Varicose veins of the legs are the visible result of chronic superficial venous insufficiency, a manifestation of venous hypertension. Veins carry blood from the feet and legs up toward the heart. Valves in these veins prevent the reflux of blood back toward the feet. It is the failure of these valves, termed valvular insufficiency, that is the root cause of this clinical condition.
Endovenous laser ablation, which received Food and Drug Administration approval in 2002, has emerged as a minimally invasive treatment alternative to surgical ligation and stripping. According to Dr. Robert J. Min, chairman of radiology at Weill Cornell Medical College, this treatment option offers the added benefit of shorter recovery times and limited anesthesia requirements when compared to conventional surgery.
Risk Factors and Symptoms
Venous insufficiency is common and is estimated to occur in 10 percent of men and 25 percent of women according to Dr. Nicos Labropoulos. Dr. Andre Cornu-Thenard cites heredity as the most common risk factor for the development of varicose veins. In fact, 90 percent of people will develop varicose veins if both parents were affected. Occupations that require standing for prolonged periods of time can increase the chances of forming varicose veins in people with a genetic predisposition.
The symptoms of superficial venous insufficiency include fatigue, aching, heaviness and throbbing. Untreated, chronic venous hypertension can lead to skin damage, including skin pigmentation and skin ulcerations.
Anatomy
The veins of the legs are anatomically divided into deep veins, closer to the bone, and superficial, closer to the skin, systems. The deep veins are the primary conduit for venous drainage of the feet and legs. The superficial system is a web-like collection of collecting veins within the subcutaneous tissues. Perforator veins are small channels connecting the superficial veins to the deep veins. The great saphenous vein and the small saphenous vein are the two superficial veins most responsible for varicose vein formation. The great saphenous vein begins on the inner foot and travels up the inner calf and thigh before joining the deep venous system in the groin. The small saphenous vein begins at the outer part of the ankle and travels along the calf until joining the deep veins behind the knee.
Pre-procedure Evaluation
Symptomatic varicose veins that have not responded to conservative therapies such as exercise and graduated compression stockings should be evaluated for ablative therapy. More advanced cases resulting in bleeding or skin damage should also be evaluated. In addition to obtaining a patient history and performing a physical examination, patients with varicose veins should be evaluated with duplex ultrasound imaging. This allows the physician to map all incompetent venous pathways in order to plan the most appropriate treatment. Conditions such as absent arterial pulses in the feet, liver disease, pregnancy, breast-feeding and uncorrectable bleeding risk may rule out the use of ablation therapy.
Procedural Technique
Prior to endovenous laser ablation, the incompetent venous pathways are once again mapped and marked on the skin. The incompetent superficial vein, at its lowest level of insufficiency, is accessed with a small needle. Ultimately, using this access, a laser fiber is advanced into the lumen of the vein. The tip of the laser is carefully positioned using ultrasound guidance. Tumescent anesthesia, a buffered, dilute anesthetic solution, is administered around the entire venous segment. Tumescent anesthesia, commonly used for liposuction procedures, makes endovenous laser ablation virtually painless, functions as a thermal shield, protecting adjacent structures from the heat of the laser fiber and compresses the treatment vein, allowing the laser fiber to directly contact the wall of the vein. Next, the laser fiber is activated and the ablation is performed by withdrawing the fiber back to its entry point at a rate of approximately two to three millimeters per second. The leg is cleaned and graduated compression stockings are immediately placed. Ambulation is encouraged at once.
Post-procedure Care
Graduated compression stockings are worn at all times for a minimum of two weeks, except to sleep or to shower. Bruising and mild tenderness of the skin is common and is usually of no medical consequence. Some patients may experience a tightening or pulling sensation of the treated vein. This will typically start by the end of the first week, peak by day seven and resolve approximately two to three weeks following the procedure. This sensation is the result of the intended scarring and contraction and often responds to graduated compression stocking use, ambulation, and non-steroidal anti-inflammatory use. Their practitioner sees most patients in seven to ten days for a follow-up.
Results
Dr. Min reported his results of endovenous laser ablation on 1,000 treated limbs. The procedure was successful in 98 percent of limbs after five year followup. All of his patients reported a decrease in visible varicosities, and 100 percent of patients reported significant improvement. There were no cases of skin burns, deep vein blood clot formation or other adverse reaction. Local anesthesia was well-tolerated in all patients.
References
- "Journal of Vascular and Interventional Radiology"; Endovenous laser treatment of saphenous vein reflux: long-term results; R Min, et al.; August 2003
- "Journal of Vascular Surgery"; Clinical correlation to various patterns of reflux; N Labropoulos; November 1997
- "The Journal of Dermatologic Surgery and Oncology"; Importance of the familial factor in varicose disease. Clinical study of 134 families; A Cornu-Thenard, et al.; May 1994
- "Techniques in Vascular and Interventional Radiology"; Duplex ultrasound for superficial venous insufficiency; N Khilnani, et al.; September 2003
