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Figure 27. 3 Instillation of tumescent uid.
microphlebectomy. Scavee noted that “no trial has proven
any signi cant advantage of TIPP technique when compared with conventional surgery, except for the number
of surgical incisions, although TIPP procedure seems to
be shorter than conventional surgery, particularly for the
11
extensive or recurrent varicose veins.”
And Luebke and
Brunwall reported a “signi cant statistical advantage of
TIPP technique over the conventional treatment, only for
number of incisions, mean cosmetic score and duration of
the procedure. However the TIPP technique seemed to be
faster only for extensive varicose veins. ere was, however,
a signi cantly reduced incidence of calf hematoma a er
hook phlebectomy compared to TIPP, and TIPP procedure
12
In a randomized clinical trial comparing traditional
microphlebectomy with TIPP, Chetter etal reported that
while TIPP had the advantage of fewer surgical incisions,
it was associated with more extensive bruising, prolonged
pain, and reduced early postoperative quality of life than
13
microphlebectomy.
And in a letter to the editor regarding Akesson’s
report, Stefano Ricci pointed out that TIPP was complicated, expensive to deliver, dangerous because of excessive
tissue removal, and “cosmetically insu cient” since 15% of
patients (3/21) had “remaining problems,” a gure much
14
higher than with microphlebectomy.
For many reasons, enthusiasm for TIPP haswaned.
C O N C L U S I O N S
Endovenous thermal ablation and TIPP are generally safe.
Technical challenges, intraoperative and postoperative
adverse events, and sequelae are infrequent and generally are
seen less frequently with endovenous thermal ablation than
with more traditional surgical procedures.
Di erences in methods of follow-up examination, and
in de nitions of successful ablation, may help explain differences in results between published reports and those
seen in the provider’s own clinical setting. Only long-term
follow-up will show where these minimally invasive methods belong in the therapeutic armamentarium of the treatment of chronic venous insu ciency of the lower extremity.
While some surgeons have expressed the view that none of
these techniques has yet been shown to improve on conventional surgery in the long term, the patient’s perception has
uniformly been that minimal invasion is better.
Figure 27. 4 Resection of varicosities.
R E F E R E N C E S
1. Spitz GA, Braxton JM, Bergan JJ. Outpatient varicose vein surgery
with transilluminated powered phlebectomy , Va s c Endovascular
Surg . 2000 . 34 : 547–555 .
2. de Zeeuw R , Wittens C , Loots M , Neumann M . Transilluminated
powered phlebectomy accomplished by local tumescent anaesthe-
sia in the treatment of tributary varicose veins:Preliminary clinical
results , Phlebology . 2007. 22 ( 2 ): 90–94 .
3. Elias SM , Frasier KL . Minimally invasive vein surgery: Its role in
the treatment of venous stasis ulceration , Am J Surg . 2004. 188 ( 1A
Suppl ): 26–30 .
4. Ray-Chaudhuri SB , Huq Z , Souter RG , McWhinnie D . A random-
ized controlled trial comparing transilluminated powered phlebec-
tomy with hook avulsions:An adjunct to day surgery?, J One Day
Surg . 2003 . 13 ( 2 ): 24–27 .
218 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
5. Aremu M, Mahendran B, Butcher W, etal. Prospective randomized
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controlled trial:Conventional versus powered phlebectomy , J Vasc
Surg . 2004 . 39 ( 1 ): 88–94 .
6 . S c a v e e V , L e s c e u O, eys S, Jamart J, Louagie Y, Schoevaerdts JC.
Hook phlebectomy versus transilluminated powered phlebectomy
for varicose vein surgery:Early results , European J Vasc Endovascular
Surg . 2003 . 25 ( 5 ): 473–475 .
7. Cheshire N , Elias SM , Keagy B, et al. Powered phlebectomy
(TriVexTM) in treatment of varicose veins , Ann Vasc Surg . 2002 .
16 ( 4 ): 488–494 .
