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450 Radiofrequency treatment of the incompetent saphenous vein
https://t.me/med1917
incidence of neovascularization are no incision and surgical
dissection of the groin resulting in angiogenic stimuli and
minimal hemodynamic disturbance thanks to preservation
of physiologic epigastric ow through the SFJ. Subsequent
to RFA, recanalization of the vein is most oen the culprit,
but the actual recurrence of SFJ reux is a more objective
measure and provides important hemodynamic information that permits the detection and possible prediction of
clinical recurrence. Reux in tributary veins or perforator
veins can also cause hemodynamic failure. Clinical failure occurs when symptoms do not resolve or recur, and is
usually associated with the reappearance of varicose veins.
Varicose vein recurrence rates aer vein stripping have been
reported between at 20% and 50% at 2–5 years,
4,4 6–51
and up
to 70% of patients have some degree of recurrent symptoms
by 10 years.52 However, the varicose vein recurrence rate can
be aected by several factors, including the completeness
of varicosity removal at the time of initial surgery and the
examiner’s subjectivity. Interestingly, 5-year data from the
VNUS Closure Registry revealed that hemodynamic failure
did not result in symptom recurrence in most patients.28 In
a more recent study, however, symptom recurrence (relative risk [RR]: 2.75) and need for additional procedures
(RR: 3.96) did correlate with recanalization as identied by
duplex, but in the 17 out of 249 limbs with recanalization,
no anatomic or patient-specic risk factors were found.
53
37.7 OTHER RF DEVICES
37.7.1 RF-induced thermotherapy
RF-induced thermotherapy (RFiTT; Celon AG, Medical
Instruments, Teltow, Germany) is a technique which utilizes bipolar RF via resistive heating of the vein wall. In
the Laser and RFA Ablation (LARA) study, RFiTT (n = 40)
was compared to EVLT with an 810-nm laser (n = 34).
Occlusion was 95% in both groups at 10 days and 74% and
78% (P = non-signicant) at 3 months in the ablation and
laser groups, respectively. In patients who were their own
controls, as they had bilateral disease with one leg treated
by laser and other by RFiTT, post-operative pain and bruising were signicantly less in the RFiTT legs in the rst 2
54
weeks.
A much larger prospective, non-randomized, mul-
ticenter study included 462 patients (569 GSVs), with follow-up at between 180 and 360 days (mean: 290 ± 84 days).
Complete occlusion was accomplished in 98.4% of patients
at a mean follow-up of 290 days when experienced operators
performed the procedure.
55
37.7.2 F Care Systems: Endovenous RF
Endovenous RF (EVRF; F Care Systems, Antwerp, Belgium)
is a monopolar RF device which applies continuous energy
for ablation of the saphenous vein using the CR45i catheter
at 4 MHz (25 W). In one unpublished, small, prospective,
non-randomized study, 30 patients (54 GSVs) were treated
with this technique. At the 1-month follow-up, 92% of
patients had complete occlusion, 6% had partial occlusion
without reux, and 2% had partial occlusion with reux.56
Szabó (unpublished data) treated 313 patients (276 GSVs) in
a single-center, prospective study, with early and mid-term
results showing complete occlusion in 99% (275/276) of veins
at 1 month. Patient satisfaction was 99% and there were no
major complications such as DVT, thermal burns, or nerve
57
injury.
37.7.3 Other endovenous or minimally
invasive treatment options
While saphenous RFA combines the benets of a minimally
invasive procedure with excellent clinical outcomes, new
endovenous modalities continue to challenge RFA as the
preferred technique for the treatment of the incompetent,
symptomatic saphenous vein. ese include tumescentless
mechanochemical endovenous ablation (MOCA), chemical
and glue ablations, and higher-wavelength laser bers, covered laser bers, and minimally invasive conventional surgical techniques. In one recent small, prospective study of
38 patients using glue—cyanoacrylate embolization (CAE)
with the VenaSeal Sapheon Closure System (Sapheon,
Inc., Morrisville, NC)—a 92% target vein closure rate was
achieved without the need for tumescent anesthesia or
post-operative compression stockings. ese outcomes
were maintained at the 2-year follow-up.58 A randomized
controlled trial published at the time of the writing of this
chapter describes the immediate 3-month follow-up results
of CAE (n = 108) versus segmental RFA (n = 114). e study
showed non-inferiority of CAE to RFA, an adequate safety
prole, less peri-procedural ecchymosis, and no need for
tumescent anesthesia.59 ere was no statistical advantage
to RFA where peri-procedural pain scores were concerned.
MOCA techniques employing the Clarivein Catheter
(Vascular Insights, Madison, CT) use mechanical injury
to the vein endothelium in combination with an infused
liquid sclerosant. Early series have reported decreased
pain and bruising with MOCA, with comparative vein
occlusion rates to the CLF segmental ablation catheter.
More denitive answers as to whether these devices have
equal ecacy and decreased pain compared to RFA will
come from two randomized trials currently enrolling
patients to compare MOCA with segmental RFA. ese
are the Mechanochemical Endovenous Ablation versus
Radiofrequency Ablation in the Treatment of Primary
Great Saphenous Vein Incompetence (MARADONA)
study for the GSV62 and the Mechanochemical Endovenous
Ablation versus Radiofrequency Ablation in the Treatment
of Primary Small Saphenous Vein Insuciency (MESSI)
study for the SSV.63 ese two trials are intended to compare peri-procedural pain and the ecacy of the MOCA
compared with RFA.
60, 61
References 451
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37.8 CONCLUSIONS
One trial compares results with all three major endovenous
options (sclerotherapy, laser, and RFA) and conventional
Endovenous ablation is now arguably the standard for the
treatment of saphenous vein incompetence. e evidence
for the ecacy—both clinical and anatomic—of RFA of
the GSV is quite robust and is derived from peer-reviewed
journal articles including 14 randomized studies and their
respective mid-term follow-up data. Nine of these studies
compare RFA to open ligation and saphenous vein strip-
7–15
ping
and ve compare RFA to endovenous laser.
29,37,54,64,65
surgery.
e most recent-generation RFA by segmental ablation has
been rapidly adopted by clinicians because of its proven ecacy, short procedure times, and mild patient recovery prole as compared to both surgery and EVLT. Although there
are now several additional modes of endovenous ablation,
none have thus far been as thoroughly evaluated and well
studied in the peer-reviewed literature as thermal RFA.
Guidelines 4.9.0 of the American Venous Forum on radiofrequency ablation of the incompetent saphenous vein
No. Guideline
4.9.1 Endovenous thermal ablations (laser and radiofrequency
ablations) are safe and effective, and we recommend
them for the treatment of saphenous incompetence.
67
4.9.2 Because of reduced convalescence and less pain and
morbidity, we recommend endovenous thermal ablation
of the incompetent saphenous vein over open surgery.
35
ese data have been systematically reviewed.
recommendation
(1: strong; 2:
67
Grade of
Grade of evidence
B:moderate quality;
weak)
C:low or very low quality)
1 B
1 B
(A:high quality;
33,66
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Laser treatment of the incompetent
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saphenousvein
NICK MORRISON
38
38.1 Introduction 455
38.2 Background 455
38.3 Patient selection 456
38.4 Technology 456
38.5 Procedure 457
38.6 Follow-up 458
38.1 INTRODUCTION
Lower extremity varicose vein disorders are most oen
associated with truncal venous insuciency involving the
saphenous system: the great saphenous vein (GSV), the small
saphenous vein (SSV), and/or incompetent major tributaries
or perforator veins. Varicose vein disorders have historically
been treated with stripping of the saphenous vein and interruption/ligation and removal of the major tributary and
perforator veins.1 Since 1999, endovenous thermal ablation
procedures have been found to be safe and eective methods
of eliminating the proximal portion of the GSV, the SSV,
andeven tributary and perforating veins from the venous
circulation, with faster recovery and better cosmetic results
tha n strippi ng.
monly used to achieve thermal ablation of these incompetent veins are: the Venet procedure using a radiofrequency
(RF) catheter and generator (Medtronic, Minneapolis,
MN); the RF-induced thermotherapy procedure using a
bipolar RF system (Celon AF Medical Instruments, Teltow,
Germany); the endovenous laser ablation procedure using
a laser ber and generator (various manufacturers); and
the steam vein sclerosis procedure using heated vaporized
water (CERMA SA, Archamps, France). e rst three systems use electromagnetic energy, whereas the last utilizes
steam. As with a stripping procedure, following these endovenous thermal ablation procedures, it is also necessary to
treat any remaining incompetent portion of the GSV and/
or SSV, perforating veins, and varicose tributaries, typically
will primarily concern itself with endovenous laser ablation.
