ABSTRACT
Chronic venous disease (CVD) encompasses a wide spectrum of venous disorders, ranging from minor cosmetic concerns to severe chronic venous insufficiency (CVI). CVI is characterized by significant venous hypertension and is often the final stage of chronic venous disease, manifesting as venous leg ulcers (VLUs) and other severe complications.[1]
This topic provides an overview of surgical interventions that can be performed in outpatient settings (e.g. office-based settings and vein clinics) for management of CVD and resulting manifestations such as VLUs. For an introduction and assessment of patients with VLU, see "Venous Ulcers - Introduction and Assessment". For VLU treatment, prevention and patient education, see "Venous Ulcers - Treatment and Prevention". For clinical guidelines and quality measures specific to VLU, see "Venous Ulcers - Overview".
Management of patients with CVD: management of CVD involves both conservative and surgical strategies, tailored to the patient's specific condition and needs.
- Conservative management includes leg elevation, weight management, and the use of compression therapy. Venoactive drugs are also recommended by clinical practice guidelines.
- Surgical interventions are part of management strategies to prevent VLU and/or to promote VLU healing. A comprehensive duplex ultrasound (DUS) is recommended for all patients with symptomatic CVD to assess venous reflux and/or obstruction. If present, consultation with a vascular surgeon or vein specialist is advised.
Care coordination: optimal management of CVD often requires a multidisciplinary approach. Effective care coordination among clinicians is crucial for optimizing clinical outcomes and cost-effectiveness. Proper triage of potential surgical candidates can help expedite care.
- When to refer to vein specialists or vascular surgeons:
- Referral to vein specialist:
- For patients with healable VLU, early referral to a vein specialist is recommended to address any venous reflux due to superficial venous incompetence.
- Patients with symptoms of CVD, such as restless legs and cramping, should be referred.
- Patients exhibiting signs of CVD, including hemosiderin stains, color changes, hair loss, history of superficial thrombophlebitis, spider veins, or a single bulge in the middle calf, should also be referred.
- Referral to vascular surgeon: Patients with deep venous disease and conditions requiring vascular procedures that cannot be performed at vein clinics should be referred.
- Pre-surgical coordination is important in order to ensure conservative management is adequately implemented. To meet eligibility for surgery, payers may require documentation of a period of conservative therapy.
- Post-surgical coordination involves regular follow-up visits, coordination with wound care specialists, nutritional support, and mental health support to address the psychological impacts of chronic disease and surgical recovery.
Preoperative assessment: patients being considered for surgical management of chronic venous disease should have been following a personalized plan of care based on a comprehensive assessment and diagnostic results.
Surgical interventions: Surgical interventions for CVD include interventions for superficial venous incompetence and interventions for deep venous pathology.
INTRODUCTION
Overview
This topic provides an overview of the different surgical interventions available for treating patients with chronic venous disease (CVD) and resulting manifestations such as venous leg ulcers (VLU). The topic focuses on management strategies for incompetent superficial veins, such as saphenous trunks, tributaries, reticular veins, and telangiectasias, and discusses surgical interventions that can be performed in outpatient settings, like office-based clinics or vein centers.
For an introduction and assessment of venous leg ulcers (VLU) including epidemiology, risk factors, etiology, pathophysiology, history, physical examination, diagnosis, differential diagnoses, documentation and ICD-10 coding, see "Venous Ulcers - Introduction and Assessment". For management of VLU including treatment, prevention and a section for clinicians on patient education, see "Venous Ulcers - Treatment and Prevention". For clinical guidelines and quality measures specific to VLU, see "Venous Ulcers - Overview".