8. Franz RW , Knapp ED . Transilluminated powered phlebectomy surgery for varicose veins:Areview of 339 consecutive patients , Ann
Vasc Surg . 2009. 23 ( 3 ): 303–309.
9. Akesson H . Transilluminated powered phlebectomy: A clinical
report , Phlebology . 2008 . 23 : 295–298 .
10. Elias SM , Frasier KL . Minimally invasive vein surgery , Mt Sinai J
Med . 2004. 71 ( 1 ): 42–46 . Review.
11. Scavee V . Transilluminated powered phlebectomy: Not enough
advantages? Review of the literature , Eur J Vasc Endovasc Surg . 2006.
31 ( 3 ): 316–319 .
12. Luebke T , Brunkwall J . Meta-analysis of transilluminated powered
phlebectomy for super cial varicosities , J Cardiovasc Surg (Torino) .
2008. 49 ( 6 ): 757–764 .
13. Chetter IC , Mylankal KJ , Hughes H , Fitridge R . Randomized clinical trial comparing multiple stab incision phlebectomy and transilluminated powered phlebectomy for varicose veins , Br J Surg . 2006.
93 ( 2 ): 169–174 .
14. Ricci S . Letter regarding article titled “Transilluminated powered
phlebectomy:a clinical report,” Phlebology . 2009. 24 : 189 .
PRINCIPLES OF AMBULATORY PHLEBECTOMY • 219
28.
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LASER AND RADIOFREQUENCY
ABLATION
Nick Morrison
TREATMENT OBJECTIVES
Super cial venous disorders are nonlethal disease processes, treatment of which is held to a higher standard
with respect to the risk of complications than in the
treatment of a life-threatening disease. e objective of
treatment will be the ablation of venous incompetence,
whatever its source—axial, tributary, or perforator vein
re ux. Achieving this objective will nearly always involve
a combination of approaches to the di erent sources of
re ux, such as ablation of the great, small, and/or major
tributary veins, removal of other incompetent tributaries
from the venous circulation, and interruption/correction of re ux in perforator veins. erapeutic intervention should promote improved venous function using
the most cosmetically appropriate methods available,
while being mindful of the need to minimize the risk of
complications.
S U P E R F I C I A L V E N O U S
ABLATION
e indications and contraindications for endovenous
ablation procedures are essentially the same for any
super cial venous ablative procedure. Indications should
include: symptoms and physical signs of venous insu ciency; duplex scan showing a patent proximal vein with
re ux greater than 0.5 s; patent deep venous system; vein
conducive to instrumentation; and a fully mobile patient.
Contraindications may include patients with arteriovenous malformations, restricted ambulation, and deep
venous obstruction. Aduplex scan of the entire deep and
super cial system, performed by a quali ed sonographer, is
mandatory prior to any intervention. Speci c indications/
contraindications will be ampli ed in relation to speci c
techniques.
ENDOVENOUS THERMAL ABLATION
INTRODUCTION
Since 2000, endovenous thermal ablation has been reported
to be a safe and e ective method of removing the great
saphenous vein (GSV) from the venous circulation, with
faster recovery and better cosmetic results than either
the traditional or perforate invagination (PIN) stripping
1–10
procedures.
e ClosureFAST radiofrequency (RF)
system (Covidien, Mans eld, Massachusetts) results in
segmental destruction of the vein wall by means of conductive heating. Another RF system is available in Europe
(Olympus Celon RFITT Olympus Medical Systems,
Hamburg, Germany), but clinical data regarding this device
in English literature are scarce. Various laser generators produce wavelengths of 808 to 1500nm to induce vein wall
destruction with conduction and/or convective heating.
Extensive international experience with endovenous
thermal ablation has resulted in widespread adoption by
phlebologists, particularly in the United States. As a result of
this experience successful ablation of additional veins such
as the small saphenous vein (SSV), major tributaries such as
the anterior or posterior accessory saphenous vein (AASV,
11–19
PASV), and perforator veins have been reported.
