is standing (Fig. 3). Apply tumescent anesthesia in the region of planned phlebectomy. Make a microincision or puncture near the vein. Insert the vein hook and grasp the vein, bringing it out of the dermatotomy. Grasp the vein with a mosquito clamp. Gently tease the vein out of the puncture site while successively clamping the vein closer to the skin. Once the vein is avulsed, repeat the process in a new location until the entire segment is removed. The puncture sites should be covered with bandages to absorb leakage of tumescent anesthetic. A class 2 (30-40 mm Hg) compression stocking or short stretch bandage should be applied immediately and worn for 48 hours continuously followed by wearing a GCS for 10-14 days. The patient should be encouraged to walk for 1 hour immediately following the procedure and then 1-2 hours per day for 2 weeks.
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Figure 3 Stepwise demonstration of ambulatory phlebectomy procedure. (A) Grasping of the vein with the vein hook. (B) Clamping the vein with a mosquito clamp. (C and D) Gentle traction on the vein for vein removal. (Color version of figure is available online.)
Chemical Ablation Identify the pathway of veins to be eliminated.32,33 Transillumination may help to identify the varicose veins and outline them with a surgical marker. Working from proximal to distal, inject sclerosant into the veins with the patient in the supine or reclined position allowing for visualization of veins and ergonomically appropriate positioning for the provider. The sclerosant is gently massaged after injection to improve contact with the vein wall. Compression following sclerotherapy lacks consensus, but our practice is to place the patient in a class 1 or 2 (20-30 or 30-40 mm Hg) compression stocking immediately, which is worn for 7 days. The patient should be encouraged to walk for 1 hour immediately following the procedure and then 1 hour per day. The patient should return for follow-up in 1-3 weeks. At this point, the veins may have disappeared completely, disappeared partially, or have become tender, lumpy, nodular, and hyperpigmented. If the latter occurs, removal of intravascular hematoma with a 25- or 18-gauge needle puncture is used to decrease skin pigmentation. Ultrasound-guided sclerotherapy can be used to treat tributary veins in a similar fashion, if they are not visible using other methods.
Overcoming Technical Challenges Multiple large varicose veins in well-defined pathways are best approached with AP over chemical ablation. Chemical
ablation or compression sclerotherapy is ideal for smaller more network like and may require multiple sessions for complete treatment, including several visits for intravascular hematoma removal. Often both are used in combination to obtain the best results.
Recognizing and Treating Complications Complications following AP are extremely rare and vary widely depending on the provider performing the procedure.34 The most commonly reported complications include skin blistering from dressing abrasions, adhesive tape or steritrips (1.3%-20%), telangiectatic matting (1.5%-9.5%), hyperpigmentation (0.01%), missed varix (0.3%), and parasthesias (0.2%-4.6%). Common peroneal nerve (CPN) injury following phlebectomy occurred in 2%-4.7% of patients in the literature and could result in sensory loss or foot drop following SSV surgery.35 The sciatic nerve divides into the CPN and tibial nerves in the region of the popliteal fossa with the CPN most commonly located just medial to the biceps femoris tendon to near the fibular head. When planning phlebectomy, care or avoidance of this region is generally recommended to avoid CPN injury.35 The advantage of performing these procedures in patients who are awake is that they are aware of nerve manipulation. Complications after chemical ablation are also extremely rare including medication allergy, skin ulceration, skin pigmentation, telangiectatic matting, and DVT.
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Clinical Follow-Up Standard follow-up for AP would include a visit at 3-4 weeks following treatment to assess for healing of the skin puncture sites. At this time, it is also possible to treat additional remaining tributary or varicose veins with sclerotherapy if necessary for the desired result. A subsequent AP may be useful in some cases (ie, circumferentially distributed veins involving all sides of a leg). Follow-up evaluation after sclerotherapy is typically at 3 weeks, at which point removal of intravascular hematoma can be performed as well as treatment of other untreated veins.