Background
Chronic venous disease (CVD) encompasses a wide spectrum of venous disorders, ranging from minor cosmetic concerns to severe chronic venous insufficiency (CVI). CVI is characterized by significant venous hypertension and is often the final stage of chronic venous disease, manifesting as venous leg ulcers (VLUs) and other severe complications.[1]
- The term “chronic venous insufficiency” (CVI) is reserved for advanced CVD, which is applied to functional abnormalities of the venous system, producing edema, skin changes, or venous ulcers, corresponding with C3 to C6 of the CEAP classification.[1]
Classification of CVD is required by payers, in order to assess coverage eligibility. The CVD classification systems recommended by clinical practice guidelines are [1][2]:
- The CEAP (Clinical-Etiology-Anatomy-Pathophysiology) system, which ranges from C0 (no visible or palpable signs of venous disease) to C6 (active venous ulcer) (see Table 1).
- The Venous Clinical Severity Score (VCSS), which includes 10 clinical descriptors (pain, varicose veins, venous edema, skin pigmentation, inflammation, induration, number of active ulcers, duration of active ulceration, size of ulcer, and compressive therapy use), scored from 0 to 3 (total possible score, 30) that may be used to assess changes in response to therapy.[3]
Table 1. The 2020 revision of CEAP: Abbreviations and Descriptions of the Clinical Component of CEAP [4]
| CEAP Clinical Description |
- C0 No visible or palpable signs of venous disease
- C1 Telangiectasias or reticular veins
- C2 Varicose veins
- C2r Recurrent varicose veins
- C3 Edema
- C4 Changes in skin and subcutaneous tissue secondary to chronic venous disease
- C4a Pigmentation or eczema
- C4b Lipodermatosclerosis or atrophie blanche
- C4c Corona phlebectatica
- C5 Healed ulcer
- C6 Active venous ulcer
- C6r Recurrent active venous ulcer
|
Management of patients with CVD involves both conservative and surgical strategies, tailored to the patient's specific condition and needs.
- Conservative management: conservative therapy for uncomplicated cases may be sufficient for symptom relief and early signs of venous insufficiency.[5][6] Patients with symptomatic CVD with or without an active VLU will benefit from conservative treatment, whether they are not undergoing interventional treatment, awaiting intervention, or experiencing persistent symptoms after intervention.[1] Conservative management includes leg elevation, weight management for the overweight and obese, and the use of compression therapy (e.g. graduated compression stockings, bandages or wraps). Leg elevation helps venous return and decreases venous hypertension; in contrast, standing for long periods or sitting with legs dependent for long periods, can aggravate the symptoms and signs of venous insufficiency.[5][6] Venoactive drugs are also recommended by clinical practice guidelines.[1] For details, see topic "Venous Ulcers - Treatment and Prevention".
- Surgical management: surgical interventions can be included as part of management strategies to prevent VLU and/or to promote VLU healing. A comprehensive duplex ultrasound (DUS) is recommended for all patients with symptomatic CVD to assess venous reflux and/or obstruction.[1][2][5][6] If venous reflux or obstruction is present, consultation with a vascular surgeon or vein specialist is recommended.
Care Coordination
Optimal management of CVD often requires a multidisciplinary approach, involving primary care physicians, vascular specialists, wound care specialists, nutritionists, and mental health professionals. Effective care coordination among clinicians is crucial for optimizing clinical outcomes and cost-effectiveness.
Pre-Surgical Coordination
- To meet eligibility for surgery, payers may require documentation of a period of conservative therapy (2 to 4 weeks, with exact duration depending on the insurance company or Medicare Administrative Contractor) including graduated compression (20-30 mmHg or greater), ambulation, elevation, and avoidance of prolonged sitting and standing.[5][6] This conservative management phase should be closely monitored and documented to ensure compliance and effectiveness.
Referrals
Proper triage of potential surgical candidates can help expedite care:
Referral to Vein Specialist
- For patients with healable VLU, early referral to a vein specialist is recommended to address any venous reflux due to superficial venous incompetence.
- Patients with symptoms of CVD, such as restless legs and cramping, should be referred.
- Patients exhibiting signs of CVD, including hemosiderin stains, color changes, hair loss, history of superficial thrombophlebitis, spider veins, or a single bulge in the middle calf, should also be referred.