2,3
e currently ava ilable methods most com-
4
is chapter
38.7 Outcomes 458
38.8 Perforator vein laser ablation 460
38.9 Summary 461
38.10 Conclusions 461
References 461
38.2 BACKGROUND
38.2.1 Animal studies
ere are no reports of animal testing of laser technology
in saphenous vein ablation prior to the initial publication
of clinical case series. In 2002, Weiss5 described in vivo caprine jugular veins treated with RF and pulsed-mode 810-nm
diode lasers, with uoroscopic and histologic examinations
demonstrating extensive vein wall damage and frequent
perforations with laser ablation compared with RF ablation.
Min etal.6 recorded temperatures outside the porcine vein
during laser ablation with injected perivenous anesthetic
(as is standard for human treatment), and demonstrated
temperatures no higher than 40°C within 2 mm of the
vein. Later, Fan and Anderson7 treated blood-lled bovine
saphenous veins with laser ablation, producing inconsistent
transmural thermal damage with perforations, and concluded that direct thermal damage is the likely mechanism
of vein wall destruction, not steam bubbles as had been previously postulated.
8
38.2.2 Human studies
Prior to the publication of single-center case series reports
of endovenous laser ablation of the incompetent saphenous
vein, no multicenter clinical trials of the safety and ecacy
of this procedure in humans were published. Since the initial published case series, some analyses of the pathophysiologic eects of laser ablation in humans have emerged.
Proebstle etal.
9
reported on the heat injury seen in a GSV
455
456 Laser treatment of the incompetent saphenousvein
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that was removed following pulsed-mode laser ablation
and found damage along the entire vein, noting more
severe damage with perforations at the site of the laser
pulses. Corcos et al.10 described histopathologic changes
in GSVs treated by laser ablation without perivenous anesthesia, in combination with saphenofemoral interruption
and excision of a portion of vein for histologic examination. Full-thickness intimal thermal damage was seen in
three-quarters of the veins, with transmural damage and/
or perforation seen in a quarter of the veins. However, several veins had been subjected to more than one ablation
period during treatment, thus limiting the importance of
the ndings.
Finally, in an attempt to quantify the risk of thermal
damage to surrounding tissue during laser ablation aer
injection of perivenous anesthetic, Beale et al.11 measured
maximum temperatures of approximately 43°C in tissues
3–5 mm from the GSV during laser ablation. ese ndings
were conrmed by Viarengo etal.
12
38.3 PATIENT SELECTION
Inclusion criteria are: symptoms and physical signs of
venous disorder; a duplex scan, performed by a fully
qualied sonographer, showing a patent vein with reux
greater than 0.5 seconds; a patent deep venous system;
a vein conducive to cannulation; and adequate patient
mobility (Box 38.1).
Exclusion criteria are: arteriovenous malformations;
restricted ambulation; acute infection; acute venous thrombosis13; and deep venous obstruction (Box 38.2).
As a surgeon’s experience with endovenous ablation procedures increases, relative exclusion criteria may be relaxed,
and patients with deep venous reux, previous venous treatment, large-diameter veins, aneurysmal vein segments, vein
tortuosity, or those on chronic anticoagulant therapy14 or
BOX 38.1: Clinical indications for laser
ablation
●
Superficial venous disorder
●
Duplex scan with reflux >0.5 seconds
●
Patent deep system
●
Vein conducive to cannulation
●
Adequate patient mobility
BOX 38.3: Relative exclusion criteria
●
Deep venous reflux
●
Previous treatment
●
Large-diameter vein
●
Anticoagulant therapy
●
Hormone-replacement therapy
●
Vein tortuosity
●
Aneurysmal vein segments
hormone-replacement therapy may be safely and successfully treated (Box 38.3).
Strong consideration of a thrombophilic condition
should be given pre-operatively to patients with a history of deep vein thrombosis, recurrent episodes of acute
supercial venous thrombophlebitis, multiple spontaneous abortions, or a strong family history of deep vein
thrombosis or clotting disorders. e physician should
be aware of the guidelines produced by the American
College of Chest Physicians for the risk assessment for
deep vein thrombosis,
15
as these guidelines may be helpful in selecting patients for laser ablation and in selecting
which patients should receive prophylactic anticoagulation before undergoing endovenous laser ablation. While
the risk of deep vein thrombosis following these procedures is low, such a potentially life-threatening outcome
following the treatment of relatively benign disease could
be catastrophic.
38.4 TECHNOLOGY
Laser generators are available from various manufacturers,
all of which appear to be eective at producing venous ablation (Table 38.1). Lower-wavelength lasers (up to 1300 nm)
target hemoglobin as the primary chromophore. More
recently, higher-wavelength lasers have been introduced
which target water in the vein wall. Lower levels of energy
are thus utilized in these systems, which results in less pain
and bruising for patients.
