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N.M. Khilnani

when the examination is performed and for differ-

ent clinical indications. In general, DUS is used to

evaluate patients soon after treatment for survey

for DVT and satisfactory elimination of the

sources of re ﬂ ux. Later, evaluation is use to evalu-

ate patients for the mechanisms responsible for

any new or residual varicose veins or symptoms.

After sclerotherapy and thermal ablation, or

any other treatment where the treated veins are

not removed, periodic surveillance is suggested

to ascertain the outcome of these treatments and

to determine if additional intervention is required

to prevent early recurrences [

2 ] . The ideal interval

for evaluation has not been evaluated. DVT after

ablative procedures can occur at the connections

between the deep and treated super ﬁ cial veins.

In order to identify these, DUS would need to be

performed early after ablation. In asymptomatic

patients, a limited evaluation of the remainder of

the deep system is generally included given the

low incidence of DVT in this population. A typical

post treatment exam in an asymptomatic patient

would include an assessment of the junctions to

exclude thrombus extension into the deep veins

as well as evaluation of the femoral, popliteal and

gastrocnemius veins. In symptomatic patients

(those with swelling or pain away from the sites

being treated or with more than a minimal extent

SVT) the entire deep system should be evaluated.

Another complication to be sought for after

thermal ablation is an arteriovenous ﬁ stula

(AVF). This can lead to partially patent vein

segments that have pulsatility. This has been

described between the proximal SSV and the

sural artery and between the super ﬁ cial external

epigastric artery and proximal GSV although it

can potentially occur anywhere along the length

of treatment. Doppler analysis of a vein near an

AVF would demonstrate high ﬂ ow with pulsatil-

ity that does not eliminate with compression or

respiration. High levels of turbulence will be

present in the immediate vicinity of an AVF.

Surveillance of the super ﬁ cial veins should

also be done after ablative procedures to evaluate

the these veins for adequate ablation as well as to

determine if there are any new or persistent

re ﬂ uxing segments parallel to or below them.

This is generally done in the ﬁ rst few weeks after

therapy, a few months later and at yearly intervals

or until the vein disappears.

In the ideal circumstance the thermally

ablated segments will have no ﬂ ow early after

treatment and often demonstrate thick vein walls.

There should be no ﬂ ow in the entire treated vein

segment (Fig. 6.9a ). This should be distinguished

from the appearance of a thrombosed vein which

in the ﬁ rst few weeks should appear as a central

hypoechoic to moderately hyperechoic ﬁ lling

defect in a vein which is usually enlarged com-

pared with the pre-treatment diameter (Fig. 6.9b ).

Partially thrombosed veins may have some ﬂ ow.

The size of the vein early after treatment will

usually not be much smaller than before treat-

ment and can transiently be larger. Over the

course of the next few months, the vein size will

ideally shrink. Ultimately by about 1–2 years

after treatment adequately treated veins will scar

down to the point that the vein will be dif ﬁ cult to

identify with DUS and have no ﬂ ow (Fig. 6.10 ) .

Certain other patterns may be evident, some

of which should be considered failures and oth-

ers that may be considered partial successes.

Most treatment failures will be evident in the

ﬁ rst few weeks as either thrombosed vein seg-

ments that subsequently recanalize or as veins

that appear unchanged compared with the pre-

liminary exam. In our experience, most GSV

treatment failures are segmental beginning at

the SFJ and extending downward a variable

length to the takeoff of an incompetent tributary.

Below this level, the vein is often successfully

treated. Occasionally on long term evaluation

the targeted vein may be segmentally patent but

will no longer have re ﬂ ux.

https://t.me/med1917

436 Venous Duplex Ultrasound in Patients with Chronic Venous Disorders

Fig. 6.9 Axial DUS images

after endovenous thermal

ablation ( EVTA ) of the GSV.

