Endovenous Ablation for the Treatment of Varicose Veins and Lower Extremity Venous Insufficiency

Endovenous Ablation for the Treatment of Varicose Veins and Lower Extremity Venous Insufficiency

Endovenous Ablation for the Treatment of Varicose Veins and Lower Extremity Venous Insufficiency j Sanjoy Kundu, MD, BSc, RVT, RPVI, FRCPC, DABR, FASA...

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Endovenous Ablation for the Treatment of Varicose Veins and Lower Extremity Venous Insufficiency j Sanjoy Kundu, MD, BSc, RVT, RPVI, FRCPC, DABR, FASA, FCIRSE, FSIR; and Milad Modabber, MSc ABSTRACT: Lower extremity venous insufficiency is a common condition with a variety of clinical presentations, the most cited of which is varicose veins. Venous insufficiency and varicose veins tend to progress over time because of worsening of venous valvular insufficiency. There are a number of treatment options ranging from conservative therapy with compression stockings to the most invasive option of surgical stripping and/or ligation. Endovenous ablation (EVA) is a relatively new treatment, which has revolutionized the treatment of venous insufficiency and its secondary manifestations, such as varicose veins, over the last 20 years. EVA is an outpatient, low-risk procedure with minimal recovery time. Attentive procedural technique and detailed procedural instructions are essential for good results and patient satisfaction. (J Radiol Nurs 2011;30:36-42.) KEYWORDS: Endovenous ablation; Laser; Radiofrequency; Venous insufficiency; Varicose veins.

INTRODUCTION Lower extremity venous insufficiency is one of the most common vascular conditions encountered in the population at large. The prevalence of this condition varies widely, but is estimated to be in the range of 30% to 35% in women and 10% to 15% of men in Western society (Callam, 1994; Sisto, Reunanen, & Laurikka, 1995). Varicose veins are the most common presentation of lower extremity venous insufficiency. Lower extremity venous insufficiency is most commonly rooted in reflux in the great saphenous vein secondary to an incompetent saphenofemoral junction.

Sanjoy Kundu, MD, BSc, RVT, RPVI, FRCPC, DABR, FASA, FCIRSE, FSIR, is the Medical Director of The Vein Institute of Toronto, Ontario, Canada. Milad Modabber, MSc, is affiliated with The Vein Institute of Toronto, Ontario, Canada. Corresponding author: Sanjoy Kundu, The Vein Institute of Toronto, 217 Davenport, Toronto, Ontario M5R-1J3, Canada. E-mail: [email protected] theveininstitute.com 1546-0843/$36.00 Copyright Ó 2011 Published by Elsevier Inc on behalf of the Association for Radiologic & Imaging Nursing. doi: 10.1016/j.jradnu.2010.11.001

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The treatment of varicose veins may be for either cosmetic or symptomatic reasons. Historically, the traditional treatment was surgical stripping and ligation with ancillary phlebectomy of tributary varicose veins (Beale & Gough, 2005). However, treatment of lower extremity venous insufficiency has significantly evolved over the last 20 years, namely through the innovation of ultrasound guided endovenous ablation (EVA) for the treatment of axial vein insufficiency (Muller, 1966). More recently, there has been considerable refinement of the EVA technique and the treatment of branch varicose veins with adjunctive sclerotherapy or microphlebectomy (Bartholomew, King, Sahgal, & Vidimos, 2005). This review article is intended to provide an overview of the clinical presentation, diagnosis, and treatment of lower extremity venous insufficiency using EVA and such adjunctive techniques. CLINICAL PRESENTATION Lower extremity venous insufficiency can present in its most mild form as mere surface reticular veins and spider veins with no associated symptoms. Reticular veins are usually small green or blue nonbulging veins, measuring approximately 1 to 4 mm in diameter and