Each generator utilizes a laser ber of varying sizes
and designs. Earlier systems used bare-tipped bers, while
more recently, covered, centering, or radial bers are more
commonly used to reduce the risk of vein perforation and
16,17
BOX 38.2: Exclusion criteria
●
Arteriovenous malformation
●
Restricted mobility
●
Acute infection
●
Acute venous thrombosis
●
Deep venous obstruction
Table 38.1 Laser generators
Wavelength Name
810 nm Varilase
940 nm Dornier, Angiodynamics
980 nm Angiodynamics
1320 nm
1470 nm
CoolTouch
Angiodynamics, Biolitec
38.5 Procedure 457
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subsequent patient bruising and discomfort by producing
more uniform vein wall injury.
16–18
38.5 PROCEDURE
Initially, endovenous laser ablation was performed in the
hospital surgical or radiologic suite under general anesthesia or conscious sedation. However, over the past decade,
these procedures have moved to the oce setting under
local anesthesia, with or without sedation. Furthermore,
although the ablation procedure is oen performed on veins
other than saphenous veins, the technical details remain
quite similar. e following description of the procedure for
a saphenous vein (great or small) is given with the above in
mind.
Aer obtaining informed consent, patients may be
given an oral or intravenous sedative prior to the procedure. e patient is placed on an adjustable operating table
(with Trendelenburg capability) in a patient gown and
undergarments. e course of the saphenous vein, from
the saphenofemoral or saphenopopliteal junction to the
insertion site, is mapped by ultrasound. An insertion site
is chosen to maximize treatment length, minimize risk of
thermal damage to perivenous structures, and assure facile access. Most physicians will utilize a site in the distal
thigh or proximal calf for the GSV, and the mid-calf to
distal calf for the SSV.
If incompetent, the distal portion of the GSV or SSV
saphenous veins are oen not treated with endovenous
laser ablation because of the increased risk of paresthesia
from damage to the saphenous or sural nerve, which is in
close proximity to the vein distally. However, distal thermal
ablation is advocated by some investigators to eliminate the
entire incompetent segment, with no or minimal increased
incidence of nerve damage.19 Access to the saphenous vein
is generally gained using an ultrasound-guided, percutaneously placed needle. Venospasm will make access more difcult, so preventative maneuvers such as heating the access
site locally, placing the patient in reverse Trendelenburg
position, or the use of 2% nitropaste applied to the proposed
insertion site prior to the sterile surgical preparation can
be utilized to increase the chance of successful venous cannulation by dilating the vein and preventing venospasm. It
is sometimes appropriate to choose a primary access site
and a larger-diameter, secondary (back-up) access site in
case access at the primary site is unsuccessful. Perivenous
or intramural hematoma from unsuccessful attempts at
cannulation may render that portion of the saphenous vein
technically inaccessible, leading to the need for a secondary
site. As the practitioner’s ultrasound-guided technical skills
improve, even small-diameter saphenous veins can be successfully cannulated.
e rst attempt at cannulation of the vein is the most
likely to be successful, so the insertion site should be carefully chosen to make access as ergonomically feasible as
possible. Just below the knee, the GSV is relatively anterior.
With the patient’s operative leg externally rotated, this site
Figure 38.1 Leg externally rotated with the insertion site
covered with nitropaste.
becomes more advantageous than in the distal or mid-thigh
(Figure 38.1). Even though the saphenous nerve is closer to
the vein in this area, the laser sheath will protect this portion of vein, and thus limit the risk of thermal nerve damage.
e leg is cleansed from the most proximal treatment
site to the insertion site with an antiseptic. e operative
area is isolated with sterile drapes. Aer inltration of
local anesthetic at the insertion site, an introducer needle is
inserted into the vein under ultrasound guidance. A microinsertion set can be used to gain access, and the caliber of
sheath “stepped up” to accommodate the laser ber. Using
the Seldinger technique, aer placement of a guidewire
into the vein, a sheath is advanced into the vein over the
guidewire until it is identied by ultrasound to be 3–4 cm
below the saphenofemoral junction, or just inferior to the
deep angulation of the SSV, where it will join the deep system. (Alternatively, the laser ber may be advanced directly
through the access needle and carefully guided to the same
position without the use of the sheath and guidewire.)