References 1. Khilnani N, Morrison N: Clinical evaluation of patients with chronic lower extremity venous disorder. in Sadick NS, Khilnani N, Morrison N (eds.), Practical Approach to the Management and Treatment of Venous Disorders. Springer London, 25-31, 2013 2. Criqui MH, Denenberg JO, Bergan J, et al: Risk factors for chronic venous disease: The San Diego population study. J Vasc Surg 46:331-337, 2007 3. Rudkin GH, Miller TA: Lipedema: A clinical entity distinct from lymphedema. Plast Reconstr Surg 94:841-847, 1994 [discussion 848-849] 4. Khilnani NM: Duplex ultrasound evaluation of patients with chronic venous disease of the lower extremities. Am J Radiol 202:633-642, 2014 5. Eklof B, Rutherford RB, Bergan JJ, et al: Revision of the CEAP classification for chronic venous disorders: Consensus statement. J Vasc Surg 40:1248-1252, 2004 6. Vasquez MA, Munschauer CE: Venous clinical severity ccore and quality-of-life assessment tools: Application to vein practice. Phlebology 23:259-275, 2008 7. Cavezzi A, Labropoulos N, Partsch H, et al: Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs—UIP consensus document. Part II. Anatomy. Eur J Vasc Endovasc Surg 31:288-299, 2006 8. Gould MK, Garcia DA, Wren SM, et al: Prevention of VTE in nonorthopedic surgical patients: Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 141:e227S-e2277, 2012 9. Bahl V, Hu HM, Henke PK, et al: A validation study of a retrospective venous thromboembolism risk scoring method. Ann Surg 251: 344-350, 2010 10. Sadek M, Kabnick LS, Berland T, et al: Update on endovenous laser ablation: 2011. Perspect Vasc Surg Endovasc Ther 23:233-237, 2011 11. Klein JA: Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. J Dermatol Surg Oncol 16:248-263, 1990 12. Niedzwiecki G: Endovenous thermal ablation of the saphenous vein. Semin Interv Radiol 22:204-208, 2005 13. Oguzkurt L: Endovenous laser ablation for the treatment of varicose veins. Diagn Interv Radiol 18:417-422, 2012 14. Dexter D, Kabnick L, Berland T, et al: Complications of endovenous lasers. Phlebology 27:40-45, 2012 15. Rudarakanchana N, Berland TL, Chasin C, et al: Arteriovenous fistula after endovenous ablation for varicose veins. J Vasc Surg 55:1492-1494, 2012 16. Knipp BS, Blackburn SA, Bloom JR, et al: Endovenous laser ablation: Venous outcomes and thrombotic complications are independent of
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the presence of deep venous insufficiency. J Vasc Surg 48: 1538-1545, 2008 Rhee SJ, Cantelmo NL, Conrad MF, et al: Factors influencing the incidence of endovenous heat-induced thrombosis (EHIT). Vasc Endovascular Surg 47:207-212, 2013 van den Bos R, Arends L, Kockaert M, et al: Endovenous therapies of lower extremity varicosities: A meta-analysis. J Vasc Surg 49: 230-239, 2009 Huisman LC, Bruins RM, van den Berg M, et al: Endovenous laser ablation of the small saphenous vein: Prospective analysis of 150 patients, a cohort study. Eur J Vasc Endovasc Surg 38:199-202, 2009 Labropoulos N, Mansour MA, Kang SS, et al: New insights into perforator vein incompetence. Eur J Vasc Endovasc Surg 18: 228-234, 1999 Gloviczki P, Comerota AJ, Dalsing MC, et al: The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg 53:2S-48S, 2011 Elias S: Treatment of incompetent perforating veins. in Sadick NS, Khilnani N, Morrison N (eds.), Practical Approach to the Management and Treatment of Venous Disorders. Springer London, 107-115, 2013 O’Donnell TF: The role of perforators in chronic venous insufficiency. Phlebology 25:3-10, 2010 Masuda EM, Kessler DM, Lurie F, et al: The effect of ultrasoundguided sclerotherapy of incompetent perforator veins on venous clinical severity and disability scores. J Vasc Surg 43:551-556, 2006 [discussion 556-557] Kianifard B, Holdstock J, Allen C, et al: Randomized clinical trial of the effect of adding subfascial endoscopic perforator surgery to standard great saphenous vein stripping. Br J Surg 94:1075-1080, 2007 van Gent WB, Hop WC, van Praag MC, et al: Conservative versus surgical treatment of venous leg ulcers: A prospective, randomized, multicenter trial. J Vasc Surg 44:563-571, 2006 Barwell JR, Davies CE, Deacon J, et al: Comparison of surgery and compression with compression alone in chronic venous ulceration (ESCHAR study): Randomised controlled trial. Lancet 363: 1854-1859, 2004 Lawrence PF, Alktaifi A, Rigberg D, et al: Endovenous ablation of incompetent perforating veins is effective treatment for recalcitrant venous ulcers. J Vasc Surg 54:737-742, 2011 Harlander-Locke M, Lawrence P, Jimenez JC, et al: Combined treatment with compression therapy and ablation of incompetent superficial and perforating veins reduces ulcer recurrence in patients with CEAP 5 venous disease. J Vasc Surg 55:446-450, 2012 Pittaluga P, Chastanet S, Rea B, et al: Midterm results of the surgical treatment of varices by phlebectomy with conservation of a refluxing saphenous vein. J Vasc Surg 50:107-118, 2009 Kabnick L: Ambulatory phlebectomy. in Sadick NS, Khilnani N, Morrison N (eds.), Practical Approach to the Management and Treatment of Venous Disorders. Springer London, 93-106, 2013 Sadick N: Sclerotherapyand alternatives. in Sadick NS, Khilnani N, Morrison N (eds.), Practical Approach to the Management and Treatment of Venous Disorders. Springer London, 61-82, 2013 Goldman MP, Guex J-J, Weiss RA: Treatment of Varicose and Telangiectatic Leg Veins. Saunders Elsevier Philadelphia, 2011 Ramelet AA: Complications of ambulatory phlebectomy. Dermatol Surg 23:947-954, 1997 Atkin GK, Round T, Vattipally VR, et al: Common peroneal nerve injury as a complication of short saphenous vein surgery. Phlebology 22:3-7, 2007