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identified by their distinctive flat and nontortuous appearance. Spider veins are the smallest veins, measuring less than 1 mm and identified by their reddish, purple, or dark blue appearance (Bartholomew et al., 2005). In these instances, minimally invasive surface treatment composing of low-dose sclerotherapy and possibly surface laser may be the only indicated treatment option. The most common presentation of varicose veins are tortuous, dilated, bulging, blue, superficial veins measuring greater than 4 mm in diameter (Bartholomew et al., 2005). Although, varicose veins have been historically regarded as a cosmetic problem, most patients will in fact present with underlying, unrecognized symptoms such as heaviness, leg fatigue at the end of the day, pain over varicose veins or the lower leg, ankle swelling, restlessness, burning over ankle or varicose veins, and pruritus. In many patients, these symptoms are disabling enough to interfere with daily activities and can at times lead to loss of time from work (Bartholomew et al., 2005; Bergan, SchmidSchonbein, & Smith, 2006). As the severity and chronicity of venous insufficiency increases, patients may develop venous dermatitis, pigmentation changes, hemosiderin staining, and continuous swelling around the ankle regions. The most advanced stages of venous insufficiency include development of venous ulcers around the ankles and secondary lymphedema. Venous ulcers are characterized by shallow, nonpainful, and poorly circumscribed ulcers, with the risk of secondary infection. Venous ulcerations affect approximately 1% of the general population, with health care costs in the United States exceeding three billion dollars per year (Bergan, Schmid-Schonbein, et al., 2006). Varicose veins are also associated with several complications, including spontaneous rupture with secondary hemorrhage, superficial thrombophlebitis, and the risk of deep venous thrombosis, with thrombosis of proximal truncal superficial veins such as the great saphenous vein (Beale & Gough, 2005). DIAGNOSIS AND INVESTIGATION The clinical exam should begin with a very careful history focused on venous symptoms, ensuring to elicit symptoms that the patient may not be aware of, or even associate with varicose veins. A general medical and surgical history is also important to determine previous venous treatments or surgery and risk factors for thrombophilia and pigmentation. A directed physical examination is critical in detecting the presence and extent of varicose veins, sites of swelling, discoloration, pigmentation, and ulcerations. The physical examination is composed of inspection and palpation in the standing position, wherein the varicose veins are fully dilated. The appropriate assessment and recording of VOLUME 30 ISSUE 1

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patient history and physical findings are essential in serving as a reference baseline for future treatments. The CEAP classification for chronic venous disorders provides a standardized dynamic system to classify clinical findings and create a common language among all staff, clinicians, and for possible research (Eklof, Rutherford, & Bergan, 2004). The elements of the CEAP classification are clinical severity, etiology or cause, anatomy and pathophysiology. Investigation for superficial venous disease has taken a major leap forward in the last 20 years. Historically, lower extremity contrast venograms were performed with their related risk of contrast administration. Presently, duplex ultrasound is the gold standard for investigation. A focused superficial venous ultrasound is performed in a standing position to map out sites of reflux along with the underlying cause of surface varicose veins. A complete duplex ultrasound assesses the great and small saphenous veins along with any sources of perforator vein reflux or thrombosis. It is also important to assess the deep venous system for reflux and possible site of acute or chronic thrombus (Min, Khilnani, & Golia, 2003). The duplex ultrasound provides the necessary information for creating a proper treatment plan and for identifying all sources of venous reflux, which are giving rise to venous insufficiency. TREATMENT OPTIONS The primary goals of treating varicose veins and venous insufficiency are to improve the cosmetic appearance, reduce venous hypertension, prevent complications of varicose veins, and prevent the progression of venous insufficiency. The treatment options are divided into conservative noninvasive treatments, surgical treatments, and image-guided EVA procedures. CONSERVATIVE TREATMENTS Conservative treatment options for varicose veins and venous insufficiency include lifestyle modification, compression therapy, and/or pharmacotherapy. Patients with varicose veins are advised to avoid prolonged periods of standing or sitting, as this promotes the development and progression of venous valvular insufficiency (Rathbun & Kirkpatrick, 2007). When standing or sitting for prolonged periods, it is recommended to either change the standing or sitting position every 5 min or wear compression stockings to activate the calf muscular venous pump and reduce venous stasis. When sitting down, it is suggested to elevate the legs to promote superficial and deep venous circulation and reduce the stasis of blood in the lower extremities (Rathbun & Kirkpatrick, 2007). It is also recommended to lose excess weight, and to exercise to minimize swelling, reduce venous stasis, and improve the

