ORIGINAL ARTICLE

Clinical aspects and indications for endovenous treatmentsfor varicose veins

Kees-Peter de Roos

Received: 25 September 2013 /Accepted: 26 September 2013 /Published online: 23 October 2013# Springer-Verlag London 2013

Abstract Endovenous laser treatment has been around formore than a decade. A brief history of circumstances that havemade this treatment modality possible is provided.

Keywords Endovenous laser treatment . Seldingertechnique . History . Duplex ultrasound . Varicose veins

Introduction

At the beginning of this special issue on endovenous techniquesin phlebology, it may be necessary to give a short history ofcircumstances that have made these techniques possible.

Modern man Homo sapiens (130,000 y BC–current) wasnot the first creature to use bipedalism as a means of locomo-tion. He has probably evolved from an ape-like ancestor:Australopithecus afarensis (3.7–3 milj. y BC) who probablywas the first real bipedal [1]. Its ancestor Ardipithecus orAustralopithecus ramidus (pithecus , ape; ramidus , root)(5.8–5.2 milj. y BC) lived in the East African jungle and stillcombined upright walking with tree climbing [2]. The possi-bility of bipedal movement made it feasible for these speciesto move more rapidly and to hunt for small animals that livedoutside the jungle. This made it possible for these species toleave the African jungle and migrate to other areas and even-tually spread all over the world. This postural changemay alsohave had great implications for the blood column in the thoraxand legs and may even be the main reason why varicose veinsoccur more frequent in man than in animals [3].

Claudius Galen of Pergamum (129–199 AD) who started asa physician to the gladiators and inevitably became an experton trauma is believed to be the first to use a vascular ligature.

He also used a hook to remove varicose veins through severalincisions. Eventually, he was appointed as Emperor MarcusAurelius' personal surgeon [3].

The American surgeon William Lorden Keller (1874–1959) introduced a technique to remove the “internal” saphe-nous vein in 1905 [4]. He used a wire and multiple incisionsand in fact started endovenous treatment for varicose veins.Up to that time, the open procedure as introduced by FriedrichTrendelenburg (1844–1924) was considered to be the standardtechnique. Later, Mayo, Babcock, and others using variousdifferent metal devices have introduced several modifications.In a totally different era and without the help of imagingtechniques, diagnosis was made based on patient history,physical examination, and experience, a lot of experience.

The Swedish radiologist Sven-Ivar Seldinger (1921–1998)came up with a simple solution to introduce a radiographycatheter into arteries [5]. It made angiography a relatively risk-free intervention, and other fields in medicine soon adoptedthis technique to safely obtain access to blood vessels andhollow organs.

In 1970, the pencil probe of a “Parkes model 802 Dopplerblood flow velocity detector” (Fig. 1) was presented to detectperforating veins [6]. This paved the way for Doppler devicesto be used in detecting reflux in patients without using inva-sive techniques such as phlebography. In the beginning of the1980s of the last century, a combination echography andDoppler (Duplex ultrasound) was first used to visualize veinspreoperatively [7]. Near the end of that century, Duplex ultra-sound instruments had become more affordable and becomethe phlebologist's main investigative tool.

In 1972, Watts described a thermal coagulation of the “inter-nal” saphenous vein after ligation of the saphenofemoral junctionusing diathermy [8]. In 1989, Griffith et al. described a newtechnique of endoluminal diathermy of the long saphenous veinusing a bipolar electrode stating that this technique is simple andrelatively painless compared with conventional stripping [9].

K.<P. de Roos (*)DermaPark, Uden, Noord-Brabant, Netherlandse-mail: kpdr@dermapark.nl

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Somehow, however, both these thermal techniques did not reso-nate within the surgical (phlebological) community.

Jeffrey Klein, an American dermatologist, started usinghigh volumes of strongly diluted lidocaine solution as ananesthetic in liposuction in the mid-1980s and called it tumes-cent anesthesia from the Latin verb tumesco, to begin to swellor to swell up. This new technique revolutionized this field incosmetic surgery because it minimized several risks involvedin liposuction under general anesthesia, especially the occur-rence of fat emboli [10].