Occasionally, passage of the ber may be impeded by vein
tortuosity. Usually, straightening the leg or guiding the
ber by external compression/manipulation of the thigh
will enable successful advancement. Segmental stenosis
from previous sclerotherapy will also impede advancement
of the ber or guidewire. In this case, or if the vein is so
tortuous as to not allow passage, a second, more proximal
cannulation will enable treatment of rst the proximal and
then the distal segments of the saphenous vein.
Ultrasound-guided, high-volume, dilute anesthesia
(0.05%–0.25% xylocaine with epinephrine/bicarbonate) is
then injected into the saphenous compartment (Figure 38.2)
along all but the most proximal portion of the treatment
segment, completely surrounding the target vein to ensure
adequate anesthetic eect, to compress the vein for better
thermal eect, and to protect the perivenous structures
from thermal damage. It is always necessary to clearly identify several important anatomic landmarks (Figure 38.3)
458 Laser treatment of the incompetent saphenousvein
FR 4BHz
12:25:38 pm
35 mm
FR 48 Hz
M3
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RS
2D
72%
C 42
P Low
Res
P
DN
SS
LA
LF
0
1
2
Figure 38.2 Longitudinal ultrasound image of dilute LA
injected into SS. LA: local anesthesia; SS: saphenous
sheath; DN: delivery needle; LF: laser fiber. (Courtesy of
D. Neuhardt, Compudiagnostics.)
near the saphenofemoral junction prior to treatment to
eect safe and adequate treatment of the GSV. However,
one should be mindful that injection of the local anesthetic
near the intended start of treatment will obscure these landmarks, severely limiting one’s ability to see the safe nal
placement of the laser tip. e patient may then be placed in
a Trendelenburg position to further empty the vein of residual blood, with the nal position of the tip of the laser ber
conrmed by ultrasound (just inferior to the entrance of
the supercial epigastric vein into the GSV—typically 2 cm
below the saphenofemoral junction—for GSV treatment
[Figure 38.4] and just inferior to the deep angulation of the
SSV). e anesthetic solution is then injected into the tissue
surrounding the proximal 3–4 cm of the saphenous vein.
e sheath and /or laser ber are then withdrawn at a rate of
1–3 mm per second, more slowly for the proximal 10 cm and
more quickly distally. e goal is to achieve successful ablation while at the same time minimizing the incidence of vein
perforation, which is thought to contribute to post-operative
RS
P
2D
76%
C 54
P Low
Re
s
SEV
GSV
x
CFV
Laser fiber tip
2.5
Figure 38.4 Longitudinal image of the saphenofemoral
junction area with an appropriately positioned laser tip
in the GSV. SEV: superficial epigastric vein; CFV: common femoral vein; GSV: great saphenous vein; laser tip:
tip of the laser fiber just inferior to the entrance of the
superficial epigastric vein into the great saphenous vein.
(Courtesy of D. Neuhardt, Compudiagnostics.)
pain and bruising. Generally, delivering 60–100 J of laser
energy per centimeter of vein treated for lower-wavelength
lasers and 40–60 J per centimeter for higher-wavelength
lasers will accomplish these goals. On conclusion of the
procedure, Doppler conrmation of the patency of the common femoral artery and vein or popliteal artery and vein is
recorded. By consensus, patients are generally placed in compression therapy (e.g., short-stretch bandages and/or 30–40mmHg compression hose [thigh high or panty according to
patient preference]). Compression is generally maintained
for at least several days, if not longer, to minimize patient
discomfort.20 Adjunctive ligation of the saphenofemoral or
saphenopopliteal junctions is not necessary.
21
38.6 FOLLOW-UP
SEV
CFV
Figure 38.3 Longitudinal ultrasound image of the
saphenofemoral junction area. SEV: superficial epigastric
vein; GSV: great saphenous vein; CFV: common femoral vein; FV: femoral vein. (Courtesy of D. Neuhardt,
Compudiagnostics.)
FV
GSV
15L8w-S
14.0 MHz
Superf. Ven
General
70 dB T1/+1/2/4
Gain = 2 dB Δ = 3
Store in progress
LT
e necessity of follow-up duplex examination is not universally accepted.22 However, because of the possibility of
incomplete ablation or recurrent patency of the treated vein
and the need for adjunctive treatment of the distal GSV and/
or SSV, as well as the incompetent tributaries and perforator
veins, color-ow Doppler ultrasound, interviews, and physical examinations at appropriate intervals are suggested to
ensure a successful outcome.23 More frequent follow-up visits will oen reveal the need for adjunctive treatment earlier
in the post-operative course.