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function of the calf muscular venous pump. Exercise helps in reducing symptoms, such as aching, pain, venous ulcer recurrence, and also facilitating the resolution of superficial thrombophlebitis and deep venous thrombosis. Ideally, 30 min of daily lower extremity exercise is recommended (Padberg, 2004). To date, compression stockings have been the primary conservative treatment for varicose veins and venous insufficiency. Compression therapydcomposed of graduated elastic compression stockings and short stretch bandagesdis effective in reducing lower extremity pain and swelling and preventing the progression of chronic venous disease to venous ulceration (Bartholomew et al., 2005; Rathbun & Kirkpatrick, 2007). It is critical to prescribe the correct compression stocking and to educate the patient on how to correctly apply the stockings. Otherwise, the effectiveness of compression therapy will be limited by patient compliance. For patients with varicose veins or mild swelling, 30- to 40-mmHg thigh-high or waist-high compression stockings are suggested. For patients with active venous ulcers, 30to 40-mmHg or 40- to 50-mmHg thigh-high or kneehigh compression stockings are recommended. For patients who need prophylactic stockings for prolonged standing or sitting, 20- to 30-mmHg knee-high or thigh compression stockings are advised for reducing symptoms and preventing progression of varicose veins and venous insufficiency. A number of pharmacological therapies for venous insufficiency have been attempted with variable success. Low-dose diuretics have been prescribed in patients with significant lower extremity edema, albeit shown to be minimally effective in reducing pain and discomfort (Bartholomew et al., 2005; Rathbun & Kirkpatrick, 2007). Topical corticosteroids may be used with moderate effectiveness in patients with venous dermatitis to reduce inflammation and pruritis (Rathbun & Kirkpatrick, 2007). It is essential to rule out any infective cellulitis, as to prevent progression with topical corticosteroids use. Antibiotics with broad gram-positive coverage for Staphylococcus and Streptococcus should be used for treating active cellulitis or infected ulcerations (Rathbun & Kirkpatrick, 2007). It is important to use antibiotic coverage for gram-negative and anaerobic organisms in patients with underlying diabetes (Rathbun & Kirkpatrick, 2007). Nonsteroidal anti-inflammatory medications may help reduce discomfort secondary to venous insufficiency and may interfere with the pathologic inflammatory response known to damage vein walls and valves. Several short-term retrospective studies have demonstrated the efficacy of horse chestnut seed extract and its active ingredient aescin, in reducing swelling, ankle and calf circumference, and the symptoms of chronic venous insufficiency (Rathbun &

