Research Article - Clinical Practice (2023) Volume 20, Issue 3

Endovenous Laser Angio-catheterization: A Novel Alternative Phlebectomy

Corresponding Author:
Rania Agha
The University of Illinois at Chicago Department of Dermatology, and Jesse Brown VA Medical Center, Chicago, IL, United States
E-mail: drraniaagha@gmail.com
Received: 20 June, 2023, Manuscript No. fmcp-23-103355, Editor assigned: 25 June, 2023, PreQC No. fmcp-23-103355 (PQ), Reviewed: 09 July, 2023, QC No. fmcp-23-103355 (Q), Revised: 21 July, 2023, Manuscript No. fmcp-23-103355 (R), Published: 31 July, 2023, DOI. 10.37532/2044-9046.2023.20(3).

Abstract

Varicose veins are a common reason for medical referral and surgical interventions. They cause significant morbidity to patients and a burden to healthcare systems. The management of this chronic venous disease has developed over the past century to account for better clinical outcomes and fewer procedural complications. Operative management options when conservative measures fail, evolved over the years from the early surgical venous stripping to the minimally invasive sclerotherapy, phlebectomy and endovenous ablation. We present the angio-catheterization laser technique, a modified microphlebectomy approach with proven beneficial clinical outcomes in our practice and review the evolution of treatment options of varicose veins

Keywords

Phlebology, Varicose veins, Phlebectomy, Endovenous laser ablation, Novel technique laser ablation, Angiocatheterization, Sclerotherapy, Reticular veins

Introduction

Definition, epidemiology and predisposing factors of varicose veins

Varicose veins, which are dilated, saccular, tortuous, elongated, superficial veins, are among the most frequent chronic venous diseases encountered in clinical practice and constitute a significant part of the surgical workload [13]. The wide variation in the definition of venous diseases and varicose veins and the lack of a standardized classification system has made the estimation of the incidence and prevalence of varicose veins challenging. The estimated prevalence of visible tortuous veins stood at 10%-15% in males and 20%-30% in females based on a Western adult population aged 15 and above2, while the estimated incidence stood at 1.97% in males and 2.6% in females over a 2-year period in the prospective Framingham population study [2,4]. In more recent times, it is estimated that close to a quarter of the adult population in the United States of America (USA) has varicose veins and this rises to as high as three quarters of the population in females and half of the population in males when cosmetic telangiectasias are also included [5,6].

Varicose veins and chronic venous insufficiency are known to arise from valve incompetence and vein dilatation and weakening of the vein walls [5,6]. These structural changes in the vein walls result from reduced synthesis of vein wall collagen, and elastin fibers, progressive loss of smooth muscle cells and replacement by fibrous tissue [68]. Vein wall and valves exposed to cytokines released from chronic inflammation in veins exposed to increased venous pressures for a prolonged period of time are also at risk of varicose veins development [5,6,9].

Several factors increase the risk of developing varicose veins including age, sex, obesity, parity, genetic factors, family history, prolonged standing, female gender, pregnancy, smoking, obesity, and congenital valvular dysfunctions [5,6,8].

Although rarely fatal, the high prevalence and chronicity of varicose veins makes them a cause of significant morbidity that affects the overall quality of life [10]. Varicose veins can bleed, thrombose and progress to venous ulceration and leg oedema resulting in chronic ambulatory dysfunction and reduced functional status [10]. Other co-morbidities include pain, bruising, scarring, skin changes, femoral vein or nerve injury during procedures, recurrence and even deep venous thrombosis [11,12]. Beyond that, the cosmetic burden associated with varicose veins cannot be overemphasized; it is a common reason for seeking medical attention among such patients.

At a larger scale, varicose veins constitute a significant healthcare burden to healthcare systems as venous ulcers associated with varicose veins are known to cost up to two million working days and three billion dollars treatment cost per year in the United States[13], and up to three percent of healthcare expenditures in countries with developed healthcare systems [14,15].

Treatment options for varicose veins

A stepwise and multifaceted approach to the management of varicose veins has been recommended with emphasis on the clinical severity and extent of venous reflex. Conservative measures including skin care, exercise, leg elevation, weight loss and use of compression stockings are usually the first line of management in most symptomatic patients [5,16]. Pharmacologic measures including use of venoactive agents such as horse chestnut seed extract, pentoxifylline, micronized purified flavonoid fraction, though less used in the United States compared to Europe, have also been used and shown to improve on symptoms and accelerate the healing of venous ulcers [1719]. These agents are thought to affect both the venous tone and capillary permeability and reduce inflammation [5].

