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Varicose veins of the legs are a common condition caused by venous insufficiency as a result of valve reflux. Most varices are located in the greater saphenous vein (GSV) and the majority of sufferers tend to be female. The most common symptoms are described as heaviness, fatigue, or throbbing pain in the legs. Traditionally, treatment of varicose veins involved an invasive procedure of groin to ankle stripping and ligation of the GSV. More recently, minimally invasive treatments consist of endovenous laser treatment, sclerotherapy, ambulatory (mini) phlebectomy, and radiofrequency endovenous ablation (RFA). This review will focus on the RFA technology in the outpatient setting.
It's estimated that at least 20 to 25 million individuals in the United States have varicose veins.1 Most varicose vein sufferers are female, and many prolonged standing occupations contribute to varicose veins. Pregnant women and people with occupations that involve prolonged sitting are also at risk.
Varicose veins are a condition caused by leaky or defective valves in the saphenous veins of the legs. The valves become incompetent, and reflux of blood occurs. The leg vessels become tortuous and twisted, with a bulging superficial appearance. (See Vascular changes in varicose veins.) Varicosities affect physical appearance and may be a cosmetic concern. Although varicosities aren't a limb-threatening problem, they may affect quality of life and can result in lost time from work.
Ligation of the GSV, stripping and removing tributaries, has been the standard of care for treatment of varicose veins. The primary, superficial varicose veins were treated by interrupting the venous reflux through stripping, and high ligation of the saphenous veins. Unfortunately, this invasive procedure can lead to a painful and prolonged recovery, with a risk of infection, hematoma, and nerve injury. The patient isn't able to return to normal activities for 2 to 6 weeks and recurrent varicosities do occur.
RFA of the GSV was introduced in 1999 as a minimally invasive surgical technique for the treatment of saphenous vein incompetence. With this new technology, patients are now offered a convenient and less invasive option for the management of varicose veins. RFA decreases morbidity and increases patient safety because it's less invasive with minimal side effects. In addition, less scarring, decreased operating time, and cost effectiveness increase patient satisfaction.
The cause of venous disease isn't entirely known. Heredity, female sex hormones, hydrostatic force on veins from prolonged standing, or an inherited defect in vein wall collagen may be to blame.1 Morbid obesity and immobility or wearing high heels can inhibit the use of the calf muscle pump, contributing to varicose veins.1 Pregnant women may also develop symptoms during the first trimester, often within 2 to 3 weeks of gestation.
The tortuous, twisted, bulging, superficial appearance of the leg veins may be the only signs of the existence of varicose veins. With some patients, there may not be any visible symptoms. If symptoms do exist, the most common may include heaviness, fatigue, swelling, itching, aching, or throbbing pain in the legs. Symptoms usually subside with elevation of the legs or decreased time standing.
An exam of the legs for varicosities is performed on patients while sitting and standing. Size, color, and configuration of the leg veins are recorded during inspection and palpation at the time of exam. Clinical exam isn't an accurate indicator of the need for treatment and therefore further noninvasive diagnostic testing is usually necessary.
Continuous-wave Doppler ultrasound is often used as part of the initial exam. This is useful in detecting reflux at the saphenofemoral and saphenopopliteal junctions, and in determining the need for duplex scanning. Doppler ultrasound is performed by placing a probe over the vein while the patient is standing. The patient is asked to cough and if the Doppler signal is absent during the cough, no reflux is present. This Doppler test assists with the selection of patients in need of the duplex diagnostic imaging study.
The best method of assessing the venous system and diagnosing varicose veins is the duplex Doppler ultrasonography. Duplex Doppler ultrasonography provides direct visualization and evaluation of blood flow in the veins of the legs. Vessel competence and luminal diameter measurements are evaluated with the patient standing or in the reverse Trendelenburg position. The scan is done with high frequency using a transducer probe. Color flow scanning is used to visualize blood flow with change of color from red to blue depending on whether the flow is toward or away from the probe.1 During imaging, the deep veins of the legs are evaluated for occlusive disease and reflux. Identification of specific areas of reflux for treatment lowers the chance of recurrence.