Saphenous Veins Clinical Evaluation of the Patient Before performing any treatment, a directed history and physical examination of the pelvis and lower extremities should be obtained and documented.1 This should include the patient’s age, gender, medications, prior vein treatment, as well as medical, surgical, family, and pregnancy history. Other historic factors that may be important to elicit are occupations requiring prolonged sitting or standing, obesity, physical activity requiring heavy straining, neuromuscular disorders causing foot muscle pump dysfunction, history of leg trauma, clotting disorders, deep vein thrombosis (DVT) and superficial vein thrombosis, congenital vascular malformations, and connective tissue laxity.2 One should also assess for symptoms of venous disease, which include aching, tiredness or heaviness in legs, pain, throbbing, cramping, swelling, itching, or restless legs. Venous insufficiency symptoms are frequently relieved by leg elevation, activity, graduated compression stockings (GCSs), or cold compresses. Bursting pain with activity may be a symptom of iliac vein obstruction. A targeted physical examination of the legs and in some cases the pelvis should be performed, which includes
Division of Interventional Radiology, Department of Radiology, Weill Cornell Vascular, New York-Presbyterian Hospital/Weill Cornell Medical College, New York, NY. Address reprint requests to Neil M. Khilnani, MD, Division of Interventional Radiology, Department of Radiology, Weill Cornell Vascular, New York-Presbyterian Hospital/Weill Cornell Medical College, 2315 Broadway, 4th Floor, New York, NY 10024. E-mail: nmkhilna@med. cornell.edu
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visual inspection and selective use of transillumination. Physical examination findings include tortuous or dilated reticular veins; varicose veins; edema; skin changes such as discoloration, rash, eczema, or induration; and healed or active ulcerations. It is important to distinguish venous edema (aka phleboedema, which is brawny nonpitting edema) from other common causes of lower-extremity swelling, such as heart disease, renal dysfunction, and liver dysfunction as well as lymphedema. It is also important to recognize lipedema, which consists of symmetric enlargement of the lower extremities with soft fatty tissue and minimal edema sparing the feet.3 A carefully performed Doppler ultrasound (DUS) focused on the superficial venous system will elucidate underlying causes of varicose veins to adequately remove the source of venous hypertension in patients who are candidates for treatment.4 Guidelines from the American College of Phlebology and Intersocietal Accreditation Commission exist for a complete examination of the superficial venous system. DUS is typically performed with a high-frequency linear transducer (7.5-15 MHz). Standing and reverse Trendelenburg positions improve the ability to detect reflux and increase the caliber of refluxing veins compared with supine positioning. Color Doppler is used to rapidly determine the direction of blood flow. Spectral (pulsed wave) Doppler should be used to demonstrate the magnitude, duration, and direction of flow in refluxing veins. The criteria for retrograde flow in superficial veins and perforator veins are 0.5 seconds and 0.3 seconds, respectively. However, much longer periods of retrograde flow or reflux are commonly seen, extending for several seconds.
1089-2516/13/$ - see front matter & 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1053/j.tvir.2014.02.004
Superficial veins: Treatment options and techniques Multiple scoring systems exist for the physician to assess the patient’s clinical status and for the patient to report the severity of their symptoms. These include the Clinical, Etiologic, Anatomic, Pathophysiologic (CEAP) classification; the revised venous clinical severity score (VCSS); and several patient-reported metrics, including generic instruments such as the 36-Item Short Form Health Survey and several disease-specific instruments such as the Aberdeen Varicose Vein Questionnaire, Chronic Venous Insuficiency quality of life Questionnaire, Venous Insufficiency Epidemiological and Economic Study, and VVsymQ (the latter being the only instrument meeting Food and Drug Administration guidelines for use in device and drug trials). The CEAP classification is a common descriptive platform for reporting patient status in chronic venous disease.5 The classification scheme is detailed in the Table. CEAP is physician generated and relatively static; once a patient has had an ulcer they can never be better than a C5, despite treatment. As a result, it is less useful as a tool to follow disease severity after therapy. VCSS is another physician-generated scale assessing disease severity. It includes assessments of the typical signs and symptoms of venous disease rated on a scale of 0-3, including pain, varicose veins, venous edema, skin pigmentation, inflammation, induration, number of active ulcers, size of active ulcers, ulcer duration, and compression therapy.6 VCSS poorly delineates the lower end of the disease spectrum. A thorough understanding of superficial venous anatomy and anatomical variations of the lower extremities is critical to performing an accurate examination and guiding future treatment.4 The great saphenous vein (GSV) is the most commonly involved superficial vein in reflux and varicose veins. The anterior accessory GSV is a common channel within the saphenous space that can be responsible for anterior thigh varicose veins, which are present in 14% of patients with varicose veins.7 The small saphenous vein (SSV) begins on the lateral aspect of the foot and ascends posteriorly between the heads of the gastrocnemius muscle. The cephalad or thigh extension of the SSV is variable in its connection to the deep venous system and anatomy at the saphenopopliteal junction (SPJ), but it is present in 95% of patients7 (Fig. 1). Common femoral vein waveforms should be assessed bilaterally to identify evidence for an iliac vein stenosis or occlusion. An evaluation of the deep venous system for thrombosis or insufficiency in the common femoral, femoral, and popliteal veins should also be included in the DUS examination.4 Table CEAP Classification C0 C1 C2 C3 C4a C4b C5 C6
No visible or palpable signs of venous disease Telangiectasias or reticular veins Varicose veins Edema Pigmentation or eczema Lipodermatosclerosis or atrophie blanche Healed venous ulcer Active venous ulcer
83 It is important to understand the patient’s goals of treatment before initiating any therapy as managing expectations to achieve the desired outcome will lead to the perception of much better results by the patient.
Indications and Contraindications for the Treatment of Saphenous Veins Indications for treatment include clinically significant symptoms of venous insufficiency and current or prior venous ulceration as well as DUS showing axial reflux greater than 0.5 seconds in duration and a patent deep venous system. Absolute contraindications include restricted mobility and deep venous obstruction with the superficial system vital to allow venous return. Ablation can be performed to treat veins causing venous ulceration in the setting of DVT if the deep system is adequate to return blood. Relative contraindications include allergy and severe coagulopathy or thrombophilia. If a patient has an allergy to lidocaine, an amide local anesthetic, use of an ester local anesthetic such as benzocaine is suggested. Methylparaben antiseptic preservative can cause an allergy when using lidocaine in a multiuse vial, and epinephrine can cause an adverse reaction such as palpitations. Patients with a history of thrombophlebitis, DVT, known thrombophilia, or obesity are candidates for treatment with DVT prophylaxis.8 Prophylaxis is most commonly performed with low-molecular-weight heparin before or at the beginning of the procedure, although no evidence is available to support this practice. A risk assessment scale such as the Caprini Assessment tool may make this assessment more objective. A score of greater than 8 has been suggested as a valid indication for prophylaxis.9
Venous Ablation Equipment Saphenous vein ablation consists of using either a radiofrequency ablation (RFA) system or endovenous laser ablation (EVLA) system. ClosureFast (Covidien, Mansfield, MA) is the most commonly used RFA system. EVLA can be performed with multiple different laser fiber designs (ie, bare tip fibers, jacket tip fibers, and radial fibers) and diameters available from a variety of vendors. Laser generators exist with multiple different wavelengths including lower wavelengths that are considered hemoglobin specific and include 810, 940, 980, and 1064 nm. Higher wavelengths are considered water specific and include 1320 and 1470 nm. Although it is still not definitively established in the literature, some authors suggest that the higher wavelength lasers are considered to produce similar efficacy at lower power settings with less postprocedure symptoms.10
Procedural Steps Treatment of the GSV, anterior accessory GSV, and SSV is performed in a similar fashion (Fig. 2). These procedures are typically performed in an outpatient office setting without the need for oral or intravenous sedation. However,
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Figure 1 Schematic diagram of the (A) GSV and (B) SSV. (Color version of figure is available online.)
some physicians elect to prescribe an oral or intravenous sedative before the procedure. After obtaining informed consent from the patient, an ultrasound is performed to map the course of the GSV or SSV from the intended puncture site to the saphenofemoral junction (SFJ) or SPJ. The patient is placed on the procedure table in the reverse Trendelenburg position to improve dilatation of the target vein and enhance success of cannulation. The patient’s leg is prepped and draped in standard sterile fashion from the groin to the insertion site. The saphenous vein is accessed with an 18-21 gauge needle using ultrasound guidance. Following exchange over a 0.018-in wire if a 21 gauge needle is used, an angled tip 0.035-in guidewire is advanced to the SFJ (the 0.035-in wire can be placed directly through an 18-gauge or thin-walled 19-gauge needle). For some ablation tools, a vascular sheath is inserted over the guidewire near the SFJ, just peripheral to the site of the superficial epigastric vein confluence or 2 cm below the SFJ. For others, a short sheath can be used with the laser or radiofrequency (RF) tool positioned as previously stated. In the SSV, the catheter tip or laser fiber is positioned peripheral to the thigh extension of the SSV or just below the point that the vein angulates deep to join the popliteal vein. The patient’s position is usually changed to the Trendelenburg position. Dilute tumescent anesthetic is injected in the perivenous saphenous space along the entire course of the desired treatment length. The mixture for tumescent anesthetic at our institution consists of 440-mL 0.9% normal saline, 50-mL 1% Lidocaine, and 10-mL 8.4% sodium bicarbonate. The maximum patient dose of lidocaine in such a dilution for tumescent anesthetic is 35 mg/kg based on extrapolations made in the plastic surgical literature.11
Ablation is performed with the desired system. Withdrawal of the ClosureFast system is performed in 6.5-cm segments after each 7-cm section has been treated. A double cycle of the first 7 cm is performed. The RFITT system withdrawal rate is reportedly 1 cm/s. Withdrawal rate of the laser systems varies depending on the wavelength and power settings of each system. The rate using the 810-nm laser should be titrated to maintain energy transfer of 80-100 J/cm.12 Lower linear energy deposition amount have been suggested to be as effective with the more water-specific lasers. Manual compression is held over the puncture site for hemostasis and a sterile dressing is applied. A class II (30-40 mm Hg) GCS is placed on the patient immediately following the procedure and is recommended for at least one week by most practitioners. Following the procedure, the patient is encouraged to walk, and our practice is to instruct patients to take a 1-hour walk following the procedure and then 2 hours per day for 2 weeks.