Operative treatment options are often reserved in situations of failed conservative measures. It is, however, worth noting that operative options such as sclerotherapy and surface laser therapy are increasingly being done even in asymptomatic patients due to cosmetic reasons. Operative treatment options for varicose veins include venous stripping; endovenous thermal laser; and phlebectomy; the choice of which depends on several factors including the cause of the varicose veins, location, clinical presentation and also patient preferences. Combinations of these various operative techniques may also be required in specific circumstances.

Venous stripping

Venous stripping was one of the earliest described and used surgical options for the management of varicose veins as far back as a century ago [2022]. The technique at the outset involved the surgical removal of the entire great saphenous vein from the ankle to the groin, first using an external stripper, and then subsequently using a Codman or Myers stripper inserted into the saphenous veins, through minimal incisions in the groin/medial thigh [23]. The saphenous vein is then attached to the Codman stripper and pulled out. Due to infrequent occurrence of varicose veins distal to the knee, and risk of injury to the saphenous/sural nerve, surgical venous stripping was subsequently modified to involve venous stripping from the groin to the knee only, with simple ligation of veins distal to the sapheno-popliteal area (microphlebectomy) [16]. Surgical venous stripping is associated with several complications including permanent neurapraxia and numbness from saphenous nerve injury, bruising and unsightly scarring, hematoma formation, phlebitis, wound infection, deep vein thrombosis, and high recurrence rates of up to 50% after 5 years due to technical failures and neovascularization [5,9,24]. Stripping is rarely used nowadays in the USA due to the development of the newer endovenous radiofrequency ablation laser therapy techniques over the past two decades [16,25,26]. The advanced venous stripping techniques are, however, still used in other countries in the world.

Endovenous radiofrequency ablation and endovenous laser ablation

The two currently used endovenous ablation procedures for management of varicose veins are endovenous radiofrequency and laser ablation. The first successful endovenous ablation procedure was reported about 2 decades ago[27,28], and subsequently embraced and adapted by several other countries including the USA due to their satisfactory clinical outcomes and overall cost-saving nature. Both techniques rely on injury to the vein walls through thermocoagulation and consequent thrombotic and fibrotic venous occlusion [9]. Endovenous radiofrequency ablation makes use of high frequency alternating current to obliterate and occlude the lumen of the veins [11]. A bipolar catheter is percutaneously inserted into the great saphenous vein, usually at the level of the knee, via ultrasound guidance and the alternating current delivered causes destruction of the collagen in the endothelial layer of the veins with accompanying fibrotic occlusion of the vein [5,11,16]. Endovenous radiofrequency ablation is best avoided in veins too small (<2 mm) to be cannulated, large veins (>15 mm) tortuous veins, veins with thrombi, and very superficial veins [11].Endovenous laser ablation on the other hand makes use of laser energy, delivered through a tiny laser fiber percutaneously inserted into the vein at the ankle or below the knee via needle puncture using ultrasound guidance. The heat energy generated coagulates and destroys the vein.

Both procedures are minimally invasive and usually performed under general, regional or tumescent local anesthesia and offer fewer post-operative complications and significant clinical improvement [29]. Endovenous ablation procedures are often done on an outpatient basis, and recovery and return to normal activities is faster than stripping, thus they have near 97% patient satisfaction rates and are cost effective[30,16]. The few reported complications include paresthesia, bruising, erythema or hyperpigmentation, thermal injury to the skin, deep vein thrombosis and pulmonary embolism, and occasionally recanalization of the vein in up to 30% of cases[5,31].

Sclerotherapy

Sclerotherapy has existed for more than a century now [32]. Even though its uptake was more pronounced in other parts of the world such as Europe, its spread in the USA was rapidly slowed down following reports of suspected stroke and retinal embolization associated with its use [5,9]. Nevertheless, sclerotherapy remains the treatment of choice for spider angiomas, telengiectasias, reticular varicosities, branch varicosities without axial reflux, perforating veins, venous malformations and varicosities refractory of endovenous ablation [11,16].

A sclerosant such as detergents, alcohols and osmotics, in either liquid or foam preparations, is injected into the veins to cause endoluminal fibrosis through direct contact with the endothelium and subsequent venospasm and venous occlusion [9,16]. Approved sclerosants in the USA include sodium tetradecyl sulfate, sodium morrhuate, glycerin, and polidocanol. Foam therapy is preferred to liquid sclerotherapy which is used to obliterate telangiectasias. A small tuberculin syringe with a 32 g needle is used for liquid sclerotherapy to inject the sclerosant, often starting proximally and extending distally. Foam sclerotherapy involves using foam which is a mixture of air and liquid sclerosant produced via various techniques such as the Tessari or Monfreux techniques [5,16]. The sclerosing agent is mixed with air using two syringes to create micro-bubbles consisting of concentrated sclerosant [16]. The veins are ideally cannulated in supine position and the limb elevated at 30 degrees prior to injecting the foam to a maximum of 20 ml per session.

