Australia & New Zealand Society of Vascular Surgeons

Three methods of obliterating the lumen of varicose veins in-situ without ligation, stripping or surgical removal of varicosities are gaining popularity in western countries. All three require duplex scanning for monitoring during the procedures. Two of the methods heat veins to destruction; they treat only straight native saphenous trunks, so adjuvant treatment methods must subsequently be used for tributary varicosities, incompetent perforating veins and recurrent varicose veins. The saphenous trunks are cannulated distally to proximally and treated as the activated probe is withdrawn. One such technique involves bare-tipped laser obliteration of the vein trunk (810 nm ELVS and EVLT, 940 nm and 980nm under trial). Variations also exist in the level of power and pull-back speed. The other technique for straight trunks is controlled radiofrequency heating (microwaves) to obliterate the lumen (RF VNUS Closure). Multiple bipolar electrodes come in contact with the endothelium as the catheter is withdrawn. Heating the endothelial surface sufficient to cause denaturation of the collagen in the vein wall results in contraction of the lumen without vein wall necrosis. Both techniques require modified tumescent anaesthesia precisely placed under duplex guidance adjacent to the saphenous trunks to act as a heat buffer, to reduce adjacent tissue damage and importantly to keep the walls of the treated vein apposed and compressed. The third method is duplex ultrasound guided sclerotherapy (UGS) and has more of a presence in Australia. It involves duplex imaging the target saphenous trunks, major tributaries, recurrent varicose veins, perforating veins or difficult-to-get-at veins, followed by duplex guided direct needle puncture at various sites and injection of liquid or more recently foamed detergent sclerosants, then leg compression with 20-30 mmHg stockings. It is repeatable whenever required, whereas the other two methods are not. In evaluating these minimally invasive venous occlusive techniques we have limited data on short and medium term efficacy in eradication of varicosities clinically and the elimination of reflux on duplex. These methods can stop the reflux, as is evident at the time of the procedure and can clinically improve the legs for a 3-12 month period. Data is limited beyond that time for the first two methods but more data is available for UGS. Treating truncal reflux only initially by endovenous laser or VNUS greatly reduces the size and extent of the major tributary varicosities when the patient is seen again at 6 weeks with a view to a second treatment, which would involve either UGS or ambulatory phlebectomy. Treatment of the trunks and major tributaries together by UGS initially can produce superficial thrombophlebitis and discolouration under the skin which takes months to settle. If at the six week review further reflux is detected the procedure is repeated. The incidence of unwanted complications such as thromboembolic events and damage to adjacent structures, specifically nerves and skin, was significant initially but with modified techniques and experience these are reducing. The cost of the first two techniques is high, both on initial outlay of power source etc. and disposables per case. VNUS was initially rejected by Australian health insurance authorities as too costly. Laser treatment of saphenous trunks is on trial in Melbourne and an M.S.A.C. submission for an item number and rebate has been made. The cost of UGS is far less, with little hardware required except for the duplex scanner. The sclerosant is foamed at the time of the procedure using two syringes and a 3-way tap. Patient down time is short with these methods compared with varicose veins surgery. Recovery time however can be long if extensive superficial varicosities are treated. This means increased patient visits, increased duration of compression and may involve adjuvant treatments as mentioned. Meaningful results are not yet available as to whether these methods give long term control of the disease. All three methods are still evolving and several subsets of patients from multiple centres have undergone variations in treatment and are being evaluated. All three techniques have a significant learning curve as expected. Hands-on duplex experience is essential. Manual techniques already learned for endovascular procedures make the endovenous techniques relatively simple. Doctors with duplex experience but little cannulation or endovascular experience favour UGS. One major driving force in the USA for these methods was that the do not involve hospital bed stay or use of operating theatres. This cost saving is crucial. If the overall cost of tooling up and disposables approaches the cost of a day in hospital Australia seems unlikely to embrace the first two methods, especially as adjuvant UGS, at extra cost, is required to treat the non-truncal disease and long term figures on the permanent obliteration of the saphenous trunks are not yet known. UGS, in the last two years using foamed sclerosants, is available around Australia as an alternative to varicose vein surgery. As with surgery, performance levels and expertise vary, but in good hands 1-3 visits are required to eliminate reflux on duplex scan. Over time reflux reappears at the saphenofemoral junction and/or along the trunk. The rate of this approaches 50% at 5 years and the procedure is simply repeated. Varicose vein surgery has improved recently by tailoring the surgery to individual cases, using techniques such as inversion stripping and vein hooks, early ambulation and treating most surgical cases on a day-only basis. Diligent postoperative scanning however has shown a surprisingly high rate of neovascularisation and reflux at the groin level after well executed surgery. Is this neovascularisation promoted by the surgery and therefore eliminated by these endovenous obliteration techniques? Duplex scanning has required surgeons to rethink our long held views on the draining tributaries at the saphenofemoral junction, the role of the terminal and sub-terminal valves and whether our surgical strategy is correct. The three techniques discussed usually leave the saphenofemoral junction and groin tributaries alone and many surgeons would say that this is a recipe for recurrence. There are no controlled trials comparing the new techniques with surgery and only few clinical series with meaningful follow-up times. Despite these new methods currently having some limitation in their application and efficacy, as they develop they will reduce the amount of varicose veins surgery we perform. The varicose veins patient wants to see the best control of the disease for as long as possible with the least down time, fastest recovery and fewest possible complications. Insurers want to see all this at a reasonably low cost. The three procedures discussed have some way to go to prove they are better than well executed surgery in the pursuit of the above. Implicit here is that the standard of varicose vein surgery must remain high, as best as it can possibly be done and taught to others. As the endovenous obliteration techniques improve and are modified, and if their long term efficacy is found to be acceptably good and with good patient compliance and improved cost structures these techniques may well be the way forward in varicose veins treatment.