Surgical and Ablative Procedures for Varicose Veins
Case capsule:
Brief history:
A 30-year-old man, Mr. Ankit, presented to the surgery OPD with dilated and tortuous superficial veins in his right leg for the past 2 years. He is also having occasional dull aching sensations mainly during nights or after prolonged standing. He is a smoker and does not have any comorbidities.
How to evaluate this patient further?
Physical examination
The patient was examined in a standing posture.
Tortuous and dilated veins were noted in the greater saphenous vein territory along the medial side, up to above the knee level noted (Fig.1)
Fig. 1
Duplex ultrasound
The patient was further assessed with a bilateral Doppler ultrasound and showed right greater saphenous system varicosities with Saphenofemoral junction with perforator incompetence (Fig.2). The Sapheno-Popliteal junction and deep venous system are normal.
Fig.2
Routine blood evaluations showed normal study, except elevated blood cholesterol levels.
Diagnosis of this patient: right great saphenous territory varicose veins with SFJ and perforator incompetence
How to proceed further?
Varicose veins with persisting symptoms and signs of chronic venous insufficiency are ideally managed with interventions as they are seldom cured with conservative care alone.
A variety of options are available for management in this patient and he is given the choices based on the patient profile and local availability and expertise.
He is also advised with leg exercises and compression hosiery as an adjunctive measure.
Which of the options can be considered in this patient?
A brief description of the options available:
A) Treatment of Incompetent Sapheno-Femoral Junction and Long Saphenous vein.
1)Endovenous Abalation performed under ultrasound guidance:
a) Thermal ablation — Thermal ablation involves the generation of heat at a temperature high enough to denature the proteins that constitute the vein wall. This can be accomplished with radiofrequency energy, or with laser light introduced into the lumen of an incompetent vein using specialized catheters to effect closure. additional infiltration of tumescent anesthesia (local anesthetic saline mixture) is required to reduce pain along the saphenous vein and provide a cold buffer from the heat generated by the laser or radiofrequency energy.
c) Non-thermal ablation techniques are also available. Because there is no heat, nonthermal ablation has the advantage of avoiding any discomfort associated with tumescent infiltration, and there is a decreased likelihood for adjacent nerve injury. Nonthermal techniques include:
i) Mechanical occlusion chemically assisted (MOCA) ablation
ii) Cyanoacrylate embolization
2) Open Surgery:
High ligation of Sapheno-femoral junction and stripping of long saphenous vein:
The incision is usually located along the groin crease, and all tributaries at the sapheno-femoral junction are ligated to prevent persistent superficial venous flow directly into the femoral vein and potential for recurrent reflux and varicosities. Flush ligation of the GSV at the saphenofemoral junction without narrowing of the femoral vein is performed. Stripping refers to the removal of an extended segment of the GSV with an external stripper.
Among the options, the current gold standard is thermal ablation methods and it has replaced the classic Trendelenburg surgery.
B) Treatment of Incompetent Perforator:
1) Endovenous Abalation using
a) Thermal ablation
b) Ultrasound-guided injection foam sclerotherapy with 1% Polidocanol or STD
2) SEPS – Subfascial Endoscopic Perforator Surgery
3) Open ligation after pre-op marking with ultrasound
C) Treatment of Branch Varicosities:
1) USG guided injection foam sclerotherapy
2) Stab incision and hook phlebectomy
This patient was treated with endovenous ablation using RF closurefast for SFJ and LSV, USG guided injection foam sclerotherapy for incompetent perforator and branch varicosities with good results and the patient was discharged subsequently from care without any events and advised to use Class II compression stockings, full length, premium cotton with grip top for 3 months.
