Trends in the treatment of venous disease have mirrored those of arterial pathology with the development and advancement of minimally invasive technologies.
Patients with venous ulcerations or painful varicosities whose only option had previously been only traditional saphenous vein ligation and/or stripping or open perforator ligation can now be treated with a variety of endoluminal approaches. These procedures may also be combined with microphlebectomy. The goal of open and endovenous therapy is to obliterate the affected veins, thereby eliminating reflux, reducing pain, and preventing recurrence of venous ulcers
The decision as to which therapy is appropriate for any given patient depends on the patients clinical presentation, anatomy, medical co-morbidities, and treatment goals. Patients with large, tortuous varicosities and extensive reflux are best served with an open ligation and stripping. Patients with less challenging anatomy are candidates for endovenous intervention.
Endovenous techniques can be used to treat reflux in the long or short saphenous vein, in duplicate systems, and even in perforating veins. These procedures can be accomplished in an outpatient setting and with a low morbidity.
There are several methods that can be used to perform endovenous ablation. The basic unifying principal is damage to the vessel wall which results in sclerosis and obliteration of the lumen. The most common methods utilize heat energy to close the lumen.
In one case radiofrequency energy is employed and in another laser energy is used. Mechanical ablation using foams or other sclerosing agents can also be performed. These agents cause endothelial and vessel wall damage by interfering with the function of endothelial and subendothelial cell surface proteins, leading to thrombosis and fibrous obliteration of the vein.
Radiofrequency energy is a type of electrical energy whose waves cause excitement in the molecules of an object by virtue of the object’s resistance. This causes heating of the object, called “resistive heating”, resulting in collagen shrinking and fibrosis as well as denuding of the endothelium. The walls of the vein can therefore be heated in a controlled and efficient manner.
Laser treatment utilizes an optical fiber to deliver laser energy and heat the blood inside a vein. The laser delivers energy that heats the blood, damaging the vein as a result of the steam bubble and inducing the blood to clot.
Either method can used to treat the Greater (Long) Saphenous vein, the Lesser (Short) Saphenous vein, or even duplicate systems. In both procedures a percutaneous puncture is made and a catheter is introduced into the vein over a guidewire under ultrasound guidance. The catheter is then pulled back along the length of the segment to be treated. These procedures are performed under duplex ultrasound guidance with a minimal blood loss and reduced post-operative swelling and ecchymosis. Recently the radiofrequency procedure has been expanded to the treatment of incompetent perforator veins. A newer version of the radiofrequency catheter and generator permits a greatly reduced treatment time. There are several different lasers available for endovenous ablation.
In foam sclerotherapy a solution of an irritating chemical is used to damage the vessel wall. These procedures are also performed under duplex guidance.
As in other endovenous therapies a percutaneous puncture is made and a catheter placed over a guidewire. When position is confirmed, the foam agent is injected under ultrasound observation. The catheter is then slowly withdrawn and the vein closed by virtue of the chemical reaction with the wall.
Foam sclerotherapy may be useful for the treatment of varicosities emanating from pelvic venous reflux as well as in the ablation of incompetent communicating veins and perforators.
Other non-endovenous, minimally invasive vein treatments are available including Transilluminated Powered Phlebectomy and, Subfascial Endoscopic Perforator Surgery (SEPS) Color duplex ultrasonography can visualize, guide and monitor all aspects of the radiofrequency, laser, and foam sclerosant ablation procedures. This approach eliminates exposure to ionizing radiation and contrast agents. Endovenous therapy for the treatment of venous disease has continued to gain popularity. Some authors have used the methods in combination in an attempt to achieve improved results. Refinements in technology, experience, and patient selection should further improve results. -Evan Lipsitz, MD-