38.7 OUTCOMES
38.7.1 Duplex outcomes
(surrogateoutcome markers)
Navarro et al.24 published the rst case series in 2001 on
40 veins treated with laser ablation under local perivenous
anesthesia, reporti ng 100% complete ablation at a mean followup of 4.2months, with no signicant complications. Proebstle
Table 38.2 Mid-term anatomic and clinical outcomes following endovenous laser ablation
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38.7 Outcomes 459
Follow-up
Authors Number of veins
Chang and Chua
Disselhof etal.
Nandhra etal.
Myers and Jolley
Rasmussen etal.
Samuel etal.
28
38
39
55
29
31
252 19 96.8 36.5% paresthesia
93 ≥24 84 2% thrombophlebitis
44 24 81.2 NA
404 36 80 0.2% severe pain
137 60 82.1 NA
38 60 92.1 2.6% hyperpigmentation
period (months)
etal.25 reported occlusion in all 41 SSVs treated at a mean follow-up period of 6 months. Similar short-term reports of successful ablation with lasers of dierent wavelengths have been
published.
26,27
Few mid-term reports are available,28 but most
demonstrate similarly good results. In particular, Meyers and
Jolley29 have reported their carefully collected and statistically
well-analyzed data, showing a secondary or assisted successful
ablation rate of 97% at 4 years (Table 38.2).
38.7.2 Patient/physician-reported
outcomemeasures
e movement in clinical trials towards a greater emphasis
on quality of life outcome measurement tools is reected in
the endovenous laser literature comparing dierent ablation
methods. Patient- and physician-reported outcome measurement tools are now commonly used to dene successful
treatment.
Marston etal.30 reported improved CEAP classication
(C, clinical; E, etiology; A, anatomy; P, pathophysiology)
and Venous Clinical Severity Score (VCSS) following RF or
laser ablation. In reporting 5-year results comparing endovenous laser with surgical ablation of the GSV, Rasmussen
and colleagues noted no statistically signicant dierence
in physician- or patient-reported outcome measures.31
Shepherd etal. demonstrated less post-procedural pain following segmental RF ablation than with a lower-wavelength
laser, but quality of life outcomes were similar at 6 weeks.
Generally good outcomes have been reported when
laser ablation is combined with other treatment modalities. Mekako et al.33 have demonstrated the feasibility of
performing laser ablation in concert with ambulatory
phlebectomy. Neglén etal.34 demonstrated good outcomes
when combining laser ablation with deep vein stenting for
supercial venous insuciency and concomitant deep vein
obstruction. eivacumar and colleagues35 have demonstrated that, in some patients, the incompetent GSV in the
presence of a grossly incompetent anterior accessory saphenous vein will recover competence following ablation of the
anterior accessory saphenous vein alone. Myers etal.
36
have
32
Successful
ablation (%) Significant complications
4.8% skin burn
1.6% thrombophlebitis
2.2% thromboembolism
0.3% nerve palsy
2.6% post-procedural pain
advocated for laser ablation for incompetent major tributaries, while others have demonstrated the safety and ecacy
of laser ablation for the incompetent vein of Giacomini.
37
It has been assumed that most incompletely ablated veins
will be seen in the rst few months following treatment.
However, we have identied recurrence in our own patients
more than 6 years aer apparently successful ablation, with
recurrent symptoms and partially patent segments. us, it
seems prudent to perform careful follow-up of these patients
for 1 year and when recurrent symptoms occur.
Improvement in physician-reported measurement tools
such as the revised VCSS and, even more importantly,
improvement in patient-reported outcome measures are
almost uniformly seen following endovenous laser abla-
31,32,38,39
tion.
Included in many of the more recent laser
ablation reports are generic health (Short Form 36 [SF-36]
and Euroqol [EQ-5D]) and disease-specic quality of life
measurement tools (Aberdeen Varicose Vein Questionnaire
[AV VQ ]).
38.7.3 Complications
Complications may be divided into intra-operative and
post-operative adverse events. Intra-operative adverse
events include technical challenges and adverse patient
events (Box 38.4).
e technical challenges sometimes encountered are difcult access (venospasm and access location) and problems
with advancing the wire/sheath/ber (vein tortuosity, aneurysmal segments, or sclerosis from previous sclerotherapy).
BOX 38.4: Intra-operative adverse events
●
Difficult access
●
Difficult fiber advancement
●
Vagal reaction/dysrhythmia
●
Nerve pain
●
Transient heat
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