Endovascular Laser and Microphlebectomy for Treatment of Varicose Vein

Venous insufficiency is a condition that affects hundreds and thousands of individuals each year, particularly women. Venous insufficiency often results in varicose veins, phlebitis and similar physiological conditions. In general these abnormalities are thought to result from a combination of gender and heredity among other things. Historically treatment for venous insufficiencies involved very aggressive and invasive surgery which stripped veins; this process resulted in a removal of the offending veins. Often the recovery time was in excess of two weeks, with patients often only minimally mobile.

Advances in technology and procedure however have resulted in a new minimally invasive procedure that combines the use of endovascular laser surgery and microphlebectomy to remove varicosities that occur below the knee (Pearce, 2003). The use of endovascular laser is limited primarily to the greater and minor saphenous veins, which are often implicated in venous disorders. The use of endovenous laser has greatly altered the manner in which patients currently receive care. Laser treatment typically involves a one day out of office procedure conducted using local anesthesia only, though intravenous sedation may also be utilized. Microphlebectomy is then utilized to remove the smaller varicose veins that often are fed by saphenous insufficiencies in the lower calf. Microphlebectomy is also minimally invasive, requiring only pinpoint incisions to be made in the lower calf. The bulging veins are subsequently removed. Patients are asked to wear high grade compression stockings for a two-week period to prevent clotting or recurrence. They are able however, to return to work or regular activities almost immediately.

ANALYSIS

Vein disorders for purposes of this study will be examined as a whole. Traditionally an individual suffering from venous disorder will experience pain and discomfort resulting from elongated, dilated and malfunctioning vessels, which have incompetent valves, allowing blood to pool in the veins; they may be of various size and shape (Arnoldi, 1957). Traditionally physicians have attributed venous disorders to genetic and hormonal influences, though “hydrodynamic factors” may also influence the severity of the disorder.

Gravitational hydrostatic force and hydrodynamic muscular compartment force have also been implicated in venous insufficiencies and contribute to complications associated with venous insufficiency in a large majority of cases. Many women find themselves affect by venous disorders during pregnancy, as a result of hormonal influences; studies suggest in fact that more than 70% of varicosities develop during the first trimester, some within 2-3 weeks of gestation, thus may be attributed to hormonal fluctuations rather than the increased weight and pressure of the mother (Struckmann, JR, et.al, 1990). Varicose veins are often implicated from a hereditary perspective, though the research currently available on hereditary causes has not been able to adequately assess the nature of the trait (Cornu-Thenard, et. al, 1994).

People seek treatment for varicosities for a variety of reasons. A common cause for consultation includes the misshapen appearance of the leg that often results from varicosities. Large, bulging veins are not uncommon among patients with venous insufficiencies. Varicose veins also prompt consultation for a variety of other symptoms, including the following: leg pain, heaviness, and external bleeding, phlebitis, ulcer and leg fatigue.

Surprisingly, a majority of non-specialized physicians are still unaware of new technologically advanced techniques that make seeking out treatment easy and efficient (Weiss & Goldman, 1992). Some patients also are not aware that there symptoms may be alleviated through treatment, and thus suffer through the discomfort needlessly. More than 85% of patients however, will realize relief of their symptoms as a result of medical care (Weiss & Weiss, 1990).

Recurrent varicose veins may be a problem for individuals seeking out traditional forms of therapy, such as saphenous ligation (McMullin, et. al, 1991). Stripping of the saphenous vein often results in relief, however the treatment can be very painful and invasive, and the risk of recurrence is still relatively high (Stonebridge, et. al, 1995).

Studies now show that microphlebectomy can be used to detach perforator vein tributaries, while endovenous laser treatment may successfully be utilized to seal off the saphenous vein in the upper thigh. Endovenous laser treats the saphenous vein by ablating (Munn, et. al, 1981).

Endovenous laser surgery is perhaps the most non-invasive mechanisms for removing the saphenous vein. Ultrasound scanning is used in conjunction with laser treatment to highlight and effectively remove the offending veins.

One of the more commonly utilized treatments in the U.S. now other than laser vein ablation is often use of the VNUS vein treatment system, developed by VNUS Medical Technologies.

