4 Surgery Gold standard over the past century SFJ ligation +/- stripping Disadvantages:General anaesthesia / regional anaesthesiaPainful groin woundRisks of surgeryBruise is common
5 Endovenous Laser Ablation ( EVLA) First report by Bone in 1999Approved by US FDA in Jan 2002Available laser generators:Ash JL et al. Laser Treatment of Varicose veins: order out of the chaos. Semin Vasc Surg Jun;23(2):101-6.
6 Indirect thermal injury EVLA MechanismDirect thermal injuryCarbonization of vein wallIndirect thermal injuryFormation of steam bubblesTransmit heat energy to endotheliumThermal injuryThrombosis and occlusion of veinAsh JL et al. Laser Treatment of Varicose veins: order out of the chaos. Semin Vasc Surg Jun;23(2):101-6.
7 Radiofrequency Ablation ( RFA) First reported in 1998 in SwitzerlandApproved by US FDA in 1999Bipolar catheter used to generate energy1st generation2nd generation3rd generationCatheter nameClosureClosure PlusClosure FastYear199920032006Temperature (℃)85120Speed2-3 cm / min7cm segment in 20sec cycleLohr J, Kulwicki A. Radiofrequency ablation: evolution of a treatment. Semin Vasc Surg. 2010;23:
8 RFA Mechanism Denaturation of collagen matrix Vein wall collagen contractionFibrotic sealing of vessel lumen due to injury and inflammation to vein wallLohr J, Kulwicki A. Radiofrequency ablation: evolution of a treatment. Semin Vasc Surg. 2010;23:
9 EVLA / RFA Procedure Duplex ultrasound localization GSV identified and cannulatedIntroducer sheath and catheter insertedCatheter positioned 2cm from SFJInjection of tumescent solutionCatheter slowly withdrawn and fired until the tip is 1cm from the skin surface
10 Tumescent solutionNormal saline + lignocaine with adrenaline +/- 8.4% sodium bicarbonateInstilled into the saphenous sheath under ultrasound guidanceFunctions:Heat sinkSeparate of GSV from saphenous nerveContraction of the vein
11 Foam sclerotherapy Chemical ablation Sodium tetradecyl sulphate ( STS) / PolidocanolTessari techniqueMix with air / CO21: 4 ratio
12 Foam Sclerotherapy GSV cannulated under ultrasound guidance Injection of foam sclerosantFoam displaces blood in veinInduces fibrosis, causing inflammationObliteration of the lumen
13 Current evidence comparing endovenous procedure and surgery?
15 Failure to completely abolish reflux Clinical recurrence Primary outcomes:Failure to completely abolish refluxSecondary outcomes:Clinical recurrencePost op complicationsPost op painTime return to normal activities / workQOL
24 <RFA vs Surgery> Post op complicationsOutcomesNo. of studiesNo. of patientsPooled RR (95% CI)<RFA vs Surgery>Wound infection56710.3 ( 0.1, 0.4)Parasthesia77591.0 ( 0.5, 0.7)Superfical thromboplebitis66992.3 (1.1, 5.0)Haematoma4370.4 ( 0.1, 0.8)
25 Other results ( RFA vs Surgery) Less post op pain *Earlier return to normal activities / work** statistically significant
26 UGFS vs SurgeryKendler M, Wetzig T, Simon JC. Foam sclerotherapy: a possible option in therapy of varicose veins
37 CEAP classification - Clinical C0: no visible or palpable signs of venous diseaseC1: telangiectasies or reticular veinsC2: varicose veinsC3: edemaC4a: pigmentation or eczemaC4b: lipodermatosclerosis or atrophie blancheC5: healed venous ulcerC6: active venous ulcerClinical severityEtiology or causeAnatomyPathophysiology
38 CEAP classification – Etiological Ec: congenitalEp: primaryEs: secondary (post-thrombotic)En: no venous cause identified
39 CEAP classification – Anatomical As: superficial veinsAp: perforator veinsAd: deep veinsAn: no venous location identified
40 CEAP classification – Pathophysiological Pr: refluxPo: obstructionPr,o: reflux and obstructionPn: no venous pathophysiology identifiable
41 Duplex ultrasound Assess the size of the GSV Relation to overlying varicesEvaluate the reflux time in conjunction with venous diameter
42 EVLA Complications Saphenous nerve paraesthesia DVT Skin burns PhlebitisBruisesGenerally very safeDVT ( %) : though 15-20mm of GSV untreated, potential for thrombus extension into the common femoral vein. Improper placement of the catheter cause generate of steam bubbles within the CFV and a thrombotic response within the veinDUS on day 7: To assess CFV patency, To assess successful closure of GSVSaphenous nerve: becomes more superficial and travel with GSV at below knee level. Injury – medial calf numbness generally resolves in 6-8 weeksPhlebitis: 3 to 5 days post op , incidence %. Treated with NSAID + warm moist compression, resolves in a few days on onsetBruises: 23% - 100%, usu at sites where tumescent solution has been instilled
44 Conservative Weight loss Exercise Elevation of lower limbs Compression therapyDifferent graded pressures for patient with different severitiesFor mild disease , we can advise weight loss, light to moderate exercise to improve muscle pump function, or intermittent elevation to improve symptoms, and avoid factors that are known to make their symptoms worse if possible.Compression therapy can also be recommended which provide effective relief for chronic venous insufficiency and to allow healing of many ulcers.Compression stockings with different graded pressures were available for patient with different severitiesCompression: graded compression stocking, 20-30mmHg for mod disease, 30-40mmHg for more severe disease.
45 Surgery Complications Wound haematoma / infectionLymphatic leaksCommon femoral vein and artery injuriesNeurological complicationsBruises are common, can last up to 6 weeksUsually advised to return to work after days
46 Proposed Benefits Avoidance of general anaesthesia Can be done in outpatient settingMinimal painEarlier return to normal activityDecrease risk of nerve injuryLower risk of recurrenceThere are a few proposed benefits of these endovenous ablation method.First, these procedure can be done with the tumusent anaesthesia with or without sedation, in an outpatient settingAnd to the patient, there is less pain post operatively, thus earlier return to workThe risk of nerve injury may be decrease by avoiding strippingAnd the risk of recurrence may be decrease by avoidance of neovascularization