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BackTable / VI / Topic / Procedure
Vein Ablation
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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
Listen to leading physicians discuss vein ablation on the BackTable VI Podcast. Get tips, tricks, and expert guidance from your peers and level up your practice.
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• Once adequate anesthesia has been achieved, the catheter is activated and withdrawn through the vein to ablate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• Catheter is then withdrawn and sheath is removed.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
Read our exclusive BackTable VI Articles for quick insights on vein ablation, provided by physicians for physicians.
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
Watch video walkthroughs of vein ablation on the BackTable VI expanded content network.
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 https://www.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. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
Podcasts
Articles
Building a Comprehensive Vein Practice
Contributors
Dr. Chris Pittman
Dr. Aaron Shiloh
Dr. Brooke Spencer