Overcoming Technical Challenges Excellent ultrasound skill is essential for successful venous puncture. Nitropaste can be placed over the site of a planned venous puncture for vessel dilation and improved success of cannulation. Keeping the procedure room warm helps as well. A second puncture site that is more central can be used at times of access failure, but this is at the expense of treating segments of abnormal saphenous vein. Occasionally, the saphenous vein is tortuous, and it is difficult to advance the standard 0.035-in guidewire through the entire course of the vein. External compression can be utilized to direct the wire tip through areas of
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Figure 2 Images of the procedural steps involved in saphenous ablation. (A) Ultrasound image depicting the location of the laser fiber tip (small arrow) in relation to the SFJ (arrowhead) and the SEV (large arrow). (B) Axial ultrasound image of the laser fiber within the GSV (arrow). (C) Axial ultrasound image of the laser fiber (small arrow) with a surrounding halo of tumescent anesthesia (large arrow). A 25-gauge needle utilized for delivery of tumescent is seen in the saphenous space (arrowhead). (D) Ultrasound image at 4 weeks postablation with a typical “target” appearance of the saphenous vein (arrow). SEV, superficial epigastric vein. (Color version of figure is available online.)
tortuosity. A 0.035-in angled hydrophilic guidewire can also be used to navigate through tortuous segments or segments with synechia and scarring from prior superficial thrombophlebitis. In some cases of tortuosity, prior ablated segments with segmental remnant sections of GSV or after prior GSV phlebitis, multiple puncture sites and sheaths may be required to treat all refluxing segments. In extreme cases, fluoroscopy, if available, can be used to direct the wire.
Recognizing and Treating Complications Most complications of saphenous vein ablation are minor and typically most notable during the first 2 weeks following treatment.13,14 Commonly reported side effects include soreness, bruising, tenderness, and induration. Most complaints can be relieved with over-the-counter anti-inflammatory medications and GCSs. With GSV ablation, patients frequently will report tightness in the medial thigh due to the evolving fibrosis of the vein, which improves with stretching and time. Arteriovenous fistula creation is extremely rare with only 11 cases reported in the literature.14,15 The majority of them are asymptomatic, and avoidance of embolization or surgery
is recommended if possible. Skin burns are a rare complication of the procedure occurring in 0.14%-1.32% of EVLA procedures, which can be avoided with appropriate tumescent anesthetic.14 DVT occurs from propagation of thrombus from the superficial venous system to the deep venous system at the SFJ or SPJ, occurring in 0%-5.7% of patients after EVLA.16-18 The risk of venous thromboembolism is higher in patients with a history of prior DVT or phlebitis, CEAP 3 or greater, and male gender.17 Endothermal heatinduced thrombosis (EHIT) defines the extent of superficial thrombosis and its extension into the deep venous system as proposed by Rhee.17 Ultrasounds performed at 1.7 days postprocedure revealed a 4% incidence of EHIT 1 (venous thrombosis to the deep/superficial junction but not extending into the deep system) and EHIT 2, (nonocclusive thrombosis extending into the deep veins of o50% crosssectional area). However, EHIT 3 and EHIT 4 (450% femoral vein diameter and complete occlusion of the femoral vein) were not seen.17 Anticoagulation is not recommended for EHIT 1, and it is at the provider’s discretion for EHIT 2. It would be suggested for EHIT 3 and 4 to perform frequent monitoring with DUS to determine the duration of therapy. Catheter-directed thrombus elimination could be considered for EHIT
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86 4 and possibly EHIT 3. Parasthesias and nerve injury can occur due to the location of several nerves in close proximity to the saphenous vein. The great saphenous nerve approximates the GSV and is in closest proximity to the vein from the midcalf down to the ankle. Injury most commonly causes parasthesias that are typically transient but occasionally permanent. The sural nerve originates in the posterior calf and is alongside the SSV beginning near the inferior aspect of the gastrocnemius muscle down to the lateral malleolus. Sural nerve injury after thermal ablation occurs in 1.3%-11% of patients following SSV ablation, with 1 of 2 patients recovering sensation.19
Clinical Follow-Up Clinical follow-up in the office and with DUS varies among physicians performing this procedure. Although, many will see the patient 2 days to 1 week following ablation, our practice is to see most patients after a month and reserve early follow-up for patients in whom we are concerned about a postprocedure DVT. Further clinical follow-up after the initial postprocedure period is largely based on the needs of the patient and requirement for follow-up sclerotherapy or ambulatory phlebectomy (AP) to control symptoms or for esthetic enhancement. Once the patient’s quality of life affecting symptoms are resolved or you have achieved the desired cosmetic result or both, the patient can return as needed for recurrence of symptoms or cosmetic improvement.
Expected Outcomes EVLA and RFA result in high long-term success rates of obliterating the saphenous vein of 93% and 87.5%, respectively.18 GSV success rates range from 88%-100% and SSV success rates range from 88%-96%.18 Surgical ligation and stripping and ultrasound-guided foam sclerotherapy achieve poorer anatomical success (disappearance of the vein). In a meta-analysis by van den Bos et al,18 it is likely that the long-term recurrence rate after surgery is higher than that of EVLA because of neovascularization.
Perforating Veins Clinical Evaluation of the Patient Clinical evaluation of the patient is the same as stated earlier for saphenous veins involving a complete history and physical examination, transillumination, and DUS. There are approximately 60 perforating veins (PVs) in the thigh, 8 in the popliteal fossa, 55 in the calf, and 28 in the foot.20 The number of incompetent PVs per limb increases with worsening chronic venous disease (CEAP 4-6), and there is also an increasing incidence of incompetent PVs when they measure more than 4 mm.20
Indications for the Treatment of PVs Treatment of pathologic PV should be reserved for patients who have exhausted other methods of treating venous
hypertension and eliminating other sources of reflux. Although the evidence is not strong, the American Venous Forum and Society of Vascular Surgery define pathologic perforators and recommend treatment of perforators when their size is greater than 3.5 mm, when the reflux is greater than 0.5 seconds, and when they are located in close proximity to an active ulcer that persists after all superficial venous reflux is eliminated and inelastic compression bandaging used.21
Equipment Needed Percutaneous ablation of perforators (PAPS) can be performed with either the EVLA kit or RFA kit. Sclerotherapy is performed with 25-, 27-, or 30-gauge needles. Sodium tetradecyl sulfate or polidocanol detergent sclerosant is most commonly utilized as a foam created by the Tessari method, which consists of a 1:4 liquid-to-air or gas ratio.
Procedural Steps Percutaneous Ablation of Perforators (Endovenous Laser Ablation or Radiofrequency) The PV is accessed with a 21-gauge needle or a 16-gauge angiocatheter with the patient in the reverse Trendelenburg position.22 The 21-gauge needle would need to be exchanged for a micropuncture access set. The ClosureRFS stylet (Covidien, Mansfield, MA) or the laser fiber is then inserted and positioned at or just below the level of the fascia. Tumescent anesthesia is administered after placing the patient in Trendelenburg position. Ablation is performed with RF by treating all 4 quadrants of the vein wall for 1 minute each and then withdrawing the device 12 mm for a second ablation. When using laser, a pulsed technique is recommended by Elias et al21 using 15 watts and a 4-second pulse interval. Each segment of the vein is treated twice for a total delivery of 120 J to each segment for an average of 3 segments.
Sclerotherapy Ultrasound-guided injection of foam sclerotherapy is typically performed with the leg in the supine position and a volume of 0.5-1 mL. The targeted vein is usually a tributary varix connected to the incompetent perforator vein and not the incompetent perforator vein itself. The end point is filling of the incompetent perforator vein; the injection is terminated just before or after the deep vein is filled. Muscle pump activation is initiated as soon as the injection is completed.
Overcoming PAPS Technical Challenges The perforating vein has a paired artery, and careful attention during ultrasound-guided access is required to avoid puncture and injury or injection of the neighboring artery.
Superficial veins: Treatment options and techniques
Recognizing and Treating Complications The North American subfascial endoscopic perforator surgery registry had no patients with DVT within 30 days of subfascial endoscopic perforator surgery procedure. PAPS procedural complications are extremely rare with a few reported cases of tibial vein thrombosis, foot drop, and skin burn.23 Sclerotherapy also has rare thrombotic complications with a reported 0% incidence of DVT in a study by Masuda et al24 and 1 out of 80 patients who developed skin necrosis.
Clinical Follow-Up
87 veins. In addition to treating underlying axial reflux, treatment of the “varicose reservoir” can remove the low pressure sump caused by varicosities potentially resulting in a more durable removal of unwanted or painful varicose veins.30 Treatment options for elimination of varicose tributaries include AP and chemical ablation (aka sclerotherapy). Light-based therapies have limited value and only in the treatment of telangiectasia.
Indications for the Treatment of Tributary Veins
The patient should continue with compression therapy until ulcer healing. It may be prudent to see the patient weekly to track the progression of ulcer healing over time and participate in wound care.
Indications for treatment include esthetic concerns of eliminating varicose veins, discomfort over the varicose veins due to venous hypertension and vessel dilatation, and adjunctive treatment to saphenous ablation to remove the “varicose reservoir.”
Expected Outcomes
Equipment Needed
Surgery Treatment of perforator veins is controversial with several studies showing no symptomatic benefit in C2 patients or improved ulcer healing in C5 or C6 patients.25-27 Although many limitations exist in these studies, elimination of saphenous reflux may hasten ulcer healing.
For AP, incisions or punctures can be made with an 18gauge needle, an 11-blade scalpel, a 151 ophthalmic blade, or a punch biopsy device. The most widely known vein hooks used for grasping the vein include Muller, Oesch, Tretbar, Ramelet, Verady, Dortu-Mortimbeau, and KabnickGoldman. Three to 5 fine-tip curved clamps (ie, mosquito clamp) are usually used to grab and tease out the vein.31 Chemical ablation is performed in a similar fashion to previously described sclerotherapy for perforator veins using 27- or 30-gauge needles.32 Polidocanol and sodium tetradecyl sulfate are most commonly employed and are typically used in the liquid form for this purpose. A transillumination device can be useful for guidance. Common devices include the Veinlite (TransLite, LLC, Sugar Land, TX) and the VeinViewer (Christie Digital Systems, Cypress, CA). Ultrasound is sometimes necessary to visualize veins that cannot be seen visually or with transillumination.
Percutaneous Ablation of Perforators Although several studies have been performed looking at the feasibility of perforator ablation, very few studies have evaluated for ulcer healing and recurrence. One study evaluated patients with nonhealing ulcers following conservative management with compression therapy and saphenous ablation and found a greater than 90% success rate of complete ulcer healing after perforator ablation with RF.28 However, there is a prolonged learning curve to the procedure, and its use should be reserved for patients with recalcitrant venous ulcers. In a study of patients with CEAP 5 disease, healed venous ulcers, and progressive lipodermatoscleros is, ablation of at least one incompetent perforator resulted in an ulcer recurrence rate of 4.8% in another study.29 Sclerotherapy In a study by Masuda et al,24 80 limbs were treated with perforator sclerotherapy for perforator incompetence alone. The study demonstrated a significant improvement in VCSS scores and rapid ulcer healing in 86.5% of patients with a mean time of healing of 36 days.