As
with a stripping procedure, it is important to treat the
incompetent distal saphenous vein, tributaries, and persis-
tently incompetent perforator veins in order to eliminate all
20
major sources of venous insu ciency.
OUTCOME LITERATURE
Prospective randomized studies directly comparing RF
21,22
ablation with stripping, reported by Lurie,
1
and Rautio etal.
demonstrated successful ablation, with
Stotter, 23
patient-reported outcomes of less painful recovery and
220
faster return to work with RF than with stripping. Five-year
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data published in 2005 from the VNUS registry suggest
that the Closure procedure is e ective in occluding target
11
veins and abolishing re ux.
In this report, vein occlusion
was documented by duplex ultrasound in 87.1% of legs at
1year; 88.2% at 2years, 83.5% at 3years, 84.9% at 4years,
and 87.2% at 5years. Amajor de ciency of this report is
lack of life-table analysis, as the statistical analysis e ectively ignores all patients lost to follow-up, thus skewing
success rates. Although early reports are encouraging for
the newer generation RF system, it must be noted that few
peer-reviewed publications have thus far examined the suc-
24
cess and complications.
Similar rates of successful ablation are found in the
laser thermal ablation literature, mostly single-center series
5
reports, from the early reports of Min
and Proebstle 25
showing 93% and 100% success respectively, to the
6,9
well-documented series of Myers
reporting 76% primary
success at 4years by life-table analysis, and 97% secondary
success when ultrasound-guided foam sclerotherapy is used
in those patients with recurrent vein patency.
TECHNICAL EQUIPMENT
R F G E N E R A T O R
most phlebologists can agree that all commonly used laser
generators are highly e ective.
R F C A T H E T E R
Early in the RF experience, treatment of veins larger than
12 mm in diameter was not recommended. However,
experience has demonstrated that given adequate
ultrasound-guided deposition of dilute local anesthetic
completely surrounding the target vein, successful treatment
30
of veins much larger than 12mm is quite feasible.
e 7Fr
ClosureFAST catheters (Figure28.1) for treatment of truncal veins, and the ClosureRFS for perforator veins, both have
a central lumen allowing for infusion of uid (o en heparinized saline) or a guide wire to assist advancement of the
catheter to the uppermost limit of the intended treatment.
L A S E R F I B E R S
Fiber size is generally 200 to 600m, with a bare-tipped
31
ber most commonly used. Other radial-emitting bers,
8,10
tulip-shaped catheters
and jacketed bers have been
developed to avoid direct vein wall contact and to promote
a uniform delivery of laser energy, and therefore presumably
reduce the incidence of vein wall perforations during thermal ablation.
e RF ClosureFAST system destroys the vein wall with
segmental conductive heating resulting in brotic occlusion
of the target vein. e heat generated has shown tissue penetration of 1.5mm, and in the absence of dilute local anesthetic surrounding the vein, heating of surrounding tissues
can occur also by means of conduction. e addition of the
local anesthetic mitigates damage to the surrounding tissue
26
by conducted heat.
L A S E R G E N E R A T O R
e rst laser generators introduced were in the range of
800- to 1,000-nm wavelengths. More recently somewhat
higher wavelengths from 1,300nm to 1,500nm have been
used. ere remains some controversy regarding the mechanism of vein wall destruction, that is, whether it occurs by
25,27,28
direct contact or indirectly via steam bubbles.
It is
theorized that the higher wavelength lasers result in less
postoperative bruising and discomfort for patients because
the primary chromophore for the lower wavelength lasers is
the hemoglobin in intravascular blood, while for the higher
wavelength lasers it is water contained in the vein wall.
Consequently the higher wavelength lasers may produce
fewer vein wall perforations because less energy is necessary
to target the vein wall; this may lead to a more comfortable
29
recovery period than with the lower wavelength lasers.
But
CONTRAINDICATIONS
Absolute exclusion criteria include arteriovenous malformations, restricted ambulation, and deep venous obstruction. Relative exclusion criteria might also include: vein
tortuosity; veins less than 2 mm or greater than 25mm;
partial obstruction of the proximal vein; and known
thrombophilia.