Referral to Vascular Surgeon
- Patients with deep venous disease and conditions requiring vascular procedures that cannot be performed at vein clinics. Examples of such conditions include:
Post-Surgical Coordination
Post-operative care is equally important and should involve:
- Regular follow-up visits with the vein/vascular specialist to monitor healing and detect any complications early.
- Coordination with wound care specialists for patients with VLU to ensure proper wound management and prevention of recurrence.
- Nutritional support to promote healing and overall health.
- Mental health support to address any psychological impacts of chronic disease and surgical recovery.
Preoperative Assessment
Patients being considered for surgical management of chronic venous disease should have been following a personalized plan of care based on a comprehensive assessment that [5][6]:
- Includes comprehensive history and physical examination
- Identifies underlying causes of chronic venous disease and assesses risk factors contributing to development of complications (e.g. ulcers, infection)
- Identifies conditions associated with chronic venous disease (e.g. peripheral artery disease, lymphedema, etc)
- Identifies risk factors that would increase risk for complications after surgical intervention (e.g. clotting disorders)
- Differentiates from other types of edema (systemic or local), which require different treatments
- Identifies pertinent patient's/caregiver's concerns
- Uses validated classification systems (i.e. CEAP and VCSS)
- Includes diagnostic workup:
- Performs noninvasive arterial tests to rule out peripheral arterial disease (PAD) and
- Documents venous disease with a venous duplex ultrasound (DUS)
- Clinical practice guidelines recommend that DUS be performed at an Intersocietal Accreditation Commission or American College of Radiology accredited vascular laboratory by a credentialed ultrasonographer, with the patient standing whenever possible. A sitting or reverse Trendelenburg position can be used if the patient cannot stand.[2]
- Supplemental plethysmography, contrast venography, venous pressure measurements, intravascular ultrasound (IVUS), computed tomography (CT) venography, or magnetic resonance (MR) venography may be relevant to the plan of care in patients with severe or unusual presentations of venous disease in which there is possible concurrent involvement of pelvic veins or arterial-venous malformations or fistulae. Indications for these more extensive procedures should be documented in the plan of care.[5][6]
SURGICAL INTERVENTIONS FOR CHRONIC VENOUS DISEASE
Surgical interventions for CVD include interventions for superficial venous incompetence and interventions for deep venous pathology.
Interventions for Superficial Venous Incompetence
Interventions for superficial venous incompetence are indicated in the management of CVD in patients with reflux with provocative maneuvers in saphenous or perforator veins, defined as reflux lasting more than 0.5 seconds on DUS and absence of deep venous obstruction.[1][5][6]
In CVD patients with superficial venous incompetence, management strategies mainly depend on clinical presentation (history, symptoms, signs) and detailed individual DUS findings, which are all mandatory for proper decision making.[1]
Historically, superficial venous incompetence was treated with open surgical repair under general or regional anesthesia.[1] However, endovenous intervention, often performed in an ambulatory setting with tumescent anesthesia, is now the standard of care for superficial venous incompetence.[1] Initial endovenous interventions typically target larger incompetent superficial trunks and varicose tributaries, progressing to the treatment of smaller reticular veins and telangiectasias.[1][2]
Surgical Management for Superficial Venous Incompetence by CEAP Classification
Clinical practice guidelines recommendations for CVD patients with incompetent superficial veins are listed below.[1][2]
CEAP C1
- For patients with reticular veins and/or telangiectasias (CEAP clinical class C1) and/or varicose veins with mainly cosmetic concerns, intervention is not mandated.
- Treatment of C1 disease is considered medically reasonable and necessary for patients with spontaneous and/or traumatic venous hemorrhage.[5][6]
CEAP C2
- 1BFor patients with superficial venous incompetence presenting with symptomatic varicose veins (CEAP clinical class C2S), interventional treatment is recommended (Grade 1B).[1]
CEAP C3
- 2CFor patients with superficial venous incompetence presenting with edema (CEAP clinical class C3), other non-venous causes of edema should be considered before planning interventional treatment (Grade 2C).[1]
- For CVD patients with edema (CEAP clinical class C3) and no visible varicose veins, it is uncertain if they need treatment for superficial venous incompetence because the edema might have multiple causes unrelated to venous disease and may not respond to venous intervention. Other non-venous causes should be considered first.