Endovenous laser ablation was invented supposedly fol-lowing a discussion between Carlos Boné from Spain andLuis Navarro and Robert Min from the USA. Like Watts in1972, they thought that if sufficient heat was introduced into avein, it would subsequently coagulate and lose its function.They used tumescent anesthesia for the most part to avoidcollateral damage from heat into the surrounding tissues. Theypublished excellent initial results using a diode laser (810 nm):0 % recanalization in 125 treated limbs after a mean follow-upof 7 months [11]. Currently, the two predominant techniquesare endovenous laser ablation (EVLA) using several wave-lengths and radiofrequent ablative technique (RFA) usingalternating electric fields at radiofrequencies to generate heat.

Clinical aspects

Duplex ultrasound (DUS) is considered to be the “gold standard”reference test for the diagnosis of varicose veins and to assess theseverity of venous disease [12]. Investigating patients in theupright position with DUS leads to a full understanding ofhemodynamics and anatomy, the so-called “duplex anatomy.”

In contrast to the old gold standard phlebography, DUS alsovisualizes other structures such as fascia. This has changed ourdefinition of the great saphenous vein (GSV), as being that partof the vein that is situated between the muscular and subcutane-ous fascia [13]. DUS also addresses the role of reflux in saphe-nous trunks GSV and small saphenous vein (SSV) on the onehand and the role of the tributaries (such as anterior accessorysaphenous vein) on the other (Fig. 2). This will help to determinewhich treatment option to choose for each individual patient [14].

Fig. 1 Parkes model 802 Doppler blood flow velocity detector

Fig. 2 Schematic view of venous anatomy from Insightful Phlebologyan atlas for diagnosis and treatment of venous diseases of the lower limb,2009 (reprint with permission)

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The importance of DUS as part of the evaluation of patientscan be illustrated by two clinical examples. The first example isthat of a 74-year-old male patient who had made an appoint-ment because his daughters were concerned about the varicosevein on his upper right leg (Fig. 3). He had no complaintswhatsoever. By DUS examination, there was a small reflux(0.4 s) in the GSVand its diameter was approximately 4 mm.

The visual side branch varicosity was removed with ambula-tory phlebectomy under local anesthesia. After 6 weeks, DUSexamination was repeated and the reflux in the GSV haddisappeared. Removal of this varicose vein had restored thehemodynamic disorder in the GSV necessitating no furthertherapy. Both his daughters and (therefore) also the patient weresatisfied about the result.

The second example is that of a 46-year-old female patientwho presented herself with venous complaints of heavinessand cramps especially in her right leg. During the day, thesecomplaints worsened and edema formed around her ankle.The visible varicose veins (Fig. 4) were not much of a problemto her, although she would not mind if these could be re-moved. DUS examination revealed a distally partially incom-petent GSV and a connection to the so-called parallel axisproximally anterior axis of the GSV (Fig. 5). Both GSV andparallel axis were treated with EVLA. After 6 weeks, most ofthe visible varicose veins had disappeared and her complaints.

Indications

In contrast to conventional stripping procedures, endovenousablative techniques are only possible under constant DUS

monitoring. In using the Seldinger technique in combination withDUS, physicians can obtain access to veins with very small (e.g.,2 mm) diameters. The laser and RFA catheters used with thesetechniques are only semiflexible making it impossible to ablatevery tortuous varicose veins.

Both great and small saphenous veins are enveloped be-tween the muscular and subcutaneous fascia and are kept inplace by the saphenous ligament. Because of their location themajority—if not all—of these veins even when incompetentremain non-tortuous. This enables physicians to insert cathetersinto these veins. This envelope is also the natural border for thetumescent anesthesia (Fig. 6).

Varicose veins outside the abovementioned envelope, e.g.,anterior or posterior accessory vein or even perforator veinscan also be treated with endovenous techniques. Extra atten-tion has to be put on the necessary tumescent anesthesia.

Is time of the essence?

Having established that an endovenous technique is the ther-apy of choice for GSV and SSV incompetence, the nextquestion to be answered is: what is reflux?

The National Institute for Health and Clinical Excellence(NICE guidance, UK) nor the German [15] and Dutch Guide-lines mention any value for reflux as a threshold for therapy.There is nevertheless a European Consensus Statement thataddresses this problem. According to this statement, venousreflux is considered to be retrograde flow in the reversedirection to physiological flow and pathological when lastingFig. 3 “Cosmetic” varicose veins

Fig. 4 Some varicose veins on the upper leg and calf

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or more than 0.5 s, though a definitive cutoff for all veinsegments has not been agreed upon in the published literature[12]. The American Clinical Practice Guidelines agree withthis statement and recommends a cutoff value of 1 s for

abnormally reversed flow (reflux) in the femoral and poplitealveins and of 0.5 s for the great saphenous vein, the smallsaphenous vein, the tibial, deep femoral, and the perforatingveins [16].