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Kirkpatrick, 2007). Other herbal medications have demonstrated inconsistent results and are not considered first-line treatment options for chronic venous insufficiency (Siebert, 2002). SURGICAL TREATMENTS Surgical treatment options include saphenous vein stripping, ligation of the saphenofemoral junction, or ambulatory phelebectomy. Saphenous vein stripping was the historical gold standard treatment for varicose veins and venous insufficiency for over three decades (Yao, 1997). Saphenous vein stripping is performed under general anesthesia, and the procedure involves making an incision at the groin and ligating the great saphenous vein and its major tributaries (Beale & Gough, 2005; Belcaro, Cesarone, & Di Renzo, 2003; Miyazaki Nishibe & Sata, 2005). A stiff pin-stripping device is then inserted through the free end of the great saphenous vein and advanced through the vein and out through an incision usually in the lower thigh or upper calf. The great saphenous vein is then inverted and removed through the second incision in the thigh or the calf (Belcaro et al., 2003; Miyazaki Nishibe & Sata, 2005). Ancillary ambulatory phlebectomy for branch varicose veins may be performed at the same sitting or at a later date. The success rate for saphenous vein stripping has been reported in the range of 80% at 3 months and 1 year, at 78% at 3 years, and at 76% at 5 years (Bos, Arends, & Kockaert, 2009). One of the main limitations of saphenous vein stripping is the high recurrence rate of 20% to 30% at 5 years, as demonstrated in multiple studies (Allegra, Antignani, & Carlizza, 2007; Beale & Gough, 2005; Miyazaki Nishibe & Sata, 2005). Complications of saphenous vein stripping include postprocedure pain, bleeding, infection, nerve injury, superficial thrombophlebitis, deep venous thrombosis, or pulmonary embolism (Allegra et al., 2007; Miyazaki Nishibe & Sata, 2005). There is a significantly higher complication rate and longer recovery time associated with saphenous vein stripping as compared with EVA. The typical recovery time of saphenous vein stripping is in the range of 2 to 4 weeks (Allegra et al., 2007; Miyazaki Nishibe & Sata, 2005). Ligation of the saphenofemoral junction was a surgical procedure introduced as a less invasive option in the treatment of venous reflux (Bartholomew et al., 2005; Beale & Gough, 2005). The procedure is performed under local anesthesia. An incision is made parallel to the inguinal ligament at the site of the saphenofemoral junction. The saphenous vein tributaries are identified and ligated up to the saphenofemoral junction. The great saphenous vein is ligated at its junction with the femoral vein followed by closure of the incision and application of compression stockings (Bartholomew

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et al., 2005; Beale & Gough, 2005). The effectiveness of ligation is limited with a very high recurrence rate ranging from 35% to 50% at 3 and 5 years (Miyazaki Nishibe & Sata, 2005; Winterborn, Foy, & Heather, 2008). Complications of saphenofemoral ligation include pain, bleeding, hematoma, infection, nerve injury, superficial thrombophlebitis and deep venous thrombosis, and pulmonary embolus. Because of the very high recurrence rate, saphenofemoral ligation is now combined with ambulatory phlebectomy, sclerotherapy, or EVA procedures. Overall however, there is a low utilization of this procedure given its various limitations. Ambulatory phlebectomy or stab phlebectomy or microphlebectomy was introduced as a less invasive outpatient alternative to saphenous vein stripping (Bartholomew et al., 2005). Ambulatory phlebectomy is used to treat branch surface varicose veins or great or small saphenous vein tributaries under local anesthesia. Yet, in most instances, ambulatory phlebectomy cannot be used to treat great or small saphenous vein reflux because of the greater depth of these main draining superficial truncal veins (Bartholomew et al., 2005; Muller, 1966). This procedure involves the use of transillumination for guidance, followed by the application of tumescent anesthesia over the varicose vein to be treated. Small microincisions are performed over the varicose vein to be removed, followed by insertion of a phlebectomy hook to remove the varicose vein and possible closure with sutures, because of their small size. This is followed by gauze application and 30- to 40-mmHg compression stockings for a period of 2 weeks. It is very important to note that any reflux in either of the saphenous veins or the perforator veins must be treated with an adjunctive procedure, such as EVA or saphenous vein stripping to minimize the chance of recurrence (Bartholomew et al., 2005; Muller, 1966). There is a wide range of success rates for ambulatory phlebectomy from 55% to 95% depending on the technique used, and adjunctive procedures performed (Bartholomew et al., 2005; Beale & Gough, 2005; Min, Khilnani, & Zimmet, 2003; Muller, 1966; Olivencia, 1997). Complications include postprocedure pain, hyperpigmentation, cellulitis, hematoma, and nerve injury (Olivencia, 1997). Overall, ambulatory phlebectomy is a relatively minimally invasive outpatient procedure for the treatment of branch varicose veins or truncal vein tributaries as an alternative to invasive saphenous vein stripping or branch varicose vein sclerotherapy. ENDOVENOUS ABLATION EVA for the treatment of main superficial truncal vein reflux including the great and small saphenous veins may be divided into chemical or thermal ablation VOLUME 30 ISSUE 1