Figure28.1 ClosureFAST catheter.
LASER AND RADIOFREQUENCY ABLATION • 221
PROCEDURE
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Many practitioners have preferred to perform these procedures in the hospital surgical or radiological suites,
frequently under general or regional anesthesia or using
conscious sedation. More recently, in the U.S.a variety of
factors have combined to encourage displacement of the
endovenous ablation procedure out of the hospital and into
the o ce setting under local anesthesia. Furthermore, while
the thermal ablation procedure is o en performed on veins
other than the GSV, the technical details remain quite similar for other veins and for laser ablation.
A er obtaining informed consent, patients may be
given oral or intravenous sedation prior to the procedure.
Antibiotic and/or anticoagulation prophylaxis is not generally used in the U.S., unless speci c indications for them
are present. e patient is placed on an adjustable operating
table (with Trendelenberg capability), and the course of the
target vein is mapped. e insertion site is chosen to maximize treatment length and to assure facile access. Placing the
patient in a semi-erect position will help dilate the vein and
enhance successful cannulation.
e distal portions of the great and/or small saphenous vein may be treated with endovenous thermal ablation if the practitioner is highly skilled in the delivery of
ultrasound-guided local anesthetic and the patient is aware
of the potentially increased risk of paresthesia from damage
to the saphenous or sural nerve, which is in close proximity
to these veins distally. ermal ablation of the most proximal portion of the SSV nearest the saphenopopliteal junction (SPJ) should be avoided to reduce the risk of common
peroneal or posterior tibial nerve damage, with the disastrous result of footdrop.
Access to the vein may be achieved using an
ultrasound-guided, percutaneously placed needle, or via
microincision and hooking of the vein for direct venapuncture. If the percutaneous method is used, Nitropaste
may be helpful at the proposed insertion site prior to the
sterile surgical prep to improve access by dilating the vein
and preventing venospasm. It is sometimes appropriate to
choose a primary access site and a more proximal, larger
diameter, secondary (backup) 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 vein technically inaccessible,
leading to the need for a secondary site. As the practitioner’s ultrasound-guided technical skills improve, even veins
as small as 2mm in diameter or less, or more than 25mm in
diameter, can be successfully cannulated and treated.
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 advantageous
as possible. Just below the knee, the GSV is relatively anterior, and with the patient’s operative leg externally rotated,
this site becomes more advantageous than in the distal or
mid thigh. And even though the saphenous nerve is closer
to the vein in this area, the catheter/ ber sheath will prevent
treatment of this portion of vein, and thus reduce the risk of
nerve damage. e insertion site for the SSV is usually at the
junction of the middle and distal third of thecalf.
Following removal of the Nitropaste, the leg is cleansed
with an antiseptic. e operative area is isolated with sterile
drapes. A er in ltration of local anesthetic at the insertion
site, an introducer needle is inserted into the vein under
ultrasound guidance; or a small incision is made and the
vein is withdrawn through the skin incision with a phlebectomy hook. A er advancement of a guide wire into the vein,
a sheath is advanced into the vein. If desired, the tip of the
sheath can be positioned near the deep venous junction, just
below the entrance of the super cial epigastric vein into the
GSV, or to the point at which the SSV angulates to join the
popliteal vein; position of the sheath is con rmed by ultrasound. Alternatively, a shorter sheath may be used and the
bare catheter/ ber advanced to the area of the deep venous
junction. Occasionally, passage of the catheter/ ber may be
impeded by vein tortuosity. Usually straightening of the leg
or manipulation of the catheter/ ber by external compression will allow advancement. If these maneuvers are unsuccessful, a guide wire threaded through the RF catheter and
beyond the point of di culty, with subsequent advancement of the catheter over the guide wire will allow appropriate positioning of the tip of the catheter. Segmental stenosis
from previous sclerotherapy will sometimes also impede
advancement of the catheter/ ber. In this case, or if the
vein is so tortuous as to not allow passage of the catheter,
a second cannulation, with another insertion kit, will allow
treatment of rst the proximal and then the distal segments
of thevein.