Tributary Veins Clinical Evaluation of the Patient Clinical evaluation, as with previous patients with venous insufficiency, involves a complete history and physical examination, transillumination, and DUS. It is extremely important to have a clear understanding of the superficial venous anatomy and pattern of flow resulting in varicose
Procedural Steps Ambulatory Phlebectomy Use transillumination to identify the varicose veins and outline them with a surgical marker while the patient is standing (Fig. 3). Apply tumescent anesthesia in the region of planned phlebectomy. Make a microincision or puncture near the vein. Insert the vein hook and grasp the vein, bringing it out of the dermatotomy. Grasp the vein with a mosquito clamp. Gently tease the vein out of the puncture site while successively clamping the vein closer to the skin. Once the vein is avulsed, repeat the process in a new location until the entire segment is removed. The puncture sites should be covered with bandages to absorb leakage of tumescent anesthetic. A class 2 (30-40 mm Hg) compression stocking or short stretch bandage should be applied immediately and worn for 48 hours continuously followed by wearing a GCS for 10-14 days. The patient should be encouraged to walk for 1 hour immediately following the procedure and then 1-2 hours per day for 2 weeks.
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Figure 3 Stepwise demonstration of ambulatory phlebectomy procedure. (A) Grasping of the vein with the vein hook. (B) Clamping the vein with a mosquito clamp. (C and D) Gentle traction on the vein for vein removal. (Color version of figure is available online.)
Chemical Ablation Identify the pathway of veins to be eliminated.32,33 Transillumination may help to identify the varicose veins and outline them with a surgical marker. Working from proximal to distal, inject sclerosant into the veins with the patient in the supine or reclined position allowing for visualization of veins and ergonomically appropriate positioning for the provider. The sclerosant is gently massaged after injection to improve contact with the vein wall. Compression following sclerotherapy lacks consensus, but our practice is to place the patient in a class 1 or 2 (20-30 or 30-40 mm Hg) compression stocking immediately, which is worn for 7 days. The patient should be encouraged to walk for 1 hour immediately following the procedure and then 1 hour per day. The patient should return for follow-up in 1-3 weeks. At this point, the veins may have disappeared completely, disappeared partially, or have become tender, lumpy, nodular, and hyperpigmented. If the latter occurs, removal of intravascular hematoma with a 25- or 18-gauge needle puncture is used to decrease skin pigmentation. Ultrasound-guided sclerotherapy can be used to treat tributary veins in a similar fashion, if they are not visible using other methods.
Overcoming Technical Challenges Multiple large varicose veins in well-defined pathways are best approached with AP over chemical ablation. Chemical
ablation or compression sclerotherapy is ideal for smaller more network like and may require multiple sessions for complete treatment, including several visits for intravascular hematoma removal. Often both are used in combination to obtain the best results.
Recognizing and Treating Complications Complications following AP are extremely rare and vary widely depending on the provider performing the procedure.34 The most commonly reported complications include skin blistering from dressing abrasions, adhesive tape or steritrips (1.3%-20%), telangiectatic matting (1.5%-9.5%), hyperpigmentation (0.01%), missed varix (0.3%), and parasthesias (0.2%-4.6%). Common peroneal nerve (CPN) injury following phlebectomy occurred in 2%-4.7% of patients in the literature and could result in sensory loss or foot drop following SSV surgery.35 The sciatic nerve divides into the CPN and tibial nerves in the region of the popliteal fossa with the CPN most commonly located just medial to the biceps femoris tendon to near the fibular head. When planning phlebectomy, care or avoidance of this region is generally recommended to avoid CPN injury.35 The advantage of performing these procedures in patients who are awake is that they are aware of nerve manipulation. Complications after chemical ablation are also extremely rare including medication allergy, skin ulceration, skin pigmentation, telangiectatic matting, and DVT.
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Clinical Follow-Up Standard follow-up for AP would include a visit at 3-4 weeks following treatment to assess for healing of the skin puncture sites. At this time, it is also possible to treat additional remaining tributary or varicose veins with sclerotherapy if necessary for the desired result. A subsequent AP may be useful in some cases (ie, circumferentially distributed veins involving all sides of a leg). Follow-up evaluation after sclerotherapy is typically at 3 weeks, at which point removal of intravascular hematoma can be performed as well as treatment of other untreated veins.