( a ) Image demonstrating the

appearance of the GSV

1-month after EVTA. The

vein wall is thickened and

the lumen small and without

ﬂ ow. ( b ) Image demonstrat-

ing a sub-acute GSV

thrombosis with a central

mildly echogenic thrombus

with patent lumen around the

clot. The lumen was

compressible and had

Doppler ﬂ ow

https://t.me/med1917

N.M. Khilnani

Conclusion; DUS Examination

Precise anatomical and ﬂ ow mapping with

DUS is required prior to planning treatment in

all patients with C2-6 CVD and patients with

C1 disease in the GSV distribution. Patients

treated with thermal ablation or ultrasound

guided sclerotherapy bene ﬁ t from DUS soon

after treatment for screening for complications

and several months after the procedure to doc-

ument therapeutic success.

References

1. Hamper UM, Dejong MR, Scoutt LM. Ultrasound

evaluation of the lower extremity veins. Radiol Clin

North Am. 2007;45:525–47.

2. Min RJ, Khilnani NM, Golia P. Duplex ultrasound eval-

uation of lower extremity venous insuf ﬁ ciency. J Vasc

Interv Radiol. 2003;14:1233–41.

3. Coleridge-Smith P, Labropoulos N, Partsch H,

Myers K, Nicolaides A, Cavezzi A. Duplex ultrasound

investigation of the veins in chronic venous disease of

the lower limbs-UIP consensus document. Part 1: basic

principles. Eur J Vasc Endovasc Surg. 2006;31:83–92.

4. Cavezzi A, Labropoulos N, Partsch H, Ricci S, Caggati A,

Myers K, Nicolaides A, Smith PC. Duplex ultrasound

investigation of the veins in chronic venous disease of

the lower limbs-UIP consensus document. Part 2 anat-

omy. Eur J Vasc Endovasc Surg. 2006;31:288–99.

5. Labropoulos N, Borge M, Pierce K, Pappas PJ. Criteria

for de ﬁ ning signi ﬁ cant central vein stenosis with

duplex ultrasound. J Vasc Surg. 2007;46:101–7.

Fig. 6.10 Axial DUS image

of a GSV 1-year after

EVTA. The vein is a tiny

(approximately 2 mm)

echogenic cord in the

course of the previously

treated GSV

https://t.me/med1917

N.S. Sadick et al. (eds.), Practical Approach to the Management and Treatment of Venous Disorders,

DOI 10.1007/978-1-4471-2891-5_7, © Springer-Verlag London 2013

Basic Principles

Signs and symptoms of chronic venous disorders

are reviewed in Chap. 5 and will not be reiterated

here. Symptoms rarely, if ever, improve or resolve

without appropriate intervention targeting incom-

petent veins. Likewise, the physical signs will

inexorably worsen over time, although the rate

and extent to which they will do so is unpredict-

able in the individual patient.

Complications of chronic venous disorders

such as acute super ﬁ cial thrombophlebitis involv-

ing saphenous or non-saphenous veins will some-

times require early surgical intervention for ligation

(to prevent migration to the deep venous system),

evacuation of the thrombus (for more rapid resolu-

tion of the in ﬂ ammatory process), or rarely excision

in the presence of infection. Spontaneous variceal

hemorrhage will occasionally require emergent

cauterization, ligation, or foam sclerotherapy, but

usually is treated simply with leg elevation and local

compression [ 1, 2 ] . Lipodermatosclerotic changes

and atrophie blanche require intervention to pre-

vent de novo or recurrent ulceration. Ulceration

will also demand extensive wound care before and

after treatment of the underlying source of venous

insuf ﬁ ciency, whether deep (approximately 40% of

patients have purely deep obstruction or incompe-

tence), super ﬁ cial and perforator (approximately

30% of patients), or a combination of deep and

super ﬁ cial incompetence (another 25%) [ 3 ] .

Treatment Objectives

Therapeutic intervention should promote improved

venous function using the most cosmetically-

appropriate methods available, while being mind-

ful of the need to minimize the risk of complications.

After all venous disorders, with the exception of

deep vein thrombosis and its sequelae, are non-

lethal disease processes, the treatment of which

will be held to a higher standard with respect to the

risk of complications than in the treatment of a life-

threatening disorder. The objective of treatment

will be the elimination of venous incompetence,

whatever its source – axial, tributary, or perforator

vein re ﬂ ux. Achieving this objective will nearly

always involve a combination of approaches to the

different sources of re ﬂ ux, such as ablation of the

great, small, and/or major tributary saphenous

veins, removal of other incompetent tributaries

from the venous circulation, and interruption/cor-

rection of persistent re ﬂ ux in perforator veins.

