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Varicose Veins: Are Newer Techniques Really Superior and Revolutionary?

The advent of two new minimally invasive techniques for saphenous ablation has generated considerable excitement. Radiofrequency ablation or "closure" (RF) and endovenous laser (EVLT) employ similar end mechanism (heat), have similar clinical applications, and have been promoted as office procedures under local anesthesia. RF requires a nearly asanguinous field and close vein wall contact with the probe tip, and the tip temperatures range from 85º to 95º C. Typical treatment time is approximately 30 minutes. Non-thrombotic "closure" of the treated vein is the goal. In practice, thrombotic occlusion is common, eventually leading to involution or in some cases recannalization.

EVLT, on the other hand, destroys the vein more directly with fiber tip temperatures greater than 500º C but heat has dissipated to less than 50º C at the adventitial level. Contrast extravasations are common at completion venography. Heat transfer occurs partially through blood; hence, vein compression protocol is less rigid. Digital compression over the conveniently lighted tip is adequate. The initial set up times and self-test cycles are also faster than RF. Treatment times average fewer than 7 minutes.

Two-year results of ablation efficacy (± 90%), complications, and patient satisfaction with the two techniques are roughly similar. Neither is satisfactory for extremely tortuous nor large (> 12 mm) Saphena. Open stripping is the choice in EVLT when the closed techniques fail or when definitive ablation on the first try is desired in cases of advanced venous stasis.

We have performed more than 200 cases of RF procedures and about 100 cases of continuous wave EVLT procedures using an 810 nm energy source for varicose veins. We increasingly lean towards EVLT because of its relative speed and simplicity. We prefer EVLT to stripping when a concurrent additional procedure such as valve reconstruction or iliac vein stenting has to be performed; the speed, avoidance of a separate open incision, and low risk of intraoperative bleeding are definite positives. But this is based on subjective preference and operator convenience, not on long-term objective outcome differences. Are the newer techniques really "superior and revolutionary" as advertised? With the inversion technique, using duplex-guided mini incisions at crease lines, vein stripping can be performed with similar morbidity, down time, and at much less direct cost; the incisions fade into near invisibility in a few months.

For sure, the new techniques have the glint of modern technology. Enthusiasm for them has resulted in biased exaggeration of their advantages, glossing over the negatives. The advertised local anaesthesia advantage for RF and EVLT is moot; about 80% of candidates also require stab phlebectomies, which is best combined with saphenous ablation under general or epidural as a single procedure instead of two; more if sclerotherapy is used. In relative comparisons including cost, totality of treating the entire limb, not just the saphenous component, should be considered. The touted complication reduction with the newer techniques vis a vis stripping – we ourselves have not seen any – is often overshadowed by local complications of stab avulsions. Several states have started regulating office local anaesthesia with sedation, which could be more hazardous than under more controlled conditions.

A critical difference from stripping is that the upper inch of the saphenous vein and tributaries are left untreated by the newer techniques. Proponents argue this may actually be an advantage – by avoiding tributary congestion and onset of neovascularisation. Already at two years, clinical recurrences with RF (± 12%) are related to the upper tributaries or residual saphenous patency in our own and others' experience. Recent recommendation to treat even closer to the SF junction risks thermal injury to the femoral vein. Systemic vein wall weakness is a major cause of recurrence and will be unaffected regardless of the method. Duplex data after stripping have been projected into wildly exaggerated figures of "recurrence" even though about 85% of patients remain satisfied long term. Varix is a clinical disease, not a duplex lesion. Questions and concerns about recurrence most likely will not be answered until 5-year, preferably 10-year, follow up is obtained.

The newer techniques are less invasive as single procedures and will prevail in practice due to an extraordinary confluence of interests: Device manufacturers who see a big market and have invested heavily in promotion, consumers who are directly bombarded on television and other media about the near magical wonders of the new technologies (before even intermediate term results), and physicians who have eagerly adopted the techniques to expand their repertoire of office procedures.

Reference

  1. Pichot O et al. J Vasc Surg. 2004; 39: 189-95
  2. Harris EJ Jr. J Vasc Surg. 2002; 35: 1292-94
  3. Lurie F et al. J Vasc Surg. 2003; 38:207-14
  4. Min RJ et al. Interv Radiol. 2003; 14: 991-96
  5. Zimmet SE, Min RJ. Interv Radiol. 2003;14:911-15
  6. Weiss RA. Dermatol Surg. 2002; 28: 56-61
  7. Sarin S et al. Br J Surg. 1992; 79: 889-93
  8. Jones L et al. Eur J Vasc Endovasc Surg. 1996; 12:443-45

Fuente: IVMF - Interventional and Vascular Medicine Forum

Ultima actualizacion: 28 DE ENERO DE 2005

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