Using ultrasound guidance, high-volume dilute anesthetic solution is then injected into the saphenous compartment (Figure28.2) from the insertion site to below the
deep venous junction. e patient is sometimes placed in
Figure28.2 GSV, with catheter inside, compressed by local anesthetic
solution.
222 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
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Figure28.3 RF catheter in GSV with tip just inferior to entrance of the
super cial epigastric vein andSFJ.
a moderate Trendelenberg position to enhance a bloodless
vein, and the nal position of the tip of the catheter/ ber
is con rmed by ultrasound (Figures28.3 and 28.4), below
the entrance of the super cial epigastric vein in the GSV
(or alternatively, 2cm below the saphenofemoral junction
[SFJ]), and 2 to 3cm below the SPJ. e anesthetic solution
is nally injected into the tissue surrounding the proximal
3 to 4cm of the vein. Alternatively, one may use regional
(femoral nerve block) or general anesthesia, but both are far
less commonly used in the United States than internationally. e advantages of tumescent anesthesia are the patient’s
ability to ambulate immediately a er the procedure (possibly reducing the risk of venous stasis and consequent
deep vein thrombosis), and the protection of the delicate
tissues surrounding the treated vein (possible reducing the
incidence of postoperative paresthesia or neuropraxia).
e maximum volume of local anesthetic is not accurately
known, but with the use of 0.1% xylocaine with epinephrine
solution, it is thought that a dose less than 45 mg/kg lido-
32
caine (less than 3,100 mL in a 70kg patient) is safe.
e withdrawal of the ClosureFAST RF catheter is in
6.5-cm segments a er a 7-cm section has been treated, while
with the Olympus system, the rate is reportedly 1 cm/s.
Withdrawal rate of laser bers depends on the equipment
and the energy delivered, but will range from 1 to 4mm/s.
Laser energy delivery is usually reported as linear endovenous energy density (LEED) in joules per centimeter
(J/cm) and ranges from 50 to 150 J/cm. In general, the
higher the energy delivered, not only the higher the occlusion rate but also the higher the complication rate, while the
converse also appears to betrue.
On conclusion of the procedure, patients may then be
placed in compression therapy, for example, short-stretch
bandages or graduated compression hose (thigh-high or
panty—patient’s preference); some use eccentric compression with rm pads. Although level-1 evidence is lacking,
most phlebologists maintain compression for at least several
days, if not longer, to enhance patient comfort and reduce
ecchymosis and the risk of super cial thrombophlebitis.
Adjunctive SFJ ligation is thought to be not only unnecessary but also meddlesome and it increases the risk of recurrence through neovascularization.
F O L L O W U P
Because of the possibility of incomplete ablation or recurrent patency of the treated vein, and the need for adjunctive treatment of the distal saphenous veins, the re uxing
tributaries or persistently incompetent large perforator veins,
color- ow Doppler ultrasound, interviews, and physical
examinations at appropriate intervals are needed to assure
a successful outcome. At a minimum, patients should be
examined at 1 week, 6months, and 1year following thermal
ablation of the target vein. More frequent follow-up visits
will o en reveal the need for adjunctive treatment earlier in
the postoperative course, and result in more complete treatment of the venous insu ciency with better and sustained
resolution of the patient’s symptom complex. It is not appropriate to merely ablate the proximal portion of an incompetent vein and expect resolution of every patient’s symptoms
and varicosities. Unless one is committed to a program of
meticulous follow-up and adjunctive treatment, the practitioner and the patient will be le with unsatisfactory results.
Figure28.4 RF catheter tip within small saphenous vein (SSV) where
SSV angulates to join popliteal vein at the SPJ, 2 to 3cm from theSPJ.
C O M P L I C A T I O N S
Authors from the American Venous Forum and the Society
for Interventional Radiology have proposed guidelines for
reporting of results and complications following endovenous ablation techniques by which it is hoped some standardization of outcome reporting will result.