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procedures. Thermal ablation procedures may be further subdivided into endovenous laser ablation (EVLT) or endovenous radiofrequency ablation. ENDOVENOUS CHEMICAL ABLATION Endovenous chemical ablation involves the use of ultrasound to localize the most superficial accessible segment of the varicose vein or incompetent truncal vein. After localization, the target vein is accessed using ultrasound guidance followed by catheter insertion. A chemical sclerosant (polidocanol, sodium morrhuate, or sodium teradecyl sulfate [STDS]) is then combined with air or carbon dioxide to produce a foam solution. The solution is then injected through the endovenous catheter under ultrasound guidance, while simultaneously compressing the saphenofemoral or saphenopopliteal junction to limit microbubble entry from the foam solution into the deep venous system (Bergan, Pascarella, & Mekenas, 2006; Breu & Guggenbichler, 2004). The treated leg is typically elevated 45 degrees when injecting the foam solution, while the injected foam is massaged into the distal tributaries. Compression stockings are applied for a variable period after the endovenous chemical ablation procedure. The foam sclerotherapy solution displaces the blood in the treated vein, resulting in sclerosis and obliteration of the varicose veins in 1 to 6 weeks (Bergan, Pascarella, et al., 2006; Breu & Guggenbichler, 2004). Long-term results from multiple studies have demonstrated an overall chemical ablation rate of the treated vein in the range of 82% at 3 months, 81% at 1 year, 77% at 3 years, and 74% at 5 years (Bergan, Pascarella, et al., 2006; Bos et al., 2009; Breu & Guggenbichler, 2004). Complications of endovenous chemical ablation include mild to moderate pain, hyperpigmentation, superficial thrombophlebitis, deep venous thrombosis, pulmonary embolus, hematoma, skin necrosis, transient neurologic events, and rarely major neurologic events in patients with a patent foramen ovale (Bartholomew et al., 2005; Beale & Gough, 2005; Bush, Derrick, & Manjoney, 2008; Forlee, Grouden, & Moore, 2006; Guex, Allaert, Gillet, & Chleir, 2005). It is important to note that although the use of liquid sclerosant (STDS) has been approved by the FDA for treating varicose veins, the preparation and use of foam solution has still not received approval because of a lack of randomized controlled trials. Endovenous chemical ablation can be performed in an outpatient setting without any local anesthesia, and has significantly less cost compared with surgery or other endovenous procedures. Most patients are able to return to normal activity within 24 hr. It should be noted that endovenous chemical ablation has a higher recurrence rate than conventional surgery and other thermal

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EVA techniques, which will require further study (Belcaro et al., 2003). ENDOVENOUS RADIOFREQUENCY ABLATION Endovenous radiofrequency ablation acts by delivering controlled thermal energy to the vein wall using radiofrequency energy passed through an endovenous electrode. The procedure is performed under ultrasound imaging guidance. The endovenous catheter is placed under dynamic ultrasound imaging into the great or small saphenous vein. The endovenous catheter is advanced to the saphenofemoral or saphenopopliteal junction. Tumescent anesthesia under ultrasound guidance is instilled around the target vein. The endovenous catheter is retracted, exposing the bipolar radiofrequency electrode. The electrode is then activated, resulting in immediate spasm and occlusion of the target vein. Postprocedurally, compression stockings are applied for several days to 2 weeks. A recent meta-analysis reported an overall vein closure rate range of 89% at 3 months, 88% at 1 year, 84% at 3 years, and 80% at 5 years (Bos et al., 2009). Symptomatic improvement has been reported in 85% to 94% of treated limbs with initial technical success (Merchant & Pichot, 2005; Pannier & Rabe, 2006). Complications reported secondary to endovenous radiofrequency ablation include paresthesis, hematoma, skin burns, infection, bruising, superficial thrombophlebitis, deep venous thrombosis, and pulmonary embolism (Beale & Gough, 2005; Merchant & Pichot, 2005; Pannier & Rabe, 2006). Endovenous radiofrequency ablation for venous insufficiency has been shown to be more cost effective than other alternatives and requires less hospitalization and recovery time compared with conventional surgical procedures, with a typical recovery time of 3 to 5 days (Hingorani, Ascher, & Markevich, 2004; Merchant & Pichot, 2005; Zan, Contessa, & Varetto, 2007). ENDOVENOUS LASER ABLATION The first application of endoluminal laser was described by Dr. Bone in 1999 (Bone, 1999). A technique for treating the entire incompetent great saphenous vein and eliminate venous reflux was first reported by Dr. Min and Dr. Navarro in 2001 (Min, Khilnani, & Zimmet, 2003; Min, Zimmet, Issacs, & Forrestal, 2001; Navarro, Min, & Bone, 2001). EVLT received Food and Drug Administration approval in January 2002, and acts through a mechanism of nonthombotic venous occlusion of the target vein through the delivery of laser energy into the vein lumen via a laser fiber. Lasers with wavelengths of 810, 940, 980, 1040, 1320, and 1470 nm have each been successfully used for