Elimination of Truncal Vein Re ﬂ ux:

Surgery, Thermal Ablation,

and Chemical Ablation

for Chronic Venous Disorders

Nick Morrison and Neil M. Khilnani

N. Morrison , M.D. ()

Morrison Vein Institute ,

Scottsdale, AZ , USA

e-mail: nickmorrison2002@yahoo.com

N. M. Khilnani , M.D.

Weill Cornell Vascular,

Weill Medical College of Cornell University ,

New York , NY , USA

e-mail: nmkhilna@med.cornell.edu

https://t.me/med1917

N. Morrison and N.M. Khilnani

Surgical Treatment

Indications and Contraindications

The indications and contraindications are essen-

tially the same for any ablative procedure, whether

by surgical, thermal, or chemical ablation tech-

niques, and should include: symptoms and physi-

cal signs of venous insuf ﬁ ciency; duplex scan

showing re ﬂ ux greater than 0.5 s; patent deep

venous system; vein conducive to instrumentation;

and fully mobile patients. A duplex scan of the

entire deep and super ﬁ cial system, performed by a

quali ﬁ ed sonographer, is mandatory prior to any

intervention. Contraindications will include patients

with arteriovenous malformations; restricted ambu-

lation; and deep venous obstruction. Relative con-

traindications might also include inadequate

out ﬂ ow pathways to support venous return, anes-

thetic allergy, systemic malignant process, and

severe coagulopathy or thrombophilia.

Aneurysmal dilation of the proximal GSV or

SSV at their respective junctions is proposed by

some as a contraindication as possible risk factor

for thrombus extension into the deep venous sys-

tem. This concern has not been substantiated by

data and is not a contraindication for experienced

practitioners. Deep venous re ﬂ ux is not a con-

traindication for an ablative procedure [ 4, 5 ] .

In many cases segmental re ﬂ ux in the deep veins

is related to overload of the deep system by the

regurgitant fraction or related to a siphon effect of

the incompetent trunks [

6 ] . In these cases, elimina-

tion of super ﬁ cial re ﬂ ux is likely to reverse the deep

re ﬂ ux [ 7 ] .

Treatment of incompetent super ﬁ cial truncal

veins in the setting of deep vein obstruction requires

a careful assessment of the adequacy of the patent

segment of the deep venous system. If the deep sys-

tem is adequate and the super ﬁ cial venous incom-

petence is leading to CEAP Clinical Class 5 or 6,

ablation of the causative veins is justi ﬁ ed [

8 ] .

There is no data available regarding ablation

procedures on patients taking aspirin, nonsteroidal

anti-in ﬂ ammatory medications, platelet aggrega-

tion inhibitors, or Warfarin.

[Speci ﬁ c indications/contraindications will be

ampli ﬁ ed in relation to speci ﬁ c techniques.]

Table 7.1 demonstrates the various surgical

procedures that are currently or have traditionally

been used to treat super ﬁ cial venous insuf ﬁ ciency.

This chapter will cover those techniques not

speci ﬁ cally addressed by chapters elsewhere in

the book.

High Ligation/Stripping

High ligation and stripping of truncal veins was a

frequently used procedure in the past, but is being

abandoned in the U.S. and, to a lesser degree else-

where, in favor of less invasive techniques because

of complications and high recurrence rates [ 9– 11 ] .

The newer technique of “invagination” stripping

(so-called PIN stripping) limits excision to the

thigh portion of the great saphenous vein and the

proximal portion of the small saphenous vein [ 12, 13 ] ,

and can be performed as an outpatient procedure

under local anesthesia, with injection of dilute

high-volume local anesthetic directed into the

saphenous sheath under ultrasound guidance [

14– 16 ] .

Indications include any incompetent truncal vein

requiring removal from the venous circulation in

patients suitable for surgery, and contraindications

would include those patients at high risk for sur-

gery or a recent history of acute super ﬁ cial throm-

bophlebitis involving the target vein.

