Endovenous Laser Ablation and Sclerotherapy for Treatment of Varicose Veins Natasha Brasic, MD,* David Lopresti, MD,† and Hugh McSwain, MD† Superficial venous insufficiency is a common problem associated with varicose veins. Venous insufficiency and varicose veins can be symptomatic, but more commonly they are a cosmetic concern. In this article, we discuss the relevant anatomy and pathophysiology of superficial venous insufficiency, review the current literature for varicose vein treatment, and cover the technical aspects of diagnosing and treating superficial venous insufficiency. Saphenofemoral junction incompetence with resultant greater saphenous vein reflux is the most common cause of varicose veins; because this condition constitutes the majority of patients encountered in practice, we will concentrate on this area. Endovenous laser ablation and sclerotherapy are covered, including patient workup and selection, procedure set-up, and anesthesia. Semin Cutan Med Surg 27:264-275 Published by Elsevier Inc. uperficial venous insufficiency is a common problem as- multifactorial and may be caused by congenitally malformed Ssociated with varicose veins, which are usually asymp- leaflets, thrombosis, chronic turbulent flow, or thrombo- tomatic, but may cause aching, itching, edema, discoloration, phlebitis. Valvular incompetence, regardless of its primary or even frank ulceration. Varicose veins affect approximately site or etiology, causes a leakage of high pressure into the 32% of women and 40% of men.1 Multiple etiologies for superficial veins and a predictable progression of disease, varicose veins exist and include genetics, obesity, pregnancy, with sequential failure of valves as the superficial veins be- intraabdominal malignancy, and chronic, prolonged stand- come progressively more dilated in response to the increased ing. Secondary causes typically include deep venous throm- backpressure. If localized, this dilation leads to appearance of bosis. cosmetic telangiectasias (spider veins) and if more diffuse, Varicose veins are simply superficial veins that have ex- larger veins become more tortuous (varicose veins). panded in response to increased pressure and turbulence. The superficial veins serve as a primary collecting system and Relevant Anatomy are connected via perforating veins to the deep veins, which carry blood from the leg back to the central circulation. Su- and Pathophysiology perficial vein walls are inherently weak (except for the greater A detailed description of the anatomy of the lower-extremity saphenous vein [GSV] in the thigh) because they are sup- venous system is beyond the scope of this article. If more in- ported only by subcutaneous tissue and skin rather than by depth information is desired, please see the review by Min et al.2 fascia and muscle. Valve failure is the most common cause of The return of blood to the heart from the lower extremities is symptomatic venous pathology. Valvular incompetence is through 2 interconnected pathways—the superficial and deep venous systems. The superficial system consists of subcutaneous *Department of Radiology, University of California San Francisco, San Fran- thin-walled veins and truncal veins. The most pertinent veins of cisco, CA. the superficial venous system for the purposes of this article are †Department of Radiology, Naval Medical Center San Diego, San Diego, CA. the GSV and the lesser saphenous vein (LSV). The views expressed in this article are those of the authors and do not reflect The GSV begins at the level of the foot, tracks anterior to the official policy or position of the Department of the Navy, Department the medial malleolus, and continues on the medial aspect of of Defense, or the United States Government. None of the authors has the leg and thigh until it ends at the saphenofemoral junction identified a potential conflict of interest. Address correspondence to H. McSwain, Department of Radiology, Naval (SFJ) (Fig. 1A). The SFJ is the site of the GSV entering the Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA femoral vein of the deep venous system (Fig. 2). The SFJ is 92134. E-mail: [email protected] the most common site of venous reflux into the GSV. 264 1085-5629/08/$-see front matter Published by Elsevier Inc. doi:10.1016/j.sder.2008.08.001 Endovenous laser ablation and sclerotherapy 265 Figure 1 (A) Basic lower extremity venous anatomy. The GSV runs along the medial aspect of the leg and thigh to empty into the deep venous system (femoral vein) at the saphenofemoral junction. (B) Posterior view of the lower leg demonstrating the LSV running in the midline of the calf to empty into the deep venous system (popliteal vein) around the level of the knee at the saphenopopliteal junction. The LSV starts at the level of the foot, tracks posterior to (VI) can be primary or secondary (Fig. 6). 1° VI is caused by the lateral malleolus and continues in the midline of the calf inherent abnormality of the valve and can be congenital or until it ends at the saphenopopliteal junction (SPJ) around acquired. 2° VI occurs when venous valves are normal but the level of the knee (Fig. 1B); the SPJ is the site of the LSV distension of a vein causes an inability of the valves to oppose entering into the popliteal vein of the deep venous system, each other. With 2° VI, treatment of the underlying cause of though other less common anatomic variations are possible incompetence may allow the vein to decompress and regain (Fig. 3). The SPJ may be incompetent and serve as the source valvular competence. of venous reflux but this occurs much less frequently than SFJ incompetence. Both the GSV and the LSV are in the saphenous compart- Literature Review of ment at their respective levels in the lower extremity. The saphenous compartment lies between the deeper muscular fas- Treatments for Varicose Veins cia and the more superficial saphenous fascial layer (Fig. 4). On Multiple techniques have evolved in the treatment of small ultrasound (US), these fascial layers are easily identified as and large varicose veins. Long-term success in the treatment echogenic (white) lines (Fig. 5). The GSV and LSV tributary of leg varicosities, when the SFJ and the GSV are involved, veins are present in the subcutaneous fatty tissues superficial depends on the elimination of the highest point of reflux and to the saphenous fascia; because the tributaries are thin- the incompetent venous segment. This elimination may be walled and not supported by fascial layers, these veins can accomplished surgically or by endovascular methods. Sev- enlarge greatly when distended giving the typical appearance enty percent of varicose veins are attributable to incompe- of varicose veins. tence at the SFJ with reflux along the GSV.3 The deep and superficial venous systems are connected by The conventional treatment of saphenofemoral venous in- perforating veins, aptly named because they perforate the competence is surgery: ligation and GSV stripping.4 Ligation muscular fascia in their course. The larger perforating veins of varicosities is an older approach to treatment of varicose have venous valves that normally only allow blood flow from veins in which multiple incisions are made overlying visible the superficial to the deep venous system. The return of lower-extremity venous blood to the heart is varicosities and ligatures are placed every 2 to 3 cm. This a complex mechanism. Three major components of this method has proven ineffective because it fails to treat the mechanism are (1) integrity of the lower-extremity muscular origin of venous reflux and fails to extirpate the varicosities 5 pump, (2) unobstructed venous outflow, and (3) venous themselves. Patients treated in this way usually return after a valve competency. Incompetent venous valves are the most few months with recurrent varicosities immediately adjacent common source of venous insufficiency (and thus varicose to the incision sites. veins). GSV stripping is another surgical technique where the GSV Venous valves are bicuspid one-way valves present every 3 is removed with the use of a stripping tool. The SFJ and its to 4 cm in normal lower-extremity veins (deep, superficial, tributaries are flush ligated through a 2- to 3-cm incision and larger perforating components). These valves help keep placed in the skin slightly above the groin crease. After liga- venous flow in the caudal to cranial direction and from pe- tion and division of the GSV at the SFJ and all of its side ripheral to central. Valvular insufficiency or incompetence branches along the medial thigh and knee, the GSV is pulled 266 N. Brasic, D. Lopresti, and H. Mcswain these methods. These techniques aim to abolish GSV and lesser saphenous vein reflux. Endovenous RFA (Closure System, VNUS Medical Tech- nologies, Inc, Sunnyvale, CA) of the GSV was first described by Goldman in 2000 and was approved by the Food and Drug Administration in 1999.16 The Closure system consists of a bipolar generator and catheter, with sheathable elec- trodes at the catheter tip. The GSV is canulated at the level of the knee, and the catheter is inserted over a guidewire. The catheter is advanced 2 cm caudal to the SFJ as confirmed by sonography. The catheter is then slowly withdrawn at a rate of 3 cm/min, maintaining a temperature of 85°C. RF energy is passed through the unsheathed electrodes to cause con- trolled heating of the blood vessel wall. It has been suggested based on animal studies that the heat applied to the vein wall during RFA causes denaturation of the collagen fibers, result- ing in vein constriction of the vessel wall rather than throm- bosis of the vein.17 This results in vein shrinkage or occlusion by contraction of the venous wall collagen. When the vein Figure 2 (A) Line drawing and (B) US, long view, demonstrate the SFJ region anatomy. Asterisk (*) denotes the GSV on the US view. The femoral vein and the CFV are part of the deep venous system, whereas the GSV is part of the superficial venous system; the SFJ is the site of the GSV emptying into the deep system.