Vein Ablation

Overview

Pre-Procedure Prep

Indications

• Symptomatic varicose veins with proven reflux (CEAP 2)
• Symptomatic Venous Insufficiency with edema, skin changes and/or ulcerations (CEAP 3, 4, 5, 6)
• Symptoms include: aching pain, leg heaviness, leg fatigue, superficial thrombophlebitis, external bleeding, edema, ankle hyperpigmentation, skin changes, venous ulcer

Contraindications

• Significant deep venous reflux and/or DVT
• Central venous obstruction
• Severe uncorrectable coagulopathy
• Pregnant
• Inability to ambulate after the procedure

Things to Check

• History and physical exam- CEAP classification
• Preprocedure photographs to document skin changes, ulcerations etc.
• Doppler ultrasound evaluation of the lower extremity deep and superficial vein mapping, to evaluate patency and test for reflux.

Procedure Steps

Endovenous Radiofrequency Ablation

• Draw the course of the greater saphenous vein (GSV) to be treated, including branch varicosities and perforators.
• The leg is sterilely prepped and draped.

Access

• Ultrasound guided access into the small or great saphenous vein
• Micropuncture needle and 0.018" wire.
• For RFA the GSV accessed just below the knee to avoid nerve injury to the saphenous nerve
• Small saphenous vein is accessed at the inferior aspect of the gastrocnemius muscle to avoid injury to the sural nerve.
• Place vascular sheath

Ablation

• The ablation catheter is advance with its tip approximately 3 cm distal/peripheral to the saphenofemoral junction under ultrasound guidance.
• Dilute local anesthetic is then infiltrated along the course of the vein in the perivenous sheath and surrounding subcutaneous tissue under US guidance using the tumescent pump.
• Tumescent works in 3 ways: (1) anesthesia for patient comfort; (2) buffer to protect adjacent tissues from injury during thermal ablation; (3) compress the vein around the ablation device for improved vein wall apposition
• Once adequate anesthesia has been achieved, the catheter is activated and withdrawn through the vein to ablate
• For RFA, the vein is usually heated in 7 cm segments with 20 second treatment cycles
• Catheter is then withdrawn and sheath is removed.
• Manual pressure for hemostasis, usually within 5-10 min.

Small branch varicosities can be treated at the time of ablation with US guided foam sclerotherapy, or at follow up.

Post-Procedure

Post-Procedure Care

At the completion of the procedure, US evaluation of the saphenofemoral junction or saphenopopliteal junction is performed to rule out DVT.
The treated leg is immediately wrapped with ACE wrap for compression, to be worn for at least 24 hours, followed by compression stocking for 2 weeks.
Ambulation is initiated immediately and should be encouraged during post-procedure use of compression stockings.

Follow-Up

Follow up US is typically performed within 3-4 days to rule out post procedure DVT or endothermal heat-induced thrombosis (EHIT)

Complications

• Pain, ecchymosis, induration, hematoma and phlebitis are the most common adverse events, but usually self-limited
• Paresthesias
• DVT
• Skin burns
• Discoloration
• Hyperpigmentation