Varicose Vein Treatment (Endovenous)

What is Endovenous Ablation of Varicose Veins?

Endovenous ablation is a minimally invasive treatment that uses heat to cauterize or burn and seal off enlarged veins in the legs, a condition called varicose veins.

Normally, blood circulates from the heart to the legs and back again using a system of one-way valves to prevent the blood from flowing backward into the legs. When leg veins become less elastic and valves malfunction, some blood may remain in the leg where it pools and causes the vessels to become enlarged or varicose.

Endovenous ablation is an image-guided procedure that uses heat generated by radiofrequency energy or a laser to seal off the flow of blood to these faulty vessels, diverting blood flow to nearby healthy veins.

What are some common uses of the procedure?

Although this procedure may be used for cosmetic purposes, it is more commonly used to help treat symptoms. Symptoms are typically due to enlarged nonfunctional veins that cause circulatory problems (venous insufficiency). Symptoms include:

• leg pain
• swelling
• skin irritation, sores (ulcers) and discoloration
• inflammation of the veins (phlebitis), resulting in painful veins or varicosities.

How should I prepare?

You should report to your doctor all medications that you are taking, including herbal supplements, and if you have any allergies, especially to anesthesia or to contrast materials (also known as "dye" or "x-ray dye"). Your physician may advise you to stop taking aspirin or a blood thinner for a specified period of time days before your procedure.

You should wear comfortable, loose-fitting clothing. You will need to remove all clothing and jewelry in the area to be examined.

You should plan to have a relative or friend drive you home after your procedure.

You may be asked to wear a gown during the procedure.

What does the equipment look like?

In this procedure, ultrasound, a catheter, a laser or radiofrequency electrodes and a generator are used.

Ultrasound scanners consist of a console containing a computer and electronics, a video display screen and a transducer that is used to scan the body and veins. The transducer is a small hand-held device that resembles a microphone, attached to the scanner by a cord. The transducer sends out high frequency sound waves and then listens for the returning echo. The principles are similar to sonar used by boats and submarines.

The ultrasound image is immediately visible on a nearby screen that looks much like a computer or television monitor. The image is created based on the amplitude (strength), frequency and time it takes for the sound signal to return from the patient to the transducer.

A catheter is a long, thin plastic tube, about as thick as a strand of spaghetti.

Laser fiber and radiofrequency electrodes are fine wires that carry electrical energy from the power generator.

How does the procedure work?

Using an ultrasound to visualize the enlarged vein, a catheter is inserted through the skin into a blood vessel and positioned within the abnormal vein. A laser fiber or radiofrequency electrodes are then inserted through the catheter and advanced to the site. Heat generated by the laser or radiofrequency energy is then applied, heating the vessel and causing it to close. Following the procedure, the faulty vein will shrink and "scar down."

How is it performed?

Image-guided, minimally invasive procedures such as endovenous ablation are performed by a specially trained interventional radiologist.

This procedure is often done on an outpatient basis.

Your physician may use a topical anesthetic cream over the abnormal vein area before the procedure in order to reduce discomfort.

Your physician will numb the area where the catheter will enter into the abnormal vein with a local anesthetic and use the ultrasound transducer or wand to study the vein and track its path.

The leg being treated will be shaved, sterilized and covered with a surgical drape.

A very small nick is made in the skin at the site.

Using ultrasound guidance, the catheter is then inserted through the skin into the vein and positioned within the abnormal vein. The laser fiber or radiofrequency electrode is then inserted through the catheter. The tip of the fiber or electrode is exposed by pulling the catheter back slightly.

Local anesthetic is injected around the abnormal vein with ultrasound guidance. Heat is then applied as the catheter is slowly withdrawn.

Pressure will be applied to stop any bleeding and the opening in the skin is covered with a bandage. No sutures are needed.

This procedure is usually completed within an hour.

What will I experience during the procedure?

You may be asked to wear protective glasses if and when lasers are in use.

An area of your leg will be cleaned, shaved and numbed.

You will feel a slight pin prick when the local anesthetic is injected.

The area will become numb within a short time.

You may feel slight pressure when the catheter is inserted but no serious discomfort.

Injection of local anesthetic around the abnormal vein is the most bothersome part of the procedure, because it usually requires multiple injections along the vein. Actual closure of the vein with laser or radiofrequency is usually not painful.

Following the procedure, you will need to wear a compression stocking to help reduce bruising, tenderness, and the small possibility that blood clots may form.

You may resume your normal activity immediately, with the exception of lifting heavy objects or prolonged sitting (such as a long plane or bus trip). You should not remain inactive or spend too much time in bed during the recovery period since this increases the chance for clotting complications.

Who interprets the results and how do I get them?

A follow up ultrasound examination is essential in order to assess the treated vein and also to rule out potential complications. In most practices, the first ultrasound exam is needed in 24-48 hours after the treatment and the second exam six weeks later. The main vein should be completely closed at this point. Additional procedures (such as sclerotherapy or phlebectomy) may be necessary to treat associated veins.

What are the benefits vs. risks?

Benefits

• No surgical incision is needed—only a small nick in the skin that does not have to be stitched closed.
• When compared with traditional vein stripping techniques, endovenous ablation is more effective, has fewer negative outcomes, and is associated with much less pain during recovery.
• Ablation is generally complication-free and safe.
• This procedure leaves virtually no scars because catheter placement requires skin openings of only a few millimeters, not large incisions.
• Endovenous ablation offers a less invasive alternative to standard surgery.
• Most of the veins treated are effectively invisible even to ultrasound 24 months after the procedure.
• Most patients have immediate symptom relief and are able to return to normal activities within a day or two, with little or no pain.

Risks

• Any procedure where the skin is penetrated carries a risk of infection. The chance of infection requiring antibiotic treatment appears to be less than one in 1,000.
• Any procedure that involves placement of a catheter inside a blood vessel carries certain risks. These risks include damage to the blood vessel, bruising or bleeding at the puncture site, and infection.
• Some postoperative bruising and tenderness may occur, but may be alleviated by wearing a compression stocking.
• Some instances of thermal (heat) damage to nerves have been reported. This is rare and generally goes away in a short time.
• Thrombophlebitis (inflammation of the vein) is not uncommon (may cause pain and redness over the treated area), but generally responds well to nonsteroidial anti-inflammatory drugs (NSAIDs). Blood clots that formed in the veins can travel to the lungs (pulmonary embolism); however, this is an extremely rare occurrence.

What are the limitations of Endovenous Ablation of Varicose Veins?

Ablation catheters cannot be easily passed through a tortuous vein, or a vessel with many turns and bends. Consequently, the procedure is typically used to treat larger varicose veins, such as the great saphenous vein, which extends from the groin down the inside of the thigh into the inner calf.

Endovenous ablation is successful at closing the main vein almost 100 percent of the time, but small dilated branches that persist in the skin often require additional treatment with phlebectomy (a minor surgical procedure to extract them) or the injection of a liquid agent to seal them off, called sclerotherapy. Subsequent treatments are usually scheduled after an ablation procedure.