Management of great saphenous varicosities:

Endovenous therapy or conventional surgery?

Joint Hospital Surgical Grand Round19th October 2013Wong Ka Ming CandyTseung Kwan O Hospital

Introduction • Dilated, tortuous superficial veins• Affect 20-30% of adults• More common in female• Symptoms varies• May develop complications with

time• Venous ulcer in 3-6% of patients

with varicose vein

Management Options

Surgery

• Gold standard over the past century• SFJ ligation +/- stripping • Disadvantages:

1. General anaesthesia / regional anaesthesia2. Painful groin wound 3. Risks of surgery4. Bruise is common

Endovenous Laser Ablation ( EVLA)

• First report by Bone in 1999• Approved by US FDA in Jan 2002• Available laser generators:

Ash JL et al. Laser Treatment of Varicose veins: order out of the chaos. Semin Vasc Surg. 2010 Jun;23(2):101-6.

EVLA Mechanism

Ash JL et al. Laser Treatment of Varicose veins: order out of the chaos. Semin Vasc Surg. 2010 Jun;23(2):101-6.

Radiofrequency Ablation ( RFA)

• First reported in 1998 in Switzerland• Approved by US FDA in 1999• Bipolar catheter used to generate energy

1st generation 2nd generation 3rd generation

Catheter name Closure Closure Plus Closure Fast

Year 1999 2003 2006

Temperature (℃) 85 85 120

Speed 2-3 cm / min 2-3 cm / min 7cm segment in 20sec cycle

Lohr J, Kulwicki A. Radiofrequency ablation: evolution of a treatment. Semin Vasc Surg. 2010;23:90-100. 20

RFA Mechanism• Denaturation of collagen matrix• Vein wall collagen contraction• Fibrotic sealing of vessel lumen due to injury

and inflammation to vein wall

Lohr J, Kulwicki A. Radiofrequency ablation: evolution of a treatment. Semin Vasc Surg. 2010;23:90-100. 20

EVLA / RFA Procedure

1. Duplex ultrasound localization2. GSV identified and cannulated 3. Introducer sheath and catheter inserted4. Catheter positioned 2cm from SFJ5. Injection of tumescent solution6. Catheter slowly withdrawn and fired until the

tip is 1cm from the skin surface

Tumescent solution

• Normal saline + lignocaine with adrenaline +/- 8.4% sodium bicarbonate

• Instilled into the saphenous sheath under ultrasound guidance

• Functions:– Heat sink– Separate of GSV from saphenous nerve– Contraction of the vein

Foam sclerotherapy

• Chemical ablation• Sodium tetradecyl sulphate ( STS) /

Polidocanol• Tessari technique– Mix with air / CO2– 1: 4 ratio

Foam Sclerotherapy

Current evidence comparing endovenous procedure and surgery?

Published Aug 2012

EVLA versus Surgery

EVLA 1.5times higher risk of primary failure

EVLA 40% less chance of clinical recurrence

EVLA less post op complications

Outcomes No. of studies No. of patientsPooled RR (95%

CI)<EVLA vs Surgery>

Wound infection 8 1347 0.3 (0.1, 0.8)

Parasthesia 9 1387 0.8 ( 0.6, 1.1)

Superfical thromboplebitis 6 1121 1.0 (0.5 , 1.8)

Haematoma 4 708 0.5 ( 0.3, 0.8)

ecchymosis 6 876 0.7 ( 0.3, 1.6)

Other results ( EVLA vs Surgery)

• Less post-op pain *• Earlier return to normal activities / work• Better QOL ( by AVVSS)

* Statistical significantAVVSS = Aberdeen varicose vein severity score

RFA versus Surgery

RFA 1.3 times higher risk of primary failure

RFA 10% less chance of clinical recurrence

Post op complications

Outcomes No. of studies No. of patients Pooled RR (95% CI)<RFA vs Surgery>

Wound infection 5 671 0.3 ( 0.1, 0.4)

Parasthesia 7 759 1.0 ( 0.5, 0.7)

Superfical thromboplebitis 6 699 2.3 (1.1, 5.0)

Haematoma 5 437 0.4 ( 0.1, 0.8)

Other results ( RFA vs Surgery)

• Less post op pain *• Earlier return to normal activities / work*

* statistically significant

UGFS vs Surgery

Kendler M, Wetzig T, Simon JC. Foam sclerotherapy: a possible option in therapy of varicose veins

UGFS 2.4 times higher risk of primary failure

EVLA Surgery RFA Surgery UGFS Surgery

Primary failure Clinical

recurrence

Wound infection

Parasthesia

Superficial thromboplebitis

Haematoma

Post op pain

Return to normal activities

QOL

NICE guideline 2013

• Refer to vascular service if…– Symptomatic – Lower limb skin changes• Pigmentation / eczema

– Superficial vein thrombosis– Venous leg ulcer

NICE guideline 2013

• Assessment - Duplex ultrasound– Confirm diagnosis – Extent of truncal reflux

• Interventional Treatment

Thank You

CEAP classification - Clinical

• C0: no visible or palpable signs of venous disease• C1: telangiectasies or reticular veins• C2: varicose veins• C3: edema• C4a: pigmentation or eczema• C4b: lipodermatosclerosis or atrophie blanche• C5: healed venous ulcer• C6: active venous ulcer

CEAP classification – Etiological

• Ec: congenital• Ep: primary• Es: secondary (post-thrombotic)• En: no venous cause identified

CEAP classification – Anatomical

• As: superficial veins• Ap: perforator veins• Ad: deep veins• An: no venous location identified

CEAP classification – Pathophysiological

• Pr: reflux• Po: obstruction• Pr,o: reflux and obstruction• Pn: no venous pathophysiology identifiable

Duplex ultrasound

• Assess the size of the GSV• Relation to overlying varices• Evaluate the reflux time in conjunction with

venous diameter

EVLA Complications

• Saphenous nerve paraesthesia• DVT• Skin burns• Phlebitis • Bruises

Contraindications for endovenous ablation

• DVT• Non palpable pedal pulse• Inability to ambulate• General poor health• Pregnant

• Relative contraindications:– Non traversable vein segment – thrombosis / extreme

tortuosity

Conservative

• Weight loss• Exercise• Elevation of lower limbs • Compression therapy– Different graded pressures for patient with

different severities

Surgery Complications

• Wound haematoma / infection• Lymphatic leaks • Common femoral vein and artery injuries• Neurological complications

• Bruises are common, can last up to 6 weeks• Usually advised to return to work after 10-14

days

Proposed Benefits

• Avoidance of general anaesthesia• Can be done in outpatient setting • Minimal pain• Earlier return to normal activity• Decrease risk of nerve injury• Lower risk of recurrence