Do we treat reflux?

Some argue that reflux alone is not enough to decide whetheror not to treat saphenous incompetence, and that other param-eters have to be taken into consideration. Perhaps venousvolume and venous return are more important measurementsfor venous insufficiency. In an attempt to correlate this volumeand GSV incompetence, Navarro and co-workers investigated112 lower limbs with saphenofemoral junction and truncalGSV incompetence and concluded that a GSV diameter of5.5 mm or less predicted the absence of abnormal refluxwith asensitivity of 78 %, a specificity of 87 %, positive and nega-tive predictive values of 78 %, and an accuracy of 82 %. AGSV diameter of 7.3 mm or greater predicted critical reflux(VFI >7 mL/s) with an 80 % sensitivity, an 85 % specificity,and an 84 % accuracy [17]. A recent study has established arelation between clinical severity (as measured with the CEAPclassification) and the ambulatory venous pressure measure-ment. Therefore, clinical signs of venous disease correlatewell with the gold standard for determination of the severityof this condition, i.e., ambulatory pressure (Reeder et al.,

Fig. 5 Result with DUS: incompetent GSVas well as a connection to theso-called parallel axis (also incompetent)

Fig. 6 Catheter in SSV (left).Tumescent anesthesia in placewith the catheter in the center(right)

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Comparison of ambulatory venous pressure measurement andanterior compartment pressure measurement in relation to theCEAP clinical classification of chronic venous disease, sub-mitted for publication).

Anatomical considerations

Venous return in the lower extremity starts at the base of thefoot in the plantar plexus. Here, blood is collected in a venousreservoir, a structure also known as Lejar's sponge. From thisreservoir, flow is directed outward and valves prevent blood tore-enter after it has been expelled into the superficial venoussystem. The superficial venous dorsal arch connects the SSVand GSV (Fig. 2). These major branches collect blood fromveins in the subcutaneous tissue and direct it toward the deepsystem at the level of the knee pit and the groin, respectively.From the capillaries into the reticular veins and side branches,blood will flow into the major branches (GSVand SSV).

Between the superficial and the deep system, there areseveral connecting veins. They are called perforating veinsbecause they perforate the fascia that separates subcutaneousfat and muscles. Early anatomical studies have shown up to150 perforators in each leg [18]. The blood flow in theseperforators is directed inward, making influx into the deepsystem possible. Valve dysfunction at this level will causevaricose veins that resemble bubble gum under pressure, so-called “blow outs” (Fig. 7). Because of constant pressure, theskin may become extremely thin making it very vulnerable. Ifone of these blow outs is damaged, even lethal blood loss maybe the result.

The next—smaller level—veins are called reticular veinsbecause of their netlike, crisscross distribution in the superfi-cial plane. These veins collect blood from small venules andcapillaries, which when incompetent often resemble brushes,hence, brush veins (Fig. 8).

To treat or not to treat?

Over the years, several studies have shown that about 50 % ofvenous ulcers are based on superficial venous insufficiencyalone [19, 20]. It is therefore safe to say that restoration of thissuperficial hemodynamic disturbance will reduce the risk ofdeveloping a venous ulcer, which is of great socioeconomicbenefit to the society. It is furthermore safe to assume that—aswith any valve—incompetence when left untreated will dete-riorate over time.We cannot however predict at which rate thisdeterioration will take place. The decision to treat patientswith GSVor SSV incompetence should be based on a tailor-made plan after complete examination of each individualpatient. The most important considerations are complaintsand the volume of reflux [21].

Phlebology has evolved enormously over the last cen-tury. First, from an experience based to an evidence-baseddiagnostic and therapeutic strategy, and second, from treat-ment strategies that involve only rigorous surgery andcompression therapy for end-stage chronic venous diseaseinto a specialty with sophisticated noninvasive diagnostictools and minimal invasive techniques for all stages of venousdisease.

More than a century after Keller has introduced the strip-ping operation for varicose veins, the first new developmentwas endovenous laser ablation. Now, with the experience ofFig. 7 Blow out

Fig. 8 a Reticular veins before foam sclerotherapy. b Reticular veinsimmediately after foam sclerotherapy

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more than a decade, endovenous thermal ablation has becomethe new effective and patient friendly gold standard for thetreatment of varicose veins.

References

1. Wood B, Collard M (1999) The human genus. Science 284:65–712. Balter M, Gibbons A (2001) Another emissary from the dawn of

humanity. Science 293:187–1883. Roos K-P de. (2003) Ambulatory Phlebectomy. Thesis, Maastricht.

ISBN 90-9016918-0.4. Keller WL (1905) A new method of extirpating the internal saphe-

nous and similar veins in varicose conditions. A preliminary report. NY Med J 82:385–386

5. Seldinger SI (1953) Catheter replacement of the needle in percutane-ous arteriography; a new technique. Acta Radiol 39(5):368–376

6. Wyatt AP (1970) Ultrasonic localization of perforating veins. BMJ1(5694):497

7. Watts GT (1972) Endovenous diathermy destruction of internal sa-phenous. Br Med J 4(5831):53

8. Ruoff BA, Cranley JJ, Hannan LA, Aseffa N, Karkow WS, StedjeKG, Cranley RD (1987) Real-time duplex ultrasound mapping of thegreater saphenous vein before in situ infrainguinal revascularization.J Vasc Surg 6:107–113

9. Griffith CD, Dennis MJ, Blundell JW, Hopkinson BR (1989) Bipolardiathermy treatment of long saphenous vein varicosities. J R CollSurg Edinb 34(5):256–257

10. Klein JA (1987) The tumescent technique for liposuction surgery.Am J Cosmetic Surg 4:1124–1132

11. Navarro L, Min RJ, Boné C (2001) Endovenous laser: a newminimally invasive method of treatment for varicose veins;

preliminary observations using an 810 nm diode laser. DermatolSurg 2:117–122

12. Coleridge-Smith P, Labropoulos N, Partsch H, Myers K, NicolaidesA, Cavezzi A (2006) Duplex ultrasound investigation of the veins inchronic venous disease of the lower limbs-UIP consensus document.Part I. Basic Principles. Eur J Vasc Endovasc Surg 31:83–92

13. Kockaert MA, de Roos K-P, van Dijk L, Nijsten T, Neumann HAM(2012) Duplication of the greater saphenous vein: a definition prob-lem and implications for therapy. Dermatol Surg 38:77–82

14. Cavezzi A, Labropoulos N, Partsch H, Ricci S, Caggiati A, Myers Ket al (2006) Duplex ultrasound investigation of the veins in chronicvenous disease of the lower limbs–UIP consensus document. Part II.Anatomy. Eur J Vasc Endovasc Surg 31:288–299

15. Leitlinie zur Diagnostik und Therapie der Krampfadererkrankung derDeutschen Gesellschaft für Phlebologie, der Deutschen Gesellschaftfür Gefäßchirurgie, des Berufsverbandes der Phlebologen e.V. undder Arbeitsgemeinschaft der niedergelassenen GefäßchirurgenDeutschlands e.V. (http://www.phlebology.de/en/leitlinien-der-dgp-mainmenu/280-leitlinie-zur-diagnostik-und-therapie-der-krampfadererkrankung)

16. Gloviczki P, Comerota AJ, Dalsing MC et al (2011) The care ofpatients with varicose veins and associated chronic venous diseases:clinical practice guidelines of the Society for Vascular Surgery andthe American Venous Forum. J Vasc Surg 53(5 Suppl):2S–48S

17. Navarro TP, Delis KT, Ribeiro AP (2002) Clinical and hemodynamicsignificance of the greater saphenous vein diameter in chronic venousinsufficiency. Arch Surg 137:1233–1237

18. van Limborgh J, Banga DA, Meijerink CJH, Luigies JHH (1962) Devenae communicantes van het been. Ned Tijdschr Geneeskd 106:415–420

19. Feuerstein W (1979) Die Diagnose des postthrombotischensyndroms. Phleb u Proktol 8:18

20. Magnusson MB, Nelzen O, Risberg B, Sivertsson R (2001) A colourDoppler ultrasound study of venous reflux in patients with chronicleg ulcers. Eur J Vasc Endovasc Surg 21:353–360

21. Neumann HAM (2011) Skin, veins and legs. Phlebologie 40:344–355

382 Lasers Med Sci (2014) 29:377–382

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