Sclerotherapy requires careful duplex ultrasonographic identification of the diseased vessels for proper injection. Sclerotherapy offers satisfactory clinical and cosmetic outcomes with acceptable patient satisfaction as high as 70%-100% [33,34]. Use of compression stockings up to two weeks post-procedure is advised. Sclerotherapy has an overall low cost. Reported complications of sclerotherapy include allergic reactions to the sclerosing agents, skin, hyperpigmentation, matting, phlebitis, skin necrosis and superficial cellulitis with extravasations. Small ulcers could also occur with extravasation in the setting of existing lipodermatosclerosis [5]. Deep vein thrombosis have also been reported [35]. Sclerotherapy is not advised in pregnant women or breastfeeding women due to lack of safety data [5].

Phlebectomy

Phlebectomy dates as far as with the introduction of surgical venous stripping. This surgical procedure has undergone extensive adaptations and modifications over the years largely aimed at making the procedure less invasive with fewer complications. Microincision phlebectomy (microphlebectomy) also known as stab avulsion is one of the adapted phlebectomy procedures still in use among the open surgery treatment options. Microphlebectomy can be used as a varicose veins’ management procedure for removal of branch varicose veins or as a complement to the endovenous ablation procedures. Microincision phlebectomy involves using crochet hooks through micro incisions to remove the varicose veins. The veins to be stripped are marked on the skin using a marker, with the patient standing prior to commencement of the procedure. Then a rigid cannula with a large syringe or Klein infiltration pump is used to inject tumescent solution for anesthesia which also serves to transilluminate the subcutaneous tissues under the affected veins. A small beaver blade or a 15 degrees ophthalmologic blade is used to make the incision and then crochet hooks such as the Muller, Oesch Tretbar, or Dortu-Martimbeau are used to avulse the veins through the microincisions [16].

Another upgraded phlebectomy procedure in current use is the powered phlebectomy for removing large varicose vein clusters through minimal incisions. This technique is also referred to as (Transilluminated Powered Phlebectomy TIPP) and uses a central unit through which irrigation and oscillation speed is controlled. A light source is introduced through a microincision and provides a transilluminated direct visualization of the affected veins. A rotating blade or resector is then introduced and placed directly on the affected veins through counter incisions, and with powered endoscopic dissection, these veins are then suctioned [16].

Despite the good clinical outcomes of the TIPP, its cosmetic complications such as hyperpigmentation have limited its widespread use [5,16]. Likewise, the user-friendliness of the technique among clinicians has also played an important part in limiting its use in tandem with patient procedure preferences. To address the underlying cause of the varicose vein clusters, these procedures often need to be combined with saphenous vein ligation. No suturing is generally needed after both micro phlebectomy procedures, but approximation of the skin edges using strips and application of compression stockings may be required postprocedure. This procedure therefore results in minimal scarring and offers the convenience of potentially being an office visit procedure, done under local tumescent anesthesia. TIPP can, however, also be done under general, epidural or spinal anesthesia depending on patient preference [5,16]. Complications include wound infection, paresthesia, hematoma formation, skin perforation, phlebitis and deep venous thrombosis. Due to the high incomplete removal of all affected varicose veins branches, recurrence rates as high as more than 56% have also been reported and remain a major concern.

Despite TIPP becoming gradually less traumatic with advancements in different systems used and improvements in operator techniques. Further innovations and advancements in techniques and operating systems appear to be essential to ensure survival of the microphlebectomy techniques, with improved clinical outcomes and minimal complications.

Introducing the angio-catheter laser ablation

Indication and rationale

This procedure is intended for patients with both truncal and non-truncal tortuous. The technique is ideally suited for non-truncal veins with large diameters and truncal veins that are moderate to severely tortuous, and not amenable to the standard endovenous ablation techniques. The vein length can be as small as 3 cm or as large as 10 cm. As mentioned above, endovenous laser ablation and sclerotherapy are used to treat truncal and non-truncal veins but there are limitations to both. For instance, endovenous laser ablation using the traditional method is not possible in the case of severe tortuosity, and sclerotherapy can lead to unwanted sequelae when there is a perforating vein in proximity to the treated vein. In addition, the angio-catheterization laser ablation technique is more convenient for patients compared to the traditional methods, as it enables other concurrent venous abnormalities the patients have to be simultaneously addressed. For example, if a patient suffers from venous reflux of the Anterior Accessory Great Saphenous Vein (AAGSV) with multiple lateral tributary veins extensions, the latter can be treated on the same day as the ablation of the AAGSV. This technique achieves venous closure of a truncal and tributary vessel of the same origin at the same time. The recovery period is also better tolerated by the patients and the amount of time that is required to wear the compression garments is shortened. In addition to laser ablation, a sclerosant can be injected into the vein via the angio-catheter. Both foam and liquid sclerosants can be injected.

Materials and methods

Vein mapping

With the patient in the standing position, duplex imaging of incompetent varicosities is performed. The varicosities are then marked, and the entry point of each catheter is identified. The patient is subsequently placed in a supine position

Procedure

• The skin is prepped in a standard sterile manner (FIGURE 1).

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Figure 1: Vein mapping of the leg and tortuous superficial veins and Access points for catheter placements.

• The patient is placed in the Trendelenburg position. Using 0.2 cc of 1% lidocaine the skin is anesthetized at each entry point. Multiple 16-gauge angio-catheters are inserted, and the corresponding sheaths are advanced within the lumen (FIGURE 2).

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Figure 2: Image of multiple catheter placement under ultrasound guidance.

• Tumescent anesthesia using the Klein formula is infiltrated peri-venously and in the sub-fascial plane using a maximum of 25 cc per catheter, thus achieving pain control and collapse of the vein wall (FIGURE 3).

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Figure 3: Ultrasound imaging of catheter intravenous placement. Arrow points to the catheter to ensure proper placement in the vessel lumen

• After the laser fiber is inserted through the catheter and into the vein, continuous laser energy is delivered to the vein wall (FIGURE 4 and 5).

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Figure 4: Tumescent anesthesia around the catheter with collapsing of the vein walls highlighting catheter and needle placements.

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Figure 5: Endovenous laser fiber placement, the aiming beam can serve as a guide in addition to ultrasound for proper visualization of fiber placement.

• The typical power output is 6 watts. The laser fiber is then pulled back manually at a rate of 1 millimeter per second. Hemostasis is achieved spontaneously with minimal to no pressure. Ultrasound imaging immediately post-procedure shows collapse of the vein.

• In some cases, chemical ablation using the same catheter placement exclusively in the distal catheter is applied. It is important to only treat the distal segment to avoid any sclerosant diffusion to the deep system. Manual pressure and ultrasound guidance help achieve a safe sclerosant injection.

Results

Duplex ultrasound exam done immediately after the procedure shows occlusion of the vein lumen indicating successful treatment (FIGURE 6). Compression stockings are applied, and post-operative care is performed per standard protocol.

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Figure 6: Ultrasound image showing the immediate post-operative occlusion of the venous lumen (arrow).

Discussion

Advantages of the angio-catheterization technique

The technique provides several advantages including the absence of bleeding, hematoma formation or ecchymosis post-operatively. Also, as with endovenous ablations, this procedure carries minimal to no down time. The risks of infection, hyperpigmentation, post-operative pain and deep vein thrombosis are minimal to non-existent. The risk of skin necrosis or burning is significantly reduced as the amount of energy delivered is controlled. The technique offers greater patient satisfaction, with no scar formation and the convenience of not requiring any prophylactic treatments post-operatively. The technique is superior to sclerotherapy as there is no risk of sclerosants causing cutaneous ulcerations. When sclerosant is injected into that is catheterized, the placement is guaranteed to be intravenous.

FIGURE 7 and 8 respectively show a follow up ultrasound and gross photo with complete closure of the veins treated and no neovascularization to date. There are, however, still unanswered questions such as what the benefits of combining the technique with EV for truncal veins would be. Could this combination in a staged procedure offer a faster recovery compared to the EV alone? Nevertheless, the conveniences offered by this technique remain a significant highlight of this procedure.

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Figure 7: One-month post-operative ultrasound image showing at the arrows complete closure of the treated veins. Ultrasound image showing the immediate post-operative occlusion of the venous lumen (arrow).

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Figure 8: Three months postoperatively, the leg does not show any evidence of varicosities.

Conclusion

The angio catheterization technique is a modified micro-phlebectomy approach to varicose veins management with proven beneficial clinical outcomes, in current clinical practice. This technique offers greater patient satisfaction through its inherent approach that minimizes perioperative complications including infection, hyperpigmentation, pain, scarring among others. The enhanced patient recovery and option of avoiding multiple procedures are all important highlights of this technique. We hope this procedure will, therefore, offer to patients another treatment options with varicose veins.

References

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