LASER AND RADIOFREQUENCY ABLATION • 223
33
Complications may be divided into intraoperative and
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postoperative adverse events. Intraoperative adverse events
can be technical challenges and adverse patient events
(Table28.1). e technical challenges one may encounter
are:di cult access (venospasm, access location); and problems threading the catheter/ ber (vein tortuosity, aneurysmal segments), or sclerosis from previous sclerotherapy.
Adverse patient events that can occur are:dysrrythmia or
vagal reaction (o en because of anxiety); saphenous nerve
pain, or transient heat (inadequate anesthetic in ltration).
Postoperative adverse events (or expected sequelae)
include bruising, paresthesia, infection, intramural hematoma,
skin burn, super cial thrombophlebitis, lymphedema, and
deep vein thrombosis (Table28.2). Bruising is nearly always
minimal, and of less than 2 weeks’ duration. Unlike following
groin-to-ankle stripping, paresthesia following endovenous
ablation is usually mild, short-lived, and limited to the distal
2,22,24,34
thigh. It is seen in 2 to 23% of patients,
and its rate of
occurrence appears to be inversely related to the experience of
the practitioner with ultrasound-guided techniques. Infection
and skin burns are rare, occurring in less than 0.1% of patients.
ese are avoided with good sterile technique and accurately
placed and adequate ultrasound-guided anesthetic volume to
protect the structures in close proximity to the vein, and to separate the skin from the underlying vein. Super cial thrombo-
11,24,35
phlebitis is seen in less than 5% of cases,
and responds to
the usual clinical measures of anti-in ammatory medication,
compression, and ambulation. Lymphedema has not been
reported, but we have seen it in our own center, and is believed
to be most commonly caused from unrecognized impaired
lymphatic drainage usually present prior to any procedures.
Treatment of this complication (or more likely sequela) will
include therapeutic lymphatic massage, compression with multilayered low-stretch bandages, compression hose, and exercise.
Deep vein thrombosis is the most signi cant complication, and is generally reported to occur in less than 1% of
the patients (depending on the duplex scanning interval and
2,24
the quality of the examination).
Most reported cases are
calf vein thrombosis, and if stability is demonstrated by serial
duplex examinations, these are of limited clinical signi cance.
Table28.2 POSTOPERATIVE ADVERSEEVENTS
(or expected sequelae)
Bruising
Paresthesia
Skin burn
Super cial thrombophlebitis
Lymphedema
Deep vein thrombosis
Infection
erapy is usually as an outpatient, with compression, ambulation, and anti-in ammatory medication. Several reports of
SFJ or SPJ thrombus extensions have been published.
14,19,35
ese appear to be of an entirely di erent character than those
seen in association of spontaneous super cial thrombophlebitis of the GSV or SSV. Clinically relevant sequelae of these
types of thromboses are rare, and if demonstrated to be resolving by serial duplex examination, can be treated expectantly.
More extensive proximal thromboses do occur, however, and
36
should be aggressively searched for and treated,
including
with percutaneous pharmacomechanical treatment if prudent.
One complication, of interest because of its relative
absence, is neovascularization. Neovascularization is commonly seen following the traditional surgical high ligation
procedure, wherein all tributaries of the great saphenous vein
37
are carefully dissected and divided.
It is thought to be secondary to “frustrated” venous drainage from the abdominal
wall and perineum. e ultrasound picture of neovascularization, seen as grape-like clusters of veins in the groin, is
quite characteristic (Figure28.5). Whether this is actually
the development of new veins, or simply enlargement of previously existing veins, the result is recurrent re ux in veins of
the thigh and lower leg. e endovenous ablation procedure
ree years post high lig/stripping of GSV
Table28.1 INTRAOPERATIVE ADVERSEEVENTS
TECHNICAL
CHALLENGES
Di cult access Painful insertion
Dysrrythmia
Trouble threading introducer
wire/ catheter
Treatment interruption (with
ClosurePLUS)
Unable to reinsert catheter Saphenous nerve pain
GSV tortuosity
Aneurysmal segments
ADVERSE
PATIENT EVENTS
Vagal reaction
Transient heat
Figure28.5 Block arrow:common femoral vein; Line
arrow:neovascularization.