- However, patients with symptomatic varicose veins and edema (CEAP clinical Class C2, 3S) are more likely to benefit from superficial venous intervention, which can reduce edema. Unilateral limb swelling generally predicts a better response to treatment than bilateral edema.[1][7]
- Coverage: To meet coverage eligibility, the Medicare Administrative Contractors (MACs) require that patients with C2 or C3 disease and VCSS <6 have a plan of care with documented conservative therapy (2 to 4 weeks, with exact duration depending on the insurance company or Medicare Administrative Contractor), including graduated compression 20-30 mmHg or greater, ambulation, elevation, and avoidance of prolonged sitting and standing.[5][6]
CEAP C4-C6
- 1CFor patients with superficial venous incompetence presenting with skin changes as a result of chronic venous disease (CEAP clinical class C4 - C6), interventional treatment of venous incompetence is recommended (Grade 1C).[1]
- Coverage: for CEAP C4-C6 patients, the mandatory conservative therapy prior to the invasive procedure may be waived by the MACs.[5][6]
Truncal Veins (Saphenous System)
Endovenous techniques are increasingly popular for treating saphenous vein incompetence, replacing classical surgery (i.e. high ligation and stripping or HLS) in many cases. Endovenous techniques can be classified as:
- Endovenous thermal ablation (EVTA) techniques, which include:
- Endovenous laser ablation (EVLA), also known as endovenous laser ablation therapy (EVLT)
- Radiofrequency ablation (RFA), also known as Endovenous Radiofrequency Ablation (ERFA)
- Nonthermal techniques, which include:
- Ultrasound-guided foam sclerotherapy (UGFS),
- Mechanochemical ablation (MOCA), and
- Cyanoacrylate adhesive closure (CAC)
Regarding choice of endovenous techniques, clinical practice guidelines recommendations are listed below.[1]
Great saphenous vein incompetence
- 1BFor patients with great saphenous vein incompetence requiring treatment, endovenous thermal ablation is recommended as first choice treatment, in preference to high ligation/stripping (HLS) and ultrasound guided foam sclerotherapy (Grade 1B).[2][1]
- When a nonthermal technique is preferred, non-thermal techniques may be considered (i.e. mechanochemical ablation, cyanoacrylate adhesive closure or catheter directed foam sclerotherapy).[1]
- For patients with large (>10 mm), nonaneurysmal saphenous veins, thermal ablation with EVLA or RFA should be performed rather than nonthermal ablation techniques.[2]
saphenous trunk incompetence
- For patients with saphenous trunk incompetence undergoing thermal ablation, the selection of the device should be left to the discretion of the treating physician.[1]
The sections below provide a summary of endovenous techniques.
Endovenous thermal ablation (EVTA)
- Endovenous thermal ablation (EVTA) techniques include:
- Endovenous laser ablation (EVLA), also known as endovenous laser ablation therapy (EVLT)
- Radiofrequency ablation (RFA), also known as Endovenous Radiofrequency Ablation (ERFA)
General Considerations for EVTA
- The thermal ablation techniques are appropriate for the primary treatment of the great saphenous vein and/or small saphenous vein, and incompetent accessory saphenous veins.[5][6]
- Requires tumescent liquid injection around the target vein.
- Performed under duplex ultrasound (DUS) guidance.
- A laser fiber or RFA catheter is inserted and advanced to the treatment site.
- Tumescent anesthesia is injected around the vein.
- The vein is emptied as much as possible before ablation.
- Energy is emitted intraluminally to cause permanent thermal damage to the vein wall.
