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UPDATE ON DIAGNOSIS AND TREATMENT FOR VARICOSE VEINS (PART 2)



Clinical presentation of Chronic Venous Disorder can be very diverse; and strategy of treatment would vary with individual case. This article aims to describe the recent advance in treatment of varicose veins arising from trunkal reflux. i.e. the Great & Small Saphenous Veins.

The conventional treatment for varicose veins of Great Saphenous Veins is ligation of Saphenofemoral junction and its tributaries and stripping of Great Saphenous Veins. The disadvantage of this operation is the associated invasiveness and trauma. Technology is now moving towards minimally invasive therapy. As in other areas of vascular surgery, endoluminal therapy is a well-accepted option, and an evidence based practice in the treatment of varicose veins today. With the easy availability of ultrasonogram (USG) technology, most of the endovenous therapy is performed under USG guidance.



Endovenous Therapy of Varicose Veins

New technologies and improvements in established methods have had dramatic effects in the manner in which superficial venous diseases are diagnosed and treated. Duplex Scan USG is becoming an essential tool for evaluating patients with venous disease. The three techniques currently in use and with stronger clinical evidence for the treatment of varicose vein are; namely ultrasound-guided foam sclerotherapy (UGFS), endoluminal saphenous ablation includes radiofrequency ablation (RFA), and endovenous laser therapy (EVLT).



Ultrasound-guided foam sclerotherapy (UGFS)

The use of foam for sclerotherapy has greatly improved the efficacy and safety of the procedure. Sclerosants (Sodium Tetradecyl Sulfate or Polidocanol) are mixed with air or CO? to form microbubbles. Foam acts by completely displace blood away from the vein wall, and hence increase the contact area of sclerosants with the endothelium. Traditionally, sclerotherapy is mainly for closing the spiders, reticular veins, and tributaries of varicose veins. Current studies also showed that foam sclerotherapy can be safely applied in saphenous veins reflux, perforating veins reflux, and more deeply situated varicosities.

USG is used to guide the needle puncture into the target veins, and extravasation is minimized. UGFS is indicated in primary great and small saphenous veins, previously treated varicosities and recurrences after surgery.

Complications are rare, except some local cutaneous side effects such as hyperpigmentation and, rarely skin necrosis. A few weeks after the therapy, patients may experience a string-like induration of the injected vein, which is due to venous obliteration. Other reported complications are myocardial infarction, anaphylaxis, deep vein thrombosis, pulmonary embolism, visual disturbance, headache, and stroke.



RFA

RFA is mainly for treatment of Great or Small Saphenous vein reflux. By using a catheter releasing radiofrequency waves at the tip, it destroy the saphenous endothelium and denatures the vein wall collagen, resulting in the formation of a fibrous cord with obliteration of the vein. Under ultrasound guidance, the saphenous vein is accessed percutaneously near the knee. An introducer sheath is placed inside the vein and the radiofrequency catheter of less than 3mm diameter is introduced through the sheath to the Saphenofemoral junction. Local anaesthesia consisting of a dilute mixture of saline, lidocaine and adrenaline, is infused along the course of the Saphenous vein to help in obtaining better contact of the vein wall with the catheter and to provide a thermal buffer between the saphenous vein and the skin. Electric energy in the electrode is converted to heat energy, and is transmitted to the vein wall. The catheter is then slowly withdrawn, so that the entire saphenous vein in the thigh is treated. Follow-up ultrasound is done to confirm the successful ablation of Saphenous vein and to evaluate the common femoral vein for evidence of deep vein thrombosis or proximal extension of thrombus into the femoral vein.



EVLT

EVLT works very similar to RFA procedure, except that Laser energy is used. Laser fiber is inserted into the Saphenous vein under ultrasound guidance. The wavelengths used in EVLT target deoxygenated haemoglobin and/or water with the range between 810 and 1500nm. It initiates a non-thrombotic occlusion by direct and indirect thermal injury to the vein wall, causing endothelial denudation, collagen contraction and later fibrosis.



Which one to used?

RFA and EVLT can be performed under local anaesthesia, whereas UGFS does not require anaesthesia. They all can be performed safely in a clinic setting. Recent studies showed RFA and EVLT have similar efficacy and safety, when compared with stripping operation. RFA is associated with less post-operative pain and bruising than EVLT. However, UGFS has higher recurrence rate when compared with RFA, EVLT and surgery.



Conclusion

None of these therapies are prefect. Each have their own limitation, risk, and failure rate. Instead of replacing surgery, they are providing more options in the treatment of varicose veins. Treatment can now be tailored to individual patients based on their clinical status, symptoms and cosmetic concerns.

There are newer therapies coming up like glue, steam therapy etc, but evidence is not enough to prove their role yet.

Varicose vein of Great Saphenous veins

1 week after RFA therapy of GSV

Varicose vein of GSV with calf varicosities

1 month after RFA of GSV + foam slcerotherapy of calf varicosities


RFA fibre in GSV close to Saphenofemoral junction


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