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EVLT. The key to a successful EVLT treatment is to maximize the contact between laser fiber and vein wall to create sufficient damage to the vein resulting in wall thickening, nonthrombotic occlusion, and eventual contraction and fibrosis of the treated vein. The indications for EVLT treatment include varicose veins causing symptoms despite conservative methods such as compression stockings and exercise, treatment, or prevention of complications arising from chronic venous hypertension such as bleeding, superficial venous thrombophlebitis, venous dermatitis, venous ulcers, and improvement of cosmetic appearance. In the last 10 years, EVLT has evolved into an accepted option for the treatment of underlying truncal vein reflux causing varicose veins. Patients with varicose veins should undergo a careful history, directed physical exam, and duplex ultrasound imaging before consideration for EVLT. It is critical to determine the underlying source and pathophysiology of the varicose veins to create an anatomic map and proper treatment plan to ensure clinical success. There are no absolute contraindications for EVLT. The relative contraindications include absent pedal pulses limiting compression stocking use, liver abnormalities limiting local anesthesia administration, pregnancy, breast-feeding, inability to ambulate, or uncorrectable coagulopathies. After a proper clinical evaluation and creation of a treatment plan, the patient is placed in a supine position for treatment of the great saphenous vein, or in a prone position for treatment of the small saphenous vein. In most cases, the incompetent truncal vein is directly accessed using seldinger technique and ultrasound guidance. Tributary veins may also be directly accessed, but are prone to venospasm and are more difficult to access and traverse using a guidewire. For ease of access and to ensure the entire incompetent segment is treated, the target vein is usually punctured at the lowest or in the most distal segment, where the vein is incompetent or dilated. Venous access is obtained with a 19- or 21-G needle, using real-time ultrasound guidance and singlewall puncture technique. It is helpful to keep the procedure room warm and use reverse trendelenburg table position to maximize target vein distension and minimize collapse to ease venous access. Once venous access is obtained, a 5 or 6 French vascular sheath is inserted over a .035-in. guidewire to the saphenofemoral or saphenopopliteal junction under real-time ultrasound guidance. A bare-tipped laser fiber is then inserted through the sheath to the distal tip of the sheath. The sheath is retracted and the laser tip is exposed and positioned 1 cm distal to the saphenofemoral or saphenopopliteal junction. The appropriate location of the fiber tip can be confirmed via direct visualization of the red aiming beam of the laser.