This system achieves elimination of saphenous vein reflux via utilization of radiofrequency heating techniques. Electrodes are designed specifically to monitor the electrical and thermal impulses delivered by a catheter that is inserted directly into the saphenous vein. The vein responds to the RF by shrinking and contracting. The procedure has been proven effective, with more than 90% of patients realizing continued closure rates after a two-year period (Kabnick & Merchant, 2001). Intravenous sedation and tumescent anesthesia are often the forms of anesthesia used in saphenous vein ablation therapy (Goldman, 2000) though general anesthesia is also utilized.

More advanced however, is the use of light energy. Laser light energy when delivered into the saphenous cavity often results in the least invasive and most promising results for veinous patients. Laser light energy is generally delivered via a 400-750µm “sterile bare-tipped quartz fiber” (Bone, 1999). Laser light surgery results in “non-thrombotic occlusion of the vein” with almost a 100% success rate (Navarro, 2001).

Laser vein ablation “challenges traditional thinking about varicose veins” (Pearce, 2003). Endovenous surgery works by ablating the saphenous vein from the groin area to just above the knee; saphenorfemoral branches are left in tact, and microphlebectomy is used to extract varicosities that occur below the knee (Pearce, 2003). Among the benefits of laser surgery include excellent cosmetic outcomes, though some reports have detailed possible complications with the procedure including the following: recannalization, arterialization and deep vein thrombosis (Pearce, 2003).

Traditionally laser therapy has been utilized to remove surface spider veins, including those present on the face and those in the leg if they were restricted in size to less than.3 mm in diameter, however the newer endovenous laser technique is now being used to effectively close veins that are 2 to 3mm in diameter and more (Kauvar, 2000). The endovenous laser technique utilizes a bare-tipped laser fiber; a catheter is used to guide the laser into the vein, while an ultrasound technician stands close by to guide the procedure (Kauvar, 2000). At this time the procedure has resulted in positive results for a majority of patients who have participated in trials (Navarro, 2001).

Microphlebectomy is also referred to as stab avulsion or ambulatory phlebectomy, and is a technique utilized to remove veins via use of several tiny incisions through which physicians can pull out varicosities.

The goals of treatment generally include reduction of symptoms including pain and discomfort; Also physicians aspire to reduce the potential for complications, as with any surgery. For some patients, and improved cosmetic outcome is highly desirable. Exercise is encouraged both before and after procedure.

More invasive or technologically advanced procedures are often the first line of defense for patients experiencing trouble with deep vain disease. The only disadvantage for microphlebectomy for surgeons is the tedious nature of the process. In general incisions must be made every two or three inches apart to reach veins; if the area that is affected includes veins that are scattered over a wide ranging area, then obliteration of those veins can take quite a bit of time. Microphlebectomy can be accomplished however under minimal expense, and rarely are complications a problem utilizing this technique.

Not all patients are good candidates for Endovenous Laser Closure treatment. This includes patients with a repeat history of varicose veins despite previous treatment of the saphenous veins. Also, patients whose varicose veins result from reflux of the lesser saphenous vein, which is located behind the knee, may not be good candidates for Endovenous laser. Saphenous veins that are larger than one inch in diameter and varicose veins that occur as a result of branch varicosities rather than the saphenous reflux are all typically considered poor candidates for laser. Laser procedures conducted too close to the surface of the skin may result in excessive burning of the tissue. However, despite these exceptions to the rule, this still leaves a majority of patients as exceptional candidates for the procedure.

The lasers utilized to close the saphenous vein are diode lasers that often fall in narrow ranges of the infrared electromagnetic spectrum.

There has been little impetus to conduct more in depth prospective studies regarding the outcome for such treatments, as many researchers still believe that these procedures are performed primarily for cosmetic reasons (Pearce, 2003).

A majority of patients also do not seek treatment because of the potential lack of insurance coverage for the procedures. Different health insurance policies currently have different rules and regulations regarding treatment. There are still several companies that will refuse treatment on the basis of classifying veinous insufficiency as primarily a cosmetic problem.

Aetna is an example however, of a new trend in many companies that offers coverage for the procedures under certain circumstances. Microphlebectomy is more often covered than other procedures, primarily because it is minimally invasive and generally less costly than laser surgery. Generally microphlebectomy is covered and considered medically necessary when saphenous varicosities result in the following conditions: intractable ulceration that results from venous stasis, repeated incidence of hemorrhage resulting from a ruptured or superficial varicosity or payment for a single hemorrhage from a ruptured superficial varicosity most notably when a transfusion of blood is required (Aetna, 2004). Generally varicose vein excision and ambulatory phlebectomy is also considered medically necessary after treatment with more conservative methods including use of compression stockings is found to be unsuccessful, if the patient has engaged in therapeutic intervention for a period of time greater than six months, if the saphenous varicosities present result in any of the following: recurrent superficial thrombophlebitis, severe and persistent pain, or swelling that interferes with daily activities or that requires consistent and daily use of analgesic medication (Aetna, 2004).

In some circumstances, insurance companies are also willing to cover for the radiofrequency endovenous occlusions procedure when it is deemed medically necessary. However, related to transdermal laser treatment a majority of insurance companies have deemed its use for treatment of large varicose veins experimental, as yet there have been no direct comparative studies of significance that have shown it to be as effective as use of scleropathy, ligation or vein stripping in the treatment of larger varicose veins that are associated with symptoms including pain, ulceration and inflammation (Aetna, 2004). Successful treatment of small veins using this therapy, though proven effective, is generally considered cosmetic and nature and unnecessary, thus these studies cannot be related or examined.

CONCLUSIONS/RECOMMENDATIONS

Venous insufficiency is generally considered a common condition, most notably known for causing varicose veins. Varicose veins are more common in adult western populations where as many as 25% of women and 15% of men are affected (Aetna, 2004). Venous insufficiency does not always result in a medically dangerous outcome, and may not cause any symptoms other than those associated with poor cosmetic image.

A majority of varicose veins do not require treatment (Tapley, et. al, 2003). However, in many cases, the circulation in the vein may be hindered substantially resulting in a variety of medical conditions including leg pain, fatigue, heaviness and ulceration. The primary method of treatment for less invasive problems in the past has been utilization of fitted compression stockings to offer comfort and relief.

More severe complications have been associated with veinous insufficiencies however; these include superficial thrombophlebitis and venous ulcers. Modern technology however has allowed development of successful treatment options that eliminate both primary and secondary causes of venous reflux, particularly those associated with the greater saphenous vein. Among the newest treatments include use of an endovenous laser and microphlebectomy. In combination, this therapy is proving more effective.

Whereas in the past patients had only access to invasive procedures such as stripping that required long recovery times, newer procedures such as endovenous and microphlebectomy are minimally invasive, and are often performed under local anesthesia on an outpatient basis. Ambulatory phlebectomy or microphlebectomy is generally an acceptable form of outpatient therapy for patients seeking to remove superficial veins below the knee. The treatment allows excision of a majority of veins with the exception of the primary saphenous vein, which can be treated via use of laser therapy. Complications associated with microphlebectomy are generally minimal, and include formation of blisters, localized thrombophlebitis, skin necrosis or possibly edema, however use of compression stockings post surgery for a period of approximately two weeks generally alleviates these symptoms.

The risks associated with endovenous laser surgery for removal of the greater saphenous vein are somewhat more profound, and may include deep vein thrombosis and pulmonary embolism, though these complications are thought to be minimal, occurring in only rare circumstances.

Endovenous laser ablation of the saphenous vein is a superb alternative to surgical ligation and stripping. During this procedure, a small laser fiber is inserted into the damaged saphenous vein, and pulses of light are subsequently emitted into the vein causing it to collapse and seal shut. Generally the circulation within the leg is not disrupted, as the flow of blood is distributed throughout the leg using other branches and arteries. This procedure may also be performed on an outpatient basis utilizing local anesthesia. Doppler ultrasound is used in conjunction with surgery to assess and characterize the physiology of the varicose vein to ensure accurate assessment and entry into the saphenous structure. Ultrasound use has proven very effective in assisting physicians in pinpointing and targeting areas of reflux and retrograde flow within affected veins. Generally patients realize a swift recovery, but are required to utilize compression hose on the treated leg for a period of two weeks to minimize excessive side effects.

The short- and long-term follow up among patients receiving microphlebectomy and endovenous laser surgery for the treatment of varicosities is promising. Follow up conducted on a short-term and long-term basis for a period of up to 37 months post operative shows that generally the closure of the vein persists and patient symptoms including fatigue, pain and discomfort are still markedly reduced post treatment (Aetna, 2004). Studies also seem to indicate that the outcome for recurrence is much less in patients undergoing combination therapy, including use of endovenous laser therapy and microphlebectomy, as opposed to stand alone microphlebectomy or use of other single procedures, including ligation or veinous stripping alone (Belcaro, et. al, 2000). Surgery up until the present has been implicated as the treatment of choice for deep veinous insufficiency affecting the saphenous vein when demonstrated reflux exists, however the advent of lasers will likely change this (Grange, et. al, 1998).

Though a majority of insurance companies still consider treatment using laser therapy experimental, related to the larger saphenous vein, with further directed studies regarding patient outcomes it is likely that this procedure will become more widely accepted. VNUS closure, a procedure similar to endovenous therapy often also used in conjunction with microphlebectomy, has already been approved as an acceptable treatment option by a majority of companies, for patients who generally experience severe complications and side effects resulting from veinous insufficiencies.

Bibliography/References

Aetna. “Varicose Veins.” Aetna. {Online} Retrieved April 11, 2004, Available: http://www.aetna.com/cpb/data/CPBA0050.html

Anwar, S, Shrivastava, V, Welch M, al-Khaffaf H. Subfascial endoscopic perforator surgery: A review. Hosp Med. 2003; 64(8): 479-483

Arnoldi CC. The aetiology of primary varicose veins. Dan Med Bull 1957; 4: 102-107.

Belcaro, G., Nicolaides, AN, Ricci A, et. al. Foam scleropathy, surgery, sclerotherapy and combined treatment for varicose veins: A 10-year, prospective, randomized, controlled trial (VEDICO Trial). Angiology. 2003; 54 (3): 307-315

Bone C. Tratamiento endoluminal de las varices con laser de Diodo. Estudio preliminar. Rev Patol Vasc 1999; V: 35-46

Cheshire, N., Elias, SM, Keagy B, et. al. “Powered phlebectomy in treatment of varicose veins.” Annal Vascular Surgery, 16:488, 2002

Cornu-Thenard A, Boivin P, Baud JM, et al. Importance of the familial factors in varicose disease: clinical study of 134 families. J Dermatol Surg Oncol 1994; 20: 318-326

Goldman MP. Closure of the greater saphenous vein with endoluminal radiofrequency thermal heating of the vein wall in combination with ambulatory phlebectomy: preliminary 6-month followup. Dermatol Surg 2000; 26: 452-456

Grange, C, Heynen, YG, Chevallier A. Indications for surgical treatment of primary varicose veins of the legs. J de Maladies Vasculaires. 1998: 23 (4): 297-308

Kabnick LS, Merchant RF. Twelve and twenty-four-month follow-up after endovascular obliteration of saphenous vein reflux: a report from the multicenter registry. J Phlebol 2001; 1: 17-24.

Kauvar, ANB. “The Role of lasers in the treatment of leg veins.” Seminars in Cutaneous Medicine and Surgery, 19 (4): 245-252

McMullin GM, Coleridge Smith PD, Scurr JH. Objective assessment of high ligation without stripping the long saphenous vein. Br J. Surg 1991; 78: 1139-1142

Merchant, RF, DePalma, RG, Kabnick, LS: Endovascular obliteration of saphenous refulx: a multicenter study.” Journal of Vascular Surgery 35: 1190, 2002

Navarro L, Min RJ, Bone C. Endovenous laser: a new minimally invasive method of treatment for varicose veins: preliminary observations using an 810 nm diode laser. Dermatologic Surgery 2001; 27: 117-122

Pearce, William H. “The Evolution of Varicose Vein Treatment.” Medscape, WebMD. September 2003. {Online} Available: http://sinoemedicalassociation.org/medicalnews/medicalnews2/medicalnews2.htm

Stonebridge PA, Chalmers N, Beggs I, Bradbury AW, Ruckley CV. Recurrent varicose veins: a varicographic analysis leading to a new practical classification. Br J. Surg 1995; 82: 60-62.

Struckmann JR, Meiland H, Bagi P, Juul-Jorgensen B. Venous muscle pump function during pregnancy. Acta Obstet Gynecol Scand 1990; 16: 620-623

Weiss RA, Weiss MA, Goldman MP. Physicians’ negative perception of sclerotherapy for venous disorders: review of a 7-year experience with modern sclerotherapy. South Med J. 1992; 85: 1101-1106

Weiss RA, Weiss MA. Resolution of pain associated with varicose and telangiectatic leg veins after compression sclerotherapy. Dermatol Surg 1990; 16: 333-336

Weiss RA, Goldman MP. Controlled RF-mediated endovenous shrinkage and occlusion. In: Goldman MP, Weiss RA, Bergan JJ. Varicose Veins & Telangiectasias: Diagnosis and Management, 2nd ed. St. Louis: Quality Medical Publishing, 1999

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