Surgical Techniques for Perforator

Veins

Subfascial Endoscopic Perforator

Surgery (SEPS)

Indications/Contraindications

In patients with signi ﬁ cant lipodermatosclerotic

changes in the lower legs and ankles, a direct sur-

gical approach to the incompetent perforators in

Table 7.1 Surgical techniques

High ligation of saphenous vein

High ligation with “external” stripping of saphenous

vein

High ligation with “invagination” stripping of

saphenous vein

Ambulatory microphlebectomy

Powered microphlebectomy (Trivex)

Perforator avulsion/ligation

Subfascial endoscopic perforator surgery (SEPS)

Surgery for recurrent varicose veins

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477 Elimination of Truncal Vein Re ﬂ ux: Surgery, Thermal Ablation, and Chemical Ablation

that area may lead to wound-healing complica-

tions, and thus surgery in the lipodermatoscle-

rotic area is best avoided. The SEPS method was

developed to avoid such problems using laparo-

scopic instruments to: access the subfascial plane

in the proximal calf away from the lipodermato-

sclerotic tissue; create a space in the subfascial

plane with gas; identify the individual perfora-

tors; and ligate or seal and divide them [

17– 19 ] .

The incompetent distal calf perforators (formerly

Cockett’s II, III perforators), which are often of

great importance to the development and non-

healing of ulcers in the “gaiter” area of the limb,

are dif ﬁ cult to visualize and control with SEPS.

The procedure also requires an operating room,

general or regional anesthesia, and laparoscopic

technical skills, again limiting the appeal for

phlebologists. For these reasons, enthusiasm for

SEPS has diminished [ 20 ] .

Surgery for Recurrent Varicose Veins

This subject might be divided into two parts:

saphenofemoral or saphenopopliteal recurrence;

and tributary/remnant recurrence. Saphenofemoral

or saphenopopliteal recurrence is a common

cause of recurrent varicose veins. It generally

occurs because of technical failure of the origi-

nal operation or “neovascularization” whereby

tributaries and remnants of the saphenous vein

are reconstituted by means of re ﬂ ux originat-

ing in peri-junctional tissue such as lymph nodes

[ 21 ] . Technical failure may be secondary to an

incompletely identi ﬁ ed deep vein junction, with

a “stump” of saphenous vein remaining which,

by means of tributaries draining into it without

adequate out ﬂ ow, produces re ﬂ ux in some of the

tributaries with resultant recurrent varicosities.

In a report from Egan, et al., patients presenting

for surgical treatment of recurrent varicose veins

following a traditional high ligation and stripping

procedure, 55% required removal of some portion

of “retained” saphenous vein [

22 ] . Additionally

traditional surgical teaching mandated complete

dissection and ligation of tributaries in the area of

the saphenofemoral junction (SFJ). It is currently

thought that this complete surgical dissection

itself led to recurrent re ﬂ ux in the groin because

of “frustrated venous drainage” from the perineum

and abdominal wall, and/or surgical trauma stimu-

lating neovascularization [

21 ] .

The saphenopopliteal junction (SPJ) is con-

siderably more dif ﬁ cult to identify and deal with

surgically, because of its variable location, and

even whether it exists at all (sometimes the small

saphenous vein does not terminate in the popliteal

vein, but courses up the thigh as the thigh exten-

sion of the sapheous vein, terminating in the great

saphenous vein or in deep veins of the thigh, but-

tocks, or pelvis). These anatomic variations of

the small saphenous vein and SPJ have resulted

in frequent technical failure [ 23 ] .

In the groin, reoperation for recurrence requires

considerable surgical skill, patience, and dexter-

ity, and can be a frustrating enterprise because of

the dif ﬁ culties dissecting thin-walled, large recur-

rent varicosities, identifying the SFJ through a

scarred surgical site, and the not inconsiderable

blood loss often accompanying these procedures.

Saphenopopliteal recurrences will require very care-

ful investigation by duplex ultrasonography prior

to any surgical exploration. It will be important to

ascertain whether a SPJ exists, its exact location,

and whether a proximal posterior calf perforator is

the true cause of the recurrent varicosities.

Saphenous Sparing Techniques

In the past two decades several European inves-

tigators have developed and promulgated surgi-

cal techniques with the intention of sparing as

much normal truncal venous drainage as possible.

The ﬁ rst method, CHIVA (French acronym for:

Conservatrice et Hémodynamiquede l’Insuf ﬁ sance

Veineuse en Ambulatoire), was described by

Franceschi [

24 ] , and adopted by Zamboni [ 25 ] ,

Cappelli [

26 ] , Escribano [ 27 ] , and others. The

method involves acquisition by duplex examination

of speci ﬁ c super ﬁ cial venous re ﬂ ux patterns, with

correction and re-establishment of the fraction-

ated venous column normally provided by venous

valves, based on the theory that it is possible for the

great saphenous vein to regain competence once

the fractionated column has been restored. Mid and

long term results of this treatment method as com-

pared to traditional ablative surgery are encouraging

[ 28, 29 ] , and may best be applied to patients with

minimal to moderate venous problems. The second

https://t.me/med1917

N. Morrison and N.M. Khilnani

method, Ambulatory Selective Ablation of Varices

under Local anesthesia (ASVAL) proposed by

Pittaluga et al. [ 30 ] has been shown to improve or

eliminate great saphenous vein re ﬂ ux by ablating

the varicose venous reservoir, with encouraging

mid term results [

31, 32 ] .

Postoperative Care

Compression and ambulation are widely regarded

as the cornerstones of successful postoperative

management, no matter which modality is chosen,

although Level 1 evidence for the use of postopera-

tive compression is lacking. Extrinsic compression

using foam padding, short stretch and/or elastic

bandages, 30–40 mmHg compression hose, and

early ambulation and return to normal activities all

will help to minimize postoperative discomfort and

complications, such as deep venous thrombosis.

Pearls and Pitfalls

Gentle surgical technique under local anesthesia

SEPS for perforator veins

Not insigni ﬁ cant incidence of complications

(pain, paresthesia, scarring)

Recurrence common

Keys for Success

Utilize surgical methods in concert with mini-

mally invasive procedures

Invagination stripping groin-to-knee rather than

full length traditional stripping

Avoid saphenopopliteal junction re-exploration

Saphenous sparing techniques hold promise

Endovenous Thermal Ablation

Introduction

In controlled clinical trials, Radiofrequency (RF)

and laser endovenous ablation have been reported

safe and effective for destruction of the proximal

portion of the great saphenous vein, with faster

recovery and better quality of life scores than tradi-

tional or invagination stripping procedures [ 33, 34 ] .

Extensive international experience with ther-

mal ablation has resulted in widespread adoption

by phlebologists. As a result of this experience

successful ablation of the small saphenous vein,

major tributaries, and perforator veins have been

reported and adopted [

35– 40 ] . At this time the

indications and contraindications for use as well

as the success rates and safety of perforator abla-

tion have only recently begun to be evaluated. It

is clear that incompetent perforating veins will

often regain competence following elimination

of super ﬁ cial re ﬂ ux sources [ 41 ] and thus routine

ablation of incompetent perforator veins as pri-

mary treatment for venous insuf ﬁ ciency is rarely

warranted [ 42 ] .

Recently steam thermal ablation has been

studied for safety and ef ﬁ cacy, early results of

which appear promising [ 43 ] .

As with a stripping procedure, it is important

to treat the incompetent distal great saphenous

vein, tributaries, and persistently incompetent

perforator veins in order to eliminate all major

sources of venous insuf ﬁ ciency [ 40, 44 ] .

Technical Equipment

The two RF systems are the ClosureFAST™ sys-

tem (VNUS Medical, Sunnyvale, CA); and the

RF system available in Europe (Olympus Celon

RFITT™ Olympus Medical Systems, Hamburg,

Germany).

The RF ClosureFAST™ system destroys the

vein wall with segmental conductive heating result-

ing in ﬁ brotic occlusion of the target vein. The

addition of perivenous dilute local anesthetic miti-

gates damage to the surrounding tissue by con-

ducted heat [

45 ] . The ClosureFAST™ catheter has

a central lumen allowing for infusion of ﬂ uid or a

guide wire to assist advancement of the catheter to

the uppermost limit of the intended treatment.

Various wavelengths of lasers are used for

endovenous ablation, generally in the near infra-

red spectral ﬁ eld from 800 to 1,500 nm. The tar-

get chromophore of the lower wavelength lasers

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497 Elimination of Truncal Vein Re ﬂ ux: Surgery, Thermal Ablation, and Chemical Ablation

is hemoglobin, while for the higher wavelength

lasers it is water. There appears to be less early

postoperative bruising and discomfort with the

higher wavelength lasers and it is theorized that

the higher wavelength lasers may produce fewer

vein wall perforations since less energy is neces-

sary to target the vein wall, and thus lead to a

more comfortable recovery period than with the

lower wavelength lasers [

46– 48 ] . Data to support

this theory is accumulating.

Endovenous ﬁ bers used to deliver the laser

energy range from 100 and 600 m m. Some such

as the coated, jacketed, and radial ﬁ bers [ 46 ] , or

centering catheters [ 49 ] have been developed to

deliver energy more uniformly to the vein wall.

Procedure

[While the thermal ablation procedure is often

performed on veins other than the great saphen-

ous vein, the technical details remain quite similar

for other veins and for laser ablation. The follow-

ing description of the procedure for the great

saphenous vein is given with the above in mind.]

After obtaining informed consent, patients

may be given an oral or intravenous sedative prior

to the procedure. The patient is placed on an

adjustable operating table (with Trendelenberg

capability), and the course of the great saphenous

vein, from the SFJ to the insertion site, is mapped.

The insertion site is chosen to maximize treatment

length and to assure facile access. Placing the

patient in a semi-erect position will help to dilate

the vein and enhance successful cannulation.

Access to the great saphenous vein may be

achieved using an ultrasound-guided, percutane-

ously placed needle, or via microincision and

hooking of the great saphenous vein for direct

venapuncture. If the percutaneous method is

used, Nitropaste may be applied to the proposed

insertion site prior to the sterile surgical prep to

improve access by dilating the vein and prevent-

ing venospasm. It is sometimes appropriate to

choose a primary access site and a more proxi-

mal, larger diameter, secondary (backup) access

site in case access at the primary site is unsuc-

cessful. Generally the GSV is treated with thermal

ablation from the groin to the knee, although the

distal GSV may be treated with endovenous ther-

mal 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 nerve in close proximity to the vein

below the knee.

The ﬁ 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 great saphenous vein is rela-

tively 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 the proximal calf, the catheter/ ﬁ ber sheath

will prevent treatment of this portion of vein, and

thus reduce the risk of nerve damage (Fig. 7.1 ).

Following removal of the Nitropaste, the leg is

cleansed, groin-to-insertion site, with an antisep-

tic. The operative area is isolated with sterile

drapes. An introducer needle is inserted into the

great saphenous vein under ultrasound guidance

after in ﬁ ltration of local anesthetic at the insertion

site; alternatively a small incision is made over the

vein and the vein is withdrawn through the skin

incision with a phlebectomy hook. After advance-

ment of a guide wire into the vein (Fig. 7.2 ), a

sheath is advanced to near the SFJ, just below the

entrance of the super ﬁ cial epigastric vein into the

Fig. 7.1 Hatched black line marking course of great

saphenous vein with tape over nitroglycerin paste at pro-

posed insertion site in proximal left calf – cephalad to left

in image

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N. Morrison and N.M. Khilnani

great saphenous vein or 2 cm below the SFJ,

con ﬁ rmed by ultrasound. A shorter sheath may be

used and the bare catheter/ ﬁ ber advanced to the

area of the deep venous junction. [in the SSV, the

tip of the catheter/ ﬁ ber is placed at the point where

the vein angulates deep to join the popliteal vein].

Occasionally, passage of the catheter/ ﬁ ber may be

impeded by vein tortuosity. Usually straightening

of the leg or manipulation of the catheter/ ﬁ 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 dif ﬁ 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/ ﬁ ber. In this case, or if the vein is so tor-

tuous as to not allow passage of the catheter, a

second cannulation, with another insertion kit,

will allow treatment of ﬁ rst the proximal and then

the distal segments of the great saphenous vein.

Ultrasound-guided high volume, dilute

anesthesic solution (see recipe, Fig. 7.3 ) is

then injected into the saphenous compartment

(Fig.

7.4 ) from the insertion site to below the

SFJ. The patient is sometimes placed in a mod-

erate Trendelenberg position to enhance a blood-

less vein and the ﬁ nal position of the tip of the

catheter/ ﬁ ber con ﬁ rmed by ultrasound (Fig.

7.5 ).

The anesthetic solution is then injected into

the tissue surrounding the proximal 3–4 cm of

the great saphenous vein. Cold saline has been

demonstrated in a small series as an alternative

tumescent agent with similar ef ﬁ cacy to dilute

lidocaine [ 50 ] .

The withdrawal of the ClosureFAST™ cath-

eter is in 6.5 cm segments after each 7 cm sec-

tion has been treated, while with the Olympus

system, the rate is reportedly 1 cm/s. Withdrawal

rate of laser ﬁ bers depends on the equip-

ment and the energy delivered, but will range

from 1–4 mm/s. On conclusion of the proce-

dure, patients may then be placed in compres-

sion therapy, e.g. short-stretch bandages, and/

or 30–40 mmHg compression hose (thigh-high

or panty – patient’s preference). Although it

remains unsubstantiated by clinical trials, most

practitioners use compression for at least sev-

eral days, if not longer, purportedly to enhance

patient comfort, reduce ecchymosis and the

risk of super ﬁ cial thrombophlebitis. There is

no convincing data to support the routine use of

anticoagulants with thermal ablation. In Europe

however, the use of a short course of post pro-

cedural prophylactic dose low molecular weight

heparin is common [

51, 52 ] .

Adjunctive SFJ ligation is thought to be not only

unnecessary, but meddlesome and will increase the

risk of recurrence through neovascularization.

Follow Up

Because of the possibility of incomplete ablation

or recurrent patency of the treated vein, and the

need for adjunctive treatment of the distal great/

small saphenous veins or re ﬂ uxing tributaries,

color- ﬂ 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

Fig. 7.2 Sheath/guide wire in right great saphenous

vein – cephalad to right in image

Local anesthesia recipe:

500mL IV solution

50mL 1% Lidocaine with 1:100,000

epinephrine

10mL 8.4% Sodium Bicarbonate

Fig. 7.3 Local anesthesia recipe to produce 0.1%

Xylocaine with epinephrine/bicarbonate

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517 Elimination of Truncal Vein Re ﬂ ux: Surgery, Thermal Ablation, and Chemical Ablation

1 week to rule out deep venous thrombosis, and

1 year to assure successful thermal ablation of

the target vein. More frequent follow up visits

will often reveal the need for adjunctive treat-

ment at other re ﬂ ux points earlier in the post-

operative course, and result in more complete

treatment of the patient’s venous insuf ﬁ ciency

with better and more sustained resolution of

the patient’s symptom complex. It is simply

not appropriate to merely ablate the proximal

saphenous vein, and expect resolution of every

patient’s symptoms and varicosities. Unless

one is committed to a program of follow up and

adjunctive treatment, the practitioner and the

patient may be left with unsatisfactory results.

Results

[The American Venous Forum and the Society

for Interventional Radiology have proposed

guidelines for reporting of results and complica-

tions following endovenous ablation techniques

by which it is hoped some standardization of out-

come reporting will result [

53, 54 ] .]

Prospective randomized studies directly com-

paring early generation RF ablation with strip-

ping, reported by Lurie [ 34 ] , Stotter [ 55 ] , and

Rautio [

56 ] reported good successful ablation

rates, with patient-reported outcomes of less

painful recovery and faster return to work with

RF than with stripping. Reports using later

Fig. 7.4 Local anesthesia

surrounding thermal device

inside great saphenous vein.

Laser ﬁ ber ( LF ) lies inside

saphenous vein within

saphenous sheath ( SS )

surrounded by local

anesthetic ﬂ uid ( LA ) injected

via delivery needle ( DN )

Fig. 7.5 Tip of thermal device

(green marker) in great saphenous

vein ( GSV ) 2 cm caudad to

saphenofemoral junction ( SFJ ) and

caudad to superﬁ cial epigastric vein

( SEV ) and common femoral vein

( CFV )

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