Endovenous Laser Ablation (EVLA), also known as Endovenous Laser Ablation Therapy (EVLT)
- It is only a treatment option for sufficiently straight superficial vein segments that will allow passage of the device. The purpose of EVLA is to damage the endothelium of the vein resulting in fibrosis and occlusion of a vein segment to eliminate reflux.[5][6]
- Initially used bare tip laser fibers with low wavelengths (810-1064 nm).
- Higher wavelength lasers (1320-1940 nm) have been introduced, improving energy absorption by the venous wall and reducing post-operative pain and complications.
- Studies show higher wavelength lasers have comparable occlusion rates but fewer complications.
- Overall success rate of EVLA is 92%.[2][8]
- Recurrent reflux can occur in saphenofemoral junction tributaries and accessory veins, which can be mitigated by techniques like flush EVLA (fEVLA).
Radiofrequency Ablation (RFA), also known as Endovenous Radiofrequency Ablation (ERFA)
- Commonly uses segmental thermal ablation, heating vein segments at 120°C. Radiofrequency current is delivered resulting in heat destruction while an inflammatory response enhances wall destruction. The purpose of RFA is to damage the collagen of the vein wall resulting in fibrosis and occlusion of a vein segment to eliminate reflux. [5][6]
- Studies report high occlusion rates (92-97%) and low complication rates.[1][9]
Complications of EVTA
- Complications are rare with proper technique and ultrasound guidance.
- EVTA results in less pain, swelling, and quicker recovery compared to surgery.
- Low risk of venous thromboembolism (VTE) after EVTA.
- Endothermal heat-induced thrombosis (EHIT) is a specific complication.
- Other complications include superficial vein thrombosis (SVT), hyperpigmentation, paresthesia, hematoma, and thermal skin injury, which are rare with proper technique and higher wavelength lasers.
Long-term Follow-up of EVTA
- Several long-term RCTs comparing EVLA and/or RFA with HLS or UGFS have been published. A meta-analysis included three RCTs and 10 RCT follow-up studies.[10] Pooled anatomical success rate:
- EVLA: 88% (95% CI 82–92%)
- HLS: 83% (95% CI 72–90%)
- UGFS: 34% (95% CI 26–44%)
- Lower recurrence rate after EVLA compared to HLS (3.1% vs. 10%; OR 0.28 [95% CI 0.16–0.49] p < .001). [11]
- EVLA and RFA have similar safety, efficacy, post-operative pain scores, and recanalization rates. [12]
- Recanalization is the most common cause of recurrence after EVLA. [13]
Quality of Life (QoL) after EVTA
- Endovenous interventions result in equal or better QoL compared to HLS.
- EVLA and RFA have the same QoL at one and 12 months follow-up.
- QoL five years after treatment is better with EVLA compared to UGFS.
Choosing a Thermal Ablation Device
- Meta-analysis of 28 RCTs with EVLA showed no influence of different EVLA parameters on treatment efficacy. [14]
- No recommendation on the optimum device type can be made at this point, due to the absence of large, properly powered RCTs.
- Device choice is left to the discretion of the treating physician and may depend on local availability and experience.
Non-thermal ablation
Cyanoacrylate Glue Ablation (CAC)
- Description: Non-thermal, non-tumescent alternative to EVTA for occluding incompetent truncal superficial veins (not tributary veins).
- Mechanism: Cyanoacrylate solidifies via polymerization, causing an inflammatory reaction in the vein wall. This technique uses a proprietary adhesive for the treatment of refluxing saphenous veins.[5][6]
- Devices: At least three types available, differing in cyanoacrylate formulation and application techniques.
- Efficacy: Comparable to EVTA with cumulative occlusion rates up to three years.[1]
- Studies:
- WAVES study: 98% occlusion rate for SSV, AASV, and large GSV. [15]
- VeClose RCT: 94.4% occlusion for CAC vs. 91.9% for RFA at 36 months. [16]
- Other RCTs: Similar occlusion rates for CAC, EVLA, and RFA.
- QoL and Pain: Improved QoL and less pain during intervention compared to EVTA.
- Complications: Limited, with the most common being local inflammatory reactions (phlebitis), hypersensitivity reactions, DVT, hyperpigmentation, and nerve injury.