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One of the key steps of the EVLT procedure is the correct delivery of perivenous tumescent anesthesia. Tumescent anesthesia is a form of local anesthesia delivery, which uses large volumes of dilute anesthetic solutions permitting anesthesia of large areas. Proper application of tumescent anesthesia should eliminate any pain during laser activation. Tumescent anesthesia also acts to maximize safety and efficacy of the EVLT procedure. Proper delivery of tumescent anesthesia in the perivenous space will ensure apposition of the laser fiber to the vein wall and achieve circumferential contact between the vein walls and laser fiber tip. This will allow adequate transfer of laser energy to the target vein walls resulting in vein wall damage and subsequent fibrosis. The perivenous tumescent anesthesia surrounding the vein also acts as a protective barrier to prevent heating of nontarget tissues, including skin, nerves, arteries, or deep venous structures. After the administration of tumescent anesthesia, the positioning of the tip of the laser fiber at the superficial and deep venous junction is again confirmed and repositioned if necessary. It is absolutely mandatory that the tip of the laser fiber does not enter the deep venous system, as to prevent deep venous thrombosis. The laser is then activated as per the individual operator’s settings and the vascular sheath and laser fiber are withdrawn as a unit. There are many different energy settings and energy deployment options, which are beyond the scope of this document. After the sheath and laser fiber have been removed, a dressing is applied to the venous access site, followed by class II (30e40-mmHg) thighhigh or pantyhose graduated compression stockings. The stockings are applied on the procedure table immediately after the procedure, and before the patient moving off the procedure table. The compression stockings should be worn from morning to night for 2 weeks after the procedure to prevent recanalization of the treated vein. Ancillary ambulatory phlebectomy or sclerotherapy may be performed immediately after the EVLT procedure or in a delayed fashion several weeks after to treat any residual branch varicose veins. Most patients will note significant improvement in appearance and symptoms at 4 to 8 weeks after the procedure date. Clinical success after EVLT is defined as permanent occlusion of the treated vein segments with successful elimination of related branch varicose veins and improvement in clinical symptomatology. Most patients will develop bruising of the overlying skin at the site of the EVLT treatment. This is of no clinical consequence and usually resolves in 1 to 2 weeks. Some patients will experience mild discomfort over the treated vein beginning hours after the procedure and resolving in 24 to 48 hr. Many patients will also note a delayed tightness and mild to moderate tenderness over the

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treated vein, particularly over the distal segment. This sensation described as “pulling” will usually start at the end of the first week after EVLT and resolve within 4 to 6 weeks. This delayed pain is most likely secondary to venous contraction and fibrosis as the treated vein undergoes permanent closure. Most patients are followed up with duplex ultrasound at 2 to 6 weeks after the procedure date to ensure the treated vein is closed. Most patients are also followed-up on at 6- or 12-week intervals postprocedure to ensure appropriate vein closure and to perform adjunctive procedures of residual branch varicose veins through sclerotherapy or ambulatory phlebectomy. A recent meta-analysis demonstrated an overall closure rate of the treated vein in the range of 93% at 3 months and 1 year, 95% at 3 and 5 years (Bos et al., 2009). Several studies have reported that EVLT is more effective than venous stripping and other endovenous procedures in terms of obliteration and very low recurrence rates in the range of 1% to 5% (Bos et al., 2009). Complications included pain, edema, erythema, bruising, hematoma, hypo- or hyperpigmentation, superficial thrombophlebitis, and DVT. Bruising occurs in 40% of patients in the treated area with no medical consequence and resolves in 1 to 2 weeks (Pannier & Rabe, 2006). Moderate pain has been reported along the treated vein in up to 50% of patients over the treated vein within the first week of the procedure (Pannier & Rabe, 2006). Superficial thrombophlebitis has been reported in up to 12% of patients with no long-term medical consequences. Transient paresthesia occurs in less than 10% of patients over the treated vein, and this usually resolves in 2 to 6 weeks. Deep venous thrombosis has been reported in the range of 1% to 5% after the procedure, usually resulting from extension of thrombus for the saphenous vein into the common femoral vein with no cases of pulmonary embolus reported to date (Pannier & Rabe, 2006). CONCLUSION Lower extremity venous insufficiency with secondary varicose veins and associated symptoms is a common but unrecognized problem throughout the population at large. With the refinement of imaging technology and the evolution of new treatment techniques, there has been dramatic advancements in the treatment of lower extremity venous insufficiency. Minimally invasive image-guided thermal ablative treatments are now the first line of therapy for this difficult but common problem. Educating the public about lower extremity venous insufficiency and the availability of minimally invasive treatments will be of critical importance in the future.

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