224 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
deliberately avoids a groin incision and leaves the super cial
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epigastric vein intact, which, it is believed, has resulted in
11
fewer reports of neovascularization at the 5- year interval.
DISCUSSION
Considerable confusion in the literature exists regarding the
de nition of successful treatment, the means used to detect
treatment failures, and the reporting of results. Agreement on
the very de nition of success has not yet been achieved, being
39
30
and
variably reported as:sonographic absence of the target vein;
38
no ow in treated segment;
absence of visible re ux; 38 seg-
mental patency of no more than 5cm without re ux;
2
resolution of symptoms.
Extensive advancements in the technology of ultrasound since the early 2000s have allowed far
more critical evaluation of clinical results than was possible in
the past. As a result of these advancements, it is now possible
to more readily identify incompletely ablated veins. Recurrent
patency can occur anywhere in the thermally ablated portion
of the vein, either along its length or segmentally. Segmental
recurrent patency is usually seen at the site of an incompetent
perforator or a re uxing tributary. And because there are likely
to be closed segments above and/or below the patent segment,
distal compression of the closed portion of the vein to identify
re ux is futile. Likewise, using Valsalva’s maneuver to identify
proximal patency is unreliable and lacks reproducibility. e
use of more sensitive duplex ultrasound equipment and critical
ultrasound examination of treated veins brings into question
earlier reports in which success is de ned as “absence of visible
re ux” or “resolution of symptoms.” Indeed, many patients
will experience temporary resolution of symptoms following
an incomplete ablation procedure, only to have those symptoms recur when re ux becomes clinically signi cant.
Identi cation of recurrent patency, incomplete ablation, or treatment failures is ultimately dependent on the
sensitivity of the ultrasound equipment used for postoperative examination, the expertise of the sonographer, and the
vigor with which the examination is conducted. In a study
of ultrasound equipment from our center reported at the
Union Internationale De Phlebologie (UIP) meeting in
2003, ve di erent ultrasound machines commonly used in
vascular laboratories were evaluated. Six patients with moderate re ux were examined by the same registered vascular
technologist, using all ve machines. e sensitivity of each
machine was found to be:100% (for the control machine);
and 85%, 77%, 69%, and 62% for the other four machines
(Figure28.6). In other words, re ux was not identi ed in
15%, 23%, 31%, and 38% of the veins known to have re ux.
Since identi cation of ow is directly related to the sensitivity of the duplex machine, it is reasonable to assume that
following patients for postoperative results will be greatly
in uenced by the equipment used for the examinations.
Further, the expertise and independence of the sonographer,
the extent of their super cial venous experience, and the
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
Figure28.6 Comparison of sensitivity of duplex equipment.
100%
85%
77%
69%
0%
Equip A Equip B Equip C Equip D Equip E
% reflux sites
identified
62%
care with which the examination is conducted are all factors
of paramount importance in critical reporting of results.
No consensus has been established on such critical reporting issues as: duration of follow-up and duplex-scanning
intervals; quality and sensitivity of duplex equipment used
for follow-up examination of a treated vein; and training
and experience of the duplex operator.
orough Duplex examination for successful ablation
of a vein should include gray scale, compression, and color
ow Doppler. Patients o en have ultrasound-guided foam
sclerotherapy for distal segments of the treated vein, re uxing tributaries of the treated vein, and incompetent perforators. Such foam sclerotherapy has had an unexpected
e ect on critical analysis of successful ablation. e ablated
vein that remains sonographically identi able long a er
it should have disappeared, but that by all of the duplex
ultrasound criteria noted above is completely occluded, is
commonly found to have foam within the vein following
injection of a tributary, perforator, or distal segment. is
further calls into question even the most critical examination techniques. Whether these minimally patent segments
will become clinically signi cant is unknown at this time.
But certainly patients who complain of localized pain in the
area of a previously ablated vein deserve very careful examination to identify an incompletely ablated segment.
Adjunctive treatment in order to remove all sources of
insu ciency from the venous circulation is thought by most
to be mandatory. Adjunctive treatment may include such
things as: endovenous ablation (thermal or chemical) of
the incompetent accessory saphenous or major saphenous
tributaries, and/or persistently incompetent perforators;
ambulatory (micro)phlebectomy; and visual sclerotherapy.
ese techniques will help to achieve the greatest resolution
of the patient’s varicosities and symptoms.
It has been reported that most incompletely ablated
veins will be seen in the rst few months following treatment, since failure rates do not steadily increase over time.
However, we have identi ed patients more than 6years following apparently successful ablation with recurrent symptoms and partially patent segments. us, it is necessary to
11
LASER AND RADIOFREQUENCY ABLATION • 225
perform thorough follow-up of these patients for 1year, and
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then either yearly or certainly with recurrent symptoms.
e total cost of performing the procedure in-o ce in
the United States under local anesthesia, exclusive of the
provider’s time, is generally between US$400 and $1100,
depending on the equipmentused.
R E F E R E N C E S
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226 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
29.
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TREATMENT OF SMALL SAPHENOUS VEINREFLUX
Kenneth Myers , Amy Clough , Stefania Roberts , and D a m i e n J o l l e y
enous anatomy in relation to small saphenous re ux
is far more complicated than that relative to great
V
saphenous disease is poorly understood. ere is no consensus as how to best treat small saphenous re ux, largely
because of the lack of objective information regarding
outcome. e few reports available show poor results a er
traditional surgery, so that there is a swing to endovenous
treatment. Discussion will be largely based on ndings from
duplex ultrasound scanning.
In the embryo, there are three venous plexuses of the lower
limb:the axial, preaxial, and postaxial plexuses.
plexuses meet at the popliteal vein. e future small saphenous vein (SSV) and thigh extension (TE) derive from the
postaxial venous plexus that accompanies the postaxial
nerve (posterior femoral cutaneous nerve). What is now
termed the vein of Giacomini is an anastomosis between
the pre- and postaxial plexuses. Variations in the popliteal
fossa presumably re ect whether or not the postaxial plexus
maintains a connection with the poplitealvein.
saphenous re ux. e pathophysiology of small
E M B R Y O L O G Y
1,2
e three
gastrocnemius muscle. It turns deep to join the popliteal
or femoral vein at the saphenopopliteal junction (SPJ) in
approximately 75% of limbs but continues on as the TE
without an SPJ in the remainder (SEE Figure 29.1). e
SSV joins gastrocnemius veins rather than the popliteal vein
in up to one-third of limbs, usually at or near the SPJ.
distinguished from tributaries on ultrasound by the observation that it lies in a fascial compartment from above the
ankle, just as for the great saphenous vein (GSV).
S P J
e SPJ is the proximal end of the SSV above the preterminal valve otherwise referred to as the small saphenous arch.
e SPJ is rudimentary or absent in approximately 25% of
limbs (see Figure29.1). When present, it usually lies within
4cm above the knee crease. However, in approximately 25%
10
It is
10
e SSV is always present and frequently continues as the
TE. It is duplicated in less than 5% of limbs. ere is a variable connection, if any, between the SSV and deep veins,
and variable terminations of the TE. ese patterns were
well described by Giacomini in 1873
clearly de ned by ultrasound.
described in a consensus document.
e SSV originates from the lateral marginal vein of
the foot and courses proximally on the posterior aspect of
the calf, usually in the midline between the bellies of the
A N A T O M Y
S S V
5–9
Current terminology is
3,4
and have now been
10
Figure 29. 1 Presence or absence of an SPJ and variations in the
destination of gastrocnemiusveins.
227
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