- Contraindications: Known hypersensitivity to acrylate.
Foam Sclerotherapy
- Description: Chemical endovenous ablation using sclerosing agents (POL or STS) in foam or liquid form.
- Efficacy: Foam is more effective than liquid; however, UGFS is less effective than EVLA, RFA, and surgery in long-term follow-up.
- Studies:
- RCTs show lower anatomical success rates for UGFS compared to EVLA and surgery.
- Higher occlusion rates with catheter-directed foam sclerotherapy (CDFS) compared to UGFS.
- Complications: Mild and transient, including hyperpigmentation, telangiectatic matting, SVT, and rare neurological events.
- Safety: Avoid intra-arterial injection.
Mechanochemical Ablation (MOCA)
- Description: Non-thermal, non-tumescent technique combining mechanical disruption of the intima with chemical ablation. This technique is appropriate for the treatment of truncal veins.[5][6]Valuable for ablation of distal parts of below-knee great saphenous vein or small saphenous vein.[1]
- Devices: At least two types available, using rotating wire or sharp hooks for vein wall scarification.
- Efficacy: Safe and effective, but lower occlusion rates compared to EVLA and RFA in some studies.
- Studies:
- RCTs show occlusion rates of 86.5% at three years. [17]
- Lower occlusion rates for larger pre-operative GSV diameters.
- QoL and Pain: Improved QoL; less pain during and after MOCA compared to RFA.
- Complications: Induration, SVT, hematoma, DVT, and hyperpigmentation; no reported nerve or skin injuries.
Nontruncal Veins (Varicosed Tributaries)
- 1BFor patients with CVD requiring treatment of varicose tributaries, ambulatory phlebectomy, ultrasound guided foam sclerotherapy or a combination of both are recommended by clinical practice guidelines (Grade 1B).[1][2]
Phlebectomies (STAB PHLEBECTOMIES)
- Description: performed under local anesthesia, this procedure involves placing multiple small (2-3 mm) longitudinal incisions over pre-operatively marked varicose veins (VVs). VVs are removed with phlebectomy hooks and fine-tipped mosquito clamps.
- Can be performed during the same endovenous ablation procedure. Typically adjunct to truncal ablation for large incompetent tributaries (> 5 mm diameter). Can be performed in isolation if truncal competence is confirmed on duplex ultrasound (DUS).
- Complications: generally infrequent and mild: blisters (5.4%), hyperpigmentation (4.6%), matting (3.6%), superficial vein thrombosis (SVT) (2.8%), deep vein thrombosis (DVT) (0.02%), dysesthesia (0.4%), lymphocele (0.2%), post-operative hemorrhage (0.1%), large hematoma (0.1%), infection (0.07%).[1]
Sclerotherapy of Tributaries
- Description: foam-based sclerotherapy is widely used for its effectiveness and reduced sclerosant volume. Liquid sclerotherapy is reserved for reticular veins and telangiectasias. Frequently used as an adjunct to endovenous truncal ablation or to treat residual varicose tributaries and non-saphenous VVs. Larger VVs targeted initially to encourage wider foam dispersal.
- Preference: choice between ambulatory phlebectomy or UGFS depends on physician’s experience and patient expectations. Ambulatory phlebectomy preferred for large, superficial, or visible tributaries; UGFS preferred for other cases. In patients with skin changes (CEAP clinical class C4b), UGFS is a valid alternative to avoid delayed wound healing from phlebectomies.
