.png)
.png)
Vein Ablation
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.
Vein Ablation Podcasts
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• Once adequate anesthesia has been achieved, the catheter is activated and withdrawn through the vein to ablate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• Catheter is then withdrawn and sheath is removed.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.
Vein Ablation Articles
Building a Comprehensive Vein Practice
Building a vein practice requires knowledge and skills beyond the treatment of venous disease. Vein expert Dr. Spencer discusses where to start when treating patients with venous disease, when to take charge as a diagnostician, and why interventional radiologists need to start managing their patients perioperatively.
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
Vein Ablation Demos
Tessari Method for Foam Sclerosant by Dr. Peter Bream
The Tessari Method is the standard method for creating foam from liquid sclerosants. Foam sclerotherapy is a minimally invasive technique to sclerose blood vessels in varicose veins and restore the blood flow in healthy veins, with or without ultrasound guidance. In this video, Interventional Radiologist Dr. Peter Bream explains the Tessari Method for foam sclerosant (3-2-1 Foam Sclerosant Creation).
Vein Ablation Literature
Canadian Journal of Surgery (Apr 2015)
Endovenous Radiofrequency Ablation for the Treatment of Varicose Veins
Varicose veins can be treated with techniques such as saphenous venous ligation and stripping, phlebectomy, and endovenous laser therapy. The newest technology available for treating varicose veins is radiofrequency ablation, discussed in detail in this article as a safe and effective treatment modality.
Seminars in Interventional Radiology (Dec 2013)
Role of Interventional Radiologists in the Management of Lower Extremity Venous Insufficiency
The authors review the role of the interventional radiologist in managing this lower extremity venous disorder.
Journal of Vascular Surgery (May 2011)
The Care of Patients with Varicose Veins and Associated Chronic Venous Diseases: Clinical Practice Guidelines of the Society for Vascular Surgery and the American Venous Forum
The Society for Vascular Surgery (SVS) and the American Venous Forum (AVF) have developed clinical practice guidelines for the care of patients with varicose veins of the lower limbs and pelvis. The document also includes recommendations on the management of superficial and perforating vein incompetence in patients with associated, more advanced chronic venous diseases (CVDs), including edema, skin changes, or venous ulcers.
Join The Discussion
References
[1] Youn YJ, Lee J. Chronic venous insufficiency and varicose veins of the lower extremities. Korean J Intern Med. 2019;34(2):269‐283. doi:10.3904/kjim.2018.230
[2] Aziz F, Diaz J, Blebea J, Lurie F; American Venous Forum. Practice patterns of endovenous ablation therapy for the treatment of venous reflux disease. J Vasc Surg Venous Lymphat Disord. 2017;5(1):75‐81.e1. doi:10.1016/j.jvsv.2016.08.006
[2] Kayssi A, Pope M, Vucemilo I, Werneck C. Endovenous radiofrequency ablation for the treatment of varicose veins. Can J Surg. 2015;58(2):85‐86. doi:10.1503/cjs.014914
[4] Hardman RL, Rochon PJ. Role of interventional radiologists in the management of lower extremity venous insufficiency. Semin Intervent Radiol. 2013;30(4):388‐393. doi:10.1055/s-0033-1359733
[5] Gloviczki P, Gloviczki ML. Guidelines for the management of varicose veins. Phlebology. 2012;27 Suppl 1:2‐9. doi:10.1258/phleb.2012.012s28
[6] Eklöf B, Rutherford RB, Bergan JJ, et al. Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg. 2004;40(6):1248‐1252. doi:10.1016/j.jvs.2004.09.027
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients.