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Indications for Interventional Procedures
Standard indications for intervention include cosmesis, pain, itching, leg heaviness and fatigue, external bleeding and superficial thrombophlebitis. Intervention is more strongly indicated when varicose veins are part of more extensive venous disease as manifested by ankle hyperpigmentation, lipodermatosclerosis, atrophic leg changes and venous ulcers. Better results are obtained by treating before these changes occur.
Small telangectasias may be as symptomatic as larger varicosities, mainly because of the pressure on somatic nerves by the dilated veins. For example, approximately 50% of patients with telangectasias will have symptoms which will be relieved in 85% of cases by appropriate therapy.
If deep venous obstruction is identified, caution should be exercised before treating superficial venous pathology. Similarly, if there is deep venous system incompetence, the durability of the treatment of the superficial venous system is more doubtful.
Table 2 Treatment Options
Superficial Venous Abnormalities
Saphenous Vein Reflux
- Endovenous ablation
- Ligation and stripping
- Ultrasound guided sclerotherapy
- Ultrasound guided sclerotherapy
- Subfascial perforator ligation
Treatment planning should be based on the presence or absence, degree and location of reflux, the size and location of the superficial venous pathology, and the effects of venous hypertension in the lower limb.
Deep venous reflux is rarely treated, but if it is associated with superficial venous insufficiency, treatment with the above therapy may be beneficial. It is very important that the underlying venous problem is defined. If saphenous vein reflux and varicose veins coexist, treatment of the varicose veins (and associated telangectasias) without addressing the saphenous reflux will usually be unsuccessful.
Sclerotherapy has traditionally been indicated for treatment of telangectasias, dilated reticular veins and varicosities not related to saphenous vein reflux.The advent of ultrasound guided sclerotherapy, which has become widely practised over the last 10 years, has revolutionised the indications for sclerotherapy. Using ultrasound guidance, it is possible to accurately locate and treat most types of reflux including the great and small saphenous veins, post-operative residual veins, recurrent varicose veins and incompetent perforating veins. It is invaluable in locating and treating reflux which may not be evident clinically but which may contribute to varicosities elsewhere in the leg.
Recently, ultrasound guided sclerotherapy using foamed sclerosant solution (foam echosclerotherapy) has greatly increased the effectiveness of this technique. It is now an accepted and effective treatment of saphenous vein incompetence. As a general guide best results are obtained if the saphenous vein is less than 5 mm in diameter. If greater than 5 mm in diameter, endovenous ablation or ligation and stripping achieves a better long-term result. The main early complication of ultrasound guided sclerotherapy for saphenous vein incompetence is thrombophlebitis, and in long term follow-up is recanalization. In practice, patients may not be happy to wear a stocking continuously for at least two weeks with repeated treatments.
Stab avulsion phlebectomy is indicated to remove superficial varicosities and is usually performed at the same time as endovenous ablation or stripping of the saphenous veins. Occasionally phlebectomy is the only treatment needed if no incompetence at the sapheno-femoral junction is present, but these veins are also suitably treated by sclerotherapy.Tiny incisions and the use of hooks or fine forceps greatly enhance the cosmesis of this procedure. For gross varicosities, phlebectomy can be more effective than sclerotherapy and may be associated with less thrombophlebitis. It can be performed under local or general anaesthesia for patients who detest injections.
Saphenous Vein Surgery
Surgical removal of the saphenous veins has historically been the cornerstone of treatment for varicose veins. Great saphenous vein (GSV) stripping is accomplished by high ligation of the saphenous vein and all tributaries at the sapheno-femoral junction, with stripping to the knee. However, common perception of this highly effective procedure is that it is invasive and morbid causing pain, bruising and swelling with disfiguring scars.
Modern techniques for ligation and stripping have greatly reduced the trauma and morbidity associated with the procedure. Although most patients do well and have only moderate discomfort, the slow return to full ambulation (1-2 weeks) and occasional extensive bruising have limited GSV stripping to an intervention performed less frequently compared with endovenous ablation. However, there are some situations where a surgical approach to GSV reflux is preferred (Table 3).
Table 3 When may a surgical approach to saphenous vein reflux be indicated?
- Grossly dilated saphenous vein or varices
- Thrombophlebitis of the saphenous vein extending to the junction
- Failed endoluminal ablation
- Junctional reflux of saphenous vein with large proximal varicosity & distal competence of saphenous vein
- Patient preference to have veins treated this way
- GSV ligation alone has been performed to reduce the bruising from stripping and to preserve the vein for subsequent arterial bypass. However, this procedure does not adequately address the gross incompetence in the GSV and is not recommended, unless there is only proximal GSV incompetence usually associated with a dilated anterior accessory vein.
Small saphenous vein (SSV) ligation traditionally was indicated when SSV reflux and varices in the tributary veins have been documented. It is necessary to use ultrasound imaging to outline the course and relations of the small saphenous vein because of the highly variable anatomy at the sapheno-popliteal junction. Routinely, the small saphenous vein is simply ligated near the popliteal fossa, through a small crease incision, though limited stripping is sometimes indicated.
Endovenous Vein Ablation
Few procedures have been as rapidly endorsed and widely spread into practice as saphenous vein ablation. In Australia it is becoming the preferred method of treatment for saphenous vein incompetence by many surgeons and phlebologists. With this technique, percutaneous access to the lumen of the vein is obtained by a needle puncture and then either radio frequency or laser energy is used to heat and obliterate the lumen of the vein. Over time, the vein shrinks down to a fibrous cord, but in approximately 5% of cases recanalization and recurrence may occur. Long term follow up of results is necessary before accurate success rates can be claimed.
Currently, ablation is performed for reflux in the above knee segment of the GSV. The procedure is usually performed on an outpatient basis using a local anaesthetic infiltration along the GSV. Early ambulation is encouraged. If a general anaesthetic is preferred, stab avulsion phlebectomy can be performed at the same time. A follow-up venous ultrasound examination is routinely performed to exclude deep venous thrombosis and to confirm ablation of the saphenous vein. Randomized trials have established that ablation is as effective as stripping and has a shorter recovery time. Ablation of the below-knee GSV is avoided, because the calf perforating veins are not directly connected to the saphenous vein at that level and because of a high incidence of injury to the saphenous nerve.
Endoluminal ablation of the SSV is now being performed successfully in Australia. Like ablation of the GSV, it is becoming the preferred method of treatment amongst many surgeons and phlebologists. A potential problem of nerve damage exists because of the proximity of a large superficial cutaneous nerve adjacent to the vein, but current reports indicate that the treatment is safe and effective.
External Greater Saphenous Vein Wrapping
(Venocuff ™) This procedure involves placing a cuff around the proximal GSV to reduce the diameter and restore competence at the sapheno-femoral junction. It has the advantage of preserving the GSV which may then be used in future arterial reconstruction or cardiac bypass surgery. With careful patient selection, the results of this technique compare favourably to those of stripping, but only a small percentage of patients are suitable.
Ovarian Vein Ablation
Vulval varicosities, usually due to multiple pregnancies, are often associated with pelvic varicosities due to a dilated, incompetent left ovarian vein. These pelvic varicosities may be quite symptomatic, giving rise to the pelvic congestion syndrome and varices down the leg, usually through the inner thigh or buttocks.
If a large incompetent ovarian vein is found on ultrasound examination, the vein can be occluded with coils and sclerosant using endovascular techniques. The procedure is performed under local anaesthetic when a fine catheter is passed from the common femoral vein to the left ovarian vein, via the left renal vein using x-ray control. This involves a day only admission to a suitable hospital with adequate imaging facilities.