Perforating Veins
- 1CFor patients with varicose veins (CEAP class C2) who have significant, symptomatic axial reflux of the great or small saphenous vein, clinical practice guidelines recommend against treatment of incompetent perforating veins concomitant with initial ablation of the saphenous veins (Grade 1C).[2]
- 2CFor patients with varicose veins (CEAP class C2) who have significant, symptomatic axial reflux of the superficial truncal veins, clinical practice guidelines suggest against treatment of incompetent perforating veins concomitant with initial ablation of the superficial truncal veins (Grade 2C).[2]
- For patients with incompetent pathologic perforators associated with symptomatic residual, recurrent, and rarely primary varicosities, without associated saphenous incompetence, either open or endovascular techniques can be used to treat the perforator veins. [1][2]
- Treatment of perforating veins is controversial as they may act as a primary source of reflux or consequence of deteriorating venous function. In early stages of CVD (C2 – C3), perforating veins may act as re-entry points for superficial venous incompetence. Treatment of refluxing trunks and tributaries is usually sufficient in these cases.[1][2]
Reticular Veins and Telangiectasias
- In symptomatic CEAP Class C1 patients with bleeding or with severe symptoms of pain or burning due to moderate to severe telangiectasias or reticular veins, DUS evaluation may be performed to exclude associated venous incompetence; however, saphenous ablation for C1 disease without bleeding is rarely required.[2]
- 1CFor patients presenting with reticular veins and/or telangiectasias and associated incompetent veins, associated incompetent veins should be treated first, before considering treatment of smaller veins (Grade 1C).[1]
- 1BFor patients with symptomatic telangiectasias and reticular veins, clinical practice guidelines recommend sclerotherapy with liquid or foam (Grade 1B).[1][2]
- 2BFor patients with symptomatic telangiectasias or reticular veins, we suggest transcutaneous laser treatment if the patient has sclerosant allergy, needle phobia, sclerotherapy ,failure or small veins (<1 mm) with telangiectatic matting (Grade 2B).[1][2]
Sclerotherapy
- Description: sclerotherapy is the gold standard for treating reticular veins and telangiectasias. Sclerosing Agents include two major categories: Detergents (POL, STS) and Osmotics (hypertonic saline, hypertonic glucose)
- Effectiveness:
- Success rate: 95% after POL, 91% after STS.
- Sclerotherapy vs. Transcutaneous Laser (TCL):
- As effective as 1064 nm Nd:YAG TCL for reticular veins > 1 mm, but less painful.
- Lower efficacy of POL for telangiectasias < 1 mm compared to 1064 nm Nd:YAG (95% vs. 53%).
- Complications: mostly mild, including transient hyperpigmentation, neovascularisation, and injection site scar.
Transcutaneous lasers and intense pulse light sources
- Description: transcutaneous lasers (TLC) uses selective photothermolysis, to obliterate blood vessels while sparing surrounding tissues. The technique is based on proper energy delivery by selecting the wavelength, the pulse duration and providing sufficient radiant exposure to cause irreversible damage to the target structure. [18] Standard Vascular Lasers include pulsed dye lasers (PDL) (585 and 595 nm), potassium titanyl phosphate (KTP) lasers (532 nm), alexandrite lasers (755 nm), diode lasers (800 – 900 nm), and Nd:YAG lasers (1064 nm).
- Laser Choice for Treatment: depends on the size of the target vessel.
- Telangiectasias: Treated effectively with shorter wavelength lasers (< 600 nm) like KTP and PDL, and also with 1064 nm Nd:YAG laser.
- Reticular Veins: Efficaciously treated with longer wavelength lasers like Nd:YAG.
Postoperative care
Compression after intervention
- For patients undergoing thermal ablation for saphenous incompetence, with or without concomitant phlebectomy, clinical practice guidelines suggest postprocedure compression therapy for a minimum of 1 week for pain reduction.[2]
- Post-procedural compression therapy for patients with superficial venous incompetence undergoing ultrasound-guided foam sclerotherapy (UGFS) or endovenous thermal ablation (EVTA) remains controversial, with conflicting evidence regarding its benefits. However, it is widely used by surgeons to minimize inflammation, pain, bruising, bleeding, hematoma, and thrombosis. The duration of compression therapy is also debated, with recommendations ranging from 24 hours to two weeks. Overall, the decision on compression therapy and its duration should be individualized.[1]
- For patients with concomitant deep venous insufficiency, compression therapy after intervention for saphenous incