Diagnostic of Varicose Veins
Progress in endovenous technology has recently focused much-needed attention on the treatment of varicose veins and venous ulcers. This change has been welcomed by both patients and physicians and both endovenous laser treatment and radiofrequency treatment of the saphenous vein have been used with increasing frequency in many hospitals, bur are still less frequently performed than open surgical stripping.
Either chemical or physical methods can be used to obliterate the saphenous lumen. Nowadays the former is in fact a micro foam ultrasound guided sclerotherapy. The latter employs fairly sophisticated techniques such as radiofrequencies and lasers. These procedures can be combined with phlebectomy, or with surgery on the perforating veins. Lasers appear to give more lasting results if compared to the obsolite electrocauterization, where the thrombus may recanalize in a very short time.
a) Radiofrequency treatment
The procedure has been used since 1999, and can be done under local, tumescent or loco-regional anesthesia. The vessel walls are treated with a heat-transmitting radio probe, which causes contraction and thickening of the adventitious collagen, so the lumen shrinks until it closes completely. The catheter's position in relation to the saphenofemoral junction is checked under duplex scanning guidance.
Immediately after surgery, when all has gone well, the saphenous vein feels like a solid, contracted cord. At one year in a multicenter observational study involving 232 checks, reported 83.6% of closed saphenous veins, 5.6% still open and 10.8% recanalized.108 A Multicenter study at 3 years showed similar follow-up percentages (88%) of vein obliteration. 106
b) Laser treatment
Endovenous laser has been employed since 1998 and approved by the Food and Drug Administration (FDA) in 2001. Local, tumescent or trunk anesthesia is preferable for laser therapy. The systematic use of duplex scanning during the procedure is mandatory, for efficacy and safety. The saphenous vein is obliterated by contraction of the collagen fibers in the wall and denudation of endothelium, which results in vein wall thickening, luminal contraction, and fibrosis of the vein, due to the heat released by the laser. Complications - ecchymosis and a short-lasting burning sensation on the skin - are negligible. Leaving aside the preliminary findings of some clinical trials, published reports 106,109,110 indicate full occlusion of the great saphenous vein at one year in all patients. In more recent studies vein obliteration after laser treatment is 94% at 2 years follow-up.
c) Foam ultrasound-guided sclerotherapy
Foam ultrasound-guided sclerotherapy studies have demonstrated effectiveness in closure of saphenous trunks. This sclerotherapy may be classified as froth, macro-mini- and micro-bubbles foam, which influences outcomes of its usage, due to the fact that micro-bubble foam better multiples the active surface of the drug. It is generally recognised that the sclerosing effect depends on the concentration of the drug within the vein, and not in the syringe, as well as a minimal effective concentration and the exposure time is a further important variable. All these features are improved with foam, hence a lower concentration shall be necessary when using sclerotherapy.
The main problem of sclerotherapy outcome is represented by the possible high degree of recurrence due to re-appearance of the retrograde flow in the treated veins, especially in case of long-term follow-up and when treating large size saphenous stems with unfavourable haemodynamic. Larger group of patients with extended follow-up are necessary for a better elucidation, but the first experiences have been remarkably promising. The easiness and cheapness of this method should account for its diffusion, though this method still has a few technical details which may be operator-dependant. An international expert conference on foam sclerotherapy ( Germany , 2004) produced some recommendations regarding use, efficacy, and side effects.
All these procedures still involve some unknown factors.
Caselists are still small in absolute terms and in relation to long-term outcomes. Follow-up of these patients - ideally 5 years - has been reached only recently. Larger numbers are made available by some Registries.
The Registries are being the most suitable tool for collecting data concerning such a technologically innovative procedure. In surgery these have become the most advantageous way to illustrate in real time the reality of clinical practice. The Registries generate immediate feedback, improve self-assessment and develop better decisionmaking, without long delays waiting for final results and enabling a larger quantity of data to be collected. The reasons for this include the learning curve, the rapid evolution of technology even while a study is in progress, the difficult ethics involved in proposing alternative surgical procedures.
Obliteration of the saphenous vein must leave a safety margin from the ostium. There therefore remains a small terminal segment into which one or more high collaterals of the saphenofemoral junction drain, whereas this does not happen with junction ligation. Supporters of the obliterative procedure maintain that this helps avoid relapses. In comparison of these new techniques to ligation/stripping, this has 5-year recurrence rate of varicose veins in 34%, with a 29% incidence of recurrent saphenofemoral incompetence caused by groin neovascularization.83
On the topic of the cost-benefit ratio, the control unit involves considerable initial expenditure, and catheters are expensive. The cost estimation of the foam sclerotherapy shows that the sclerotherapy is cheaper than the others procedures but needs more treatment in the long term. A randomized trial on a limited number of patients showed that the cost of radiofrequency treatment was double when compared to stripping surgery, but the global cost of the procedure including convalesce is in favor of radiofrequency for active patients. Laser treatment cost is somewhat less.
Although it is quite early to make definitive conclusions and well-performed, prospective, randomised, controlled trials are lacking, it seems that this development is extremely interesting for every patient and phlebologist.
Credentialing should be performed locally by committees in the individual hospitals in which physicians perform endovenous procedures or before by national committees. All physicians performing these procedures should be involved in the clinical practice of phlebology and should examine the patient to justify indications and discuss alten1ative procedure. 1 13
Recommendation
Neither of these obliterative procedures is validated as yet for long follow-up in the literature but these methods were proven to be less aggressive and effective at mid-term. They must therefore be considered as still in the clinical validation stage, and as such only used in accredited, qualified phlebology centers, after the necessary learning period. Grade B