Preoperative diagnostic testing, such as blood studies, electrocardiogram, and other provider or facility-specific testing prerequisites related to the comorbidities of the patient, needs to be completed. The day before surgery, the GSV is marked or mapped using Doppler technology. After marking, the patient is instructed not to take a shower prior to surgery.
Upon admission, instructions are provided to keep legs dependent; they shouldn't recline, as the veins need to become engorged. This may be uncomfortable for the patient, but is necessary for the surgery. If patients' veins aren't marked prior to admission, marking is completed in the standing position in the preoperative area.
RFA is a minimally invasive procedure performed under local, moderate sedation, regional, or general anesthesia in the outpatient setting. Required equipment includes an OR bed with Trendelenburg and reverse Trendelenburg capabilities, a radiofrequency generator, and a duplex ultrasound machine. Staff in attendance should be an ultrasound technologist, scrub person, circulating nurse, and anesthesia providers.
Basic instruments needed for the procedure are few: scissors, needle driver, and a #11 knife blade/handle. A baseline count of sponges, suture, syringes, and hypodermic needles are completed before the patient arrives in the OR. Other necessary supplies include skin marker, ultrasound gel, ultrasound sterile probe cover, sterile bowls, introducer, and guidewire.
The patient is positioned supine on the OR table. Occasionally, a sterile bump is placed under the knee to allow enhanced vein access. The skin of the operative leg is prepped from groin to ankle. During draping, the operative leg is exposed from groin to foot and the foot is wrapped with a sterile towel.
Duplex ultrasonography visualization of the GSV is used to identify location and length of the vein with the patient in the Trendelenburg position. The venous system is interrogated using duplex ultrasonography for optimal site for vein access and performance of vein access, presence of vein tortuosity, diameter, and tributary location.2 A local anesthetic is injected at the access site. Duplex-guided percutaneous vein access and cutdown are usually performed medially just below the knee and an introducer sheath is inserted. A guidewire is then advanced to the saphenofemoral junction and the endovenous catheter is inserted in the vein over the guidewire. The guidewire is then removed.
Occasionally, tortuosity of the vein may prevent the catheter from passing the length of the vein. Under this circumstance, a glidewire (a wire with special coating on the outside that slides easily when wet) may be used to position the endovenous catheter. If unsuccessful with the glidewire, a second sheath is placed proximal to the area of vein tortuosity or disease, and two separate treatments are performed. The position of the patient is changed to reverse Trendelenburg once catheter access is established. The catheter is then advanced to the saphenofemoral junction using duplex ultrasonography as a guide.
A tumescent anesthesia solution is used, and consists of 50 mL of 1% lidocaine (Xylocaine) with 1:200,000 epinephrine; 5 mL of 4% sodium bicarbonate (Neut) is added to 250 mL injectable 0.9% normal saline. This solution is then injected by the surgeon along and around the vein to prevent burning of the surrounding soft tissues, as well as to compress the vein to keep it in direct contact with the catheter. Injectable normal saline is also placed on the sterile field for catheter and introducer irrigation. The injectable saline, tumescent solution, and syringe used for injection should be properly labeled. The medications used in the tumescent solution are surgeon-specific and may vary in the type of drug and amounts used.
Endovenous catheters are currently sized 6 French (Fr) to 8 Fr for different vein diameters; a selection of lengths are also available. The newest technologically advanced endovenous catheters have a 7-cm electrode heated to 120[degrees] C by radiofrequency energy. The vein wall segment in contact with the catheter electrode should reach a temperature of 100[degrees] C to 110[degrees] C. The 7-cm endovenous catheter is withdrawn at a rate of 6.5 cm/minute and the actual procedure time with the 7-cm catheter averages less than 20 minutes.3
Endovenous catheters 6 Fr and 8 Fr were used before the 7-cm catheter was introduced. The temperature of the probe on the 6 Fr and 8 Fr catheters is set by the radiofrequency generator at 85[degrees] C. These catheters are withdrawn at a rate of 2.5 to 3.0 cm/minute and the actual procedure time ranges from 35 to 45 minutes.