References 1. Khilnani N, Morrison N: Clinical evaluation of patients with chronic lower extremity venous disorder. in Sadick NS, Khilnani N, Morrison N (eds.), Practical Approach to the Management and Treatment of Venous Disorders. Springer London, 25-31, 2013 2. Criqui MH, Denenberg JO, Bergan J, et al: Risk factors for chronic venous disease: The San Diego population study. J Vasc Surg 46:331-337, 2007 3. Rudkin GH, Miller TA: Lipedema: A clinical entity distinct from lymphedema. Plast Reconstr Surg 94:841-847, 1994 [discussion 848-849] 4. Khilnani NM: Duplex ultrasound evaluation of patients with chronic venous disease of the lower extremities. Am J Radiol 202:633-642, 2014 5. Eklof B, Rutherford RB, Bergan JJ, et al: Revision of the CEAP classification for chronic venous disorders: Consensus statement. J Vasc Surg 40:1248-1252, 2004 6. Vasquez MA, Munschauer CE: Venous clinical severity ccore and quality-of-life assessment tools: Application to vein practice. Phlebology 23:259-275, 2008 7. Cavezzi A, Labropoulos N, Partsch H, et al: Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs—UIP consensus document. Part II. Anatomy. Eur J Vasc Endovasc Surg 31:288-299, 2006 8. Gould MK, Garcia DA, Wren SM, et al: Prevention of VTE in nonorthopedic surgical patients: Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 141:e227S-e2277, 2012 9. Bahl V, Hu HM, Henke PK, et al: A validation study of a retrospective venous thromboembolism risk scoring method. Ann Surg 251: 344-350, 2010 10. Sadek M, Kabnick LS, Berland T, et al: Update on endovenous laser ablation: 2011. Perspect Vasc Surg Endovasc Ther 23:233-237, 2011 11. Klein JA: Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. J Dermatol Surg Oncol 16:248-263, 1990 12. Niedzwiecki G: Endovenous thermal ablation of the saphenous vein. Semin Interv Radiol 22:204-208, 2005 13. Oguzkurt L: Endovenous laser ablation for the treatment of varicose veins. Diagn Interv Radiol 18:417-422, 2012 14. Dexter D, Kabnick L, Berland T, et al: Complications of endovenous lasers. Phlebology 27:40-45, 2012 15. Rudarakanchana N, Berland TL, Chasin C, et al: Arteriovenous fistula after endovenous ablation for varicose veins. J Vasc Surg 55:1492-1494, 2012 16. Knipp BS, Blackburn SA, Bloom JR, et al: Endovenous laser ablation: Venous outcomes and thrombotic complications are independent of
17.
18.
19.
20.
21.
22.
23. 24.
25.
26.
27.
28.
29.
30.
31.
32.
33. 34. 35.
the presence of deep venous insufficiency. J Vasc Surg 48: 1538-1545, 2008 Rhee SJ, Cantelmo NL, Conrad MF, et al: Factors influencing the incidence of endovenous heat-induced thrombosis (EHIT). Vasc Endovascular Surg 47:207-212, 2013 van den Bos R, Arends L, Kockaert M, et al: Endovenous therapies of lower extremity varicosities: A meta-analysis. J Vasc Surg 49: 230-239, 2009 Huisman LC, Bruins RM, van den Berg M, et al: Endovenous laser ablation of the small saphenous vein: Prospective analysis of 150 patients, a cohort study. Eur J Vasc Endovasc Surg 38:199-202, 2009 Labropoulos N, Mansour MA, Kang SS, et al: New insights into perforator vein incompetence. Eur J Vasc Endovasc Surg 18: 228-234, 1999 Gloviczki P, Comerota AJ, Dalsing MC, et al: The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg 53:2S-48S, 2011 Elias S: Treatment of incompetent perforating veins. in Sadick NS, Khilnani N, Morrison N (eds.), Practical Approach to the Management and Treatment of Venous Disorders. Springer London, 107-115, 2013 O’Donnell TF: The role of perforators in chronic venous insufficiency. Phlebology 25:3-10, 2010 Masuda EM, Kessler DM, Lurie F, et al: The effect of ultrasoundguided sclerotherapy of incompetent perforator veins on venous clinical severity and disability scores. J Vasc Surg 43:551-556, 2006 [discussion 556-557] Kianifard B, Holdstock J, Allen C, et al: Randomized clinical trial of the effect of adding subfascial endoscopic perforator surgery to standard great saphenous vein stripping. Br J Surg 94:1075-1080, 2007 van Gent WB, Hop WC, van Praag MC, et al: Conservative versus surgical treatment of venous leg ulcers: A prospective, randomized, multicenter trial. J Vasc Surg 44:563-571, 2006 Barwell JR, Davies CE, Deacon J, et al: Comparison of surgery and compression with compression alone in chronic venous ulceration (ESCHAR study): Randomised controlled trial. Lancet 363: 1854-1859, 2004 Lawrence PF, Alktaifi A, Rigberg D, et al: Endovenous ablation of incompetent perforating veins is effective treatment for recalcitrant venous ulcers. J Vasc Surg 54:737-742, 2011 Harlander-Locke M, Lawrence P, Jimenez JC, et al: Combined treatment with compression therapy and ablation of incompetent superficial and perforating veins reduces ulcer recurrence in patients with CEAP 5 venous disease. J Vasc Surg 55:446-450, 2012 Pittaluga P, Chastanet S, Rea B, et al: Midterm results of the surgical treatment of varices by phlebectomy with conservation of a refluxing saphenous vein. J Vasc Surg 50:107-118, 2009 Kabnick L: Ambulatory phlebectomy. in Sadick NS, Khilnani N, Morrison N (eds.), Practical Approach to the Management and Treatment of Venous Disorders. Springer London, 93-106, 2013 Sadick N: Sclerotherapyand alternatives. in Sadick NS, Khilnani N, Morrison N (eds.), Practical Approach to the Management and Treatment of Venous Disorders. Springer London, 61-82, 2013 Goldman MP, Guex J-J, Weiss RA: Treatment of Varicose and Telangiectatic Leg Veins. Saunders Elsevier Philadelphia, 2011 Ramelet AA: Complications of ambulatory phlebectomy. Dermatol Surg 23:947-954, 1997 Atkin GK, Round T, Vattipally VR, et al: Common peroneal nerve injury as a complication of short saphenous vein surgery. Phlebology 22:3-7, 2007