The endovenous catheter is connected to the radiofrequency generator by the circulating nurse, and radiofrequency energy is used to heat the elements in the umbrella-like tip of the catheter. Conductive heat transfer occurs when the catheter-heating element reaches the designated temperature. The radiofrequency energy from the catheter prongs are then transmitted to the vein wall, causing the vein to contract and close. The catheter is retracted at a rate of 2.5 to 6.5 cm/minute depending on catheter size, until it reaches the insertion point. The radiofrequency generator shuts down when impedance rises, ensuring minimal heating of blood while maintaining efficient heating of the vein wall.4
Duplex ultrasonography is used to verify ablation of the GSV. Closing counts are completed, and the catheter is removed. The small incision is then closed with a topical skin adhesive or suture. Adhesive strips and gauze are placed over the incision site and a bulky dressing is applied. A large 6-inch, double-thickness bandage is wrapped over the bulky dressing. The patient is then transported to the postoperative phase II area in a procedure chair with legs elevated.
RFA is contraindicated in patients with thrombus in the vein segment of the affected leg.5 Complications include skin burns, superficial or deep vein thrombosis, thrombophlebitis, skin discoloration, pulmonary embolism, hematoma, burning or stinging pain, infection, and paresthesia due to saphenous nerve injury.
The most common complaints reported by postoperative patients are leg discomfort, tenderness, and bruising. Patients receive prescriptions for either acetaminophen and hydrocodone (Vicodin) or acetaminophen and codeine (Tylenol with codeine No. 3). Many patients have reported that after the first 24 to 48 hours, their discomfort is managed simply with acetaminophen (Tylenol).
Adhesive strips are placed over the small incisions and must not be removed. Patients wear elastic wraps from toe to groin that can be removed to shower and at bedtime. Otherwise, legs should remain wrapped for a minimum of 3 days or until the first postoperative appointment. Walking is encouraged as tolerated. Legs must be elevated when seated.
Follow-up postoperative visits will be scheduled 3 to 5 days after surgery. Patients are instructed to call their surgeons for any fever or chills, increasing redness around incisions, drainage from the incisions, increased pain or swelling in the legs, sudden onset of shortness of breath, or chest pain.
RFA is a minimally invasive technique that allows the patient a faster recovery, better cosmetic results, less bruising, decreased postoperative pain, low complication and recurrence rates, and an early return to work. Some disadvantages of the RFA are the disposable cost of the catheters, cost of the generator, operator experience, expertise and comfort with ultrasound guidance, reimbursement, and availability of ultrasound equipment and trained personnel. It will be several years before long-term data are known for the newer treatments.6
Although it's still early in the follow-up period, optimism for these procedures is rising.7 It's clear that high ligation and stripping is no longer the treatment of choice for superficial venous reflux. We are now able to offer our patients a more convenient and less invasive option for managing their varicose veins.
1. Carr S. Current management of varicose veins. Clin Obstet Gynecol. 2006;49(2):414-426. [Context Link]
2. Stirling M, Shortell C. Endovascular treatment of varicose veins. Semin Vasc Surg. 2006;03(008):109-115. [Context Link]
3. Roland L, Dietzek A. Radiofrequency ablation of the great saphenous vein performed in the office: tips for better patient convenience and comfort and how to perform it in less than an hour. Perspect Vasc Surg Endovasc Ther. 2007;19(3):309-314. [Context Link]
4. Nootheti P, Cadag K, Goldman M. Review of intravascular approaches to the treatment of varicose veins. Dermatol Surg. 2007;33:1149-1157. [Context Link]
5. Sadick N. Advances in the treatment of varicose veins: ambulatory phlebectomy, foam sclerotherapy, endovascular laser, and radiofrequency closure. Dermatol Clin. 2005;(23):443-455. [Context Link]
6. Campbell B. Varicose veins and their management. BMJ. 2006;333:287-292. [Context Link]
7. Morrison N. Saphenous ablation: what are the choices, laser or RF energy. Semin Vasc Surg. 2004;12(006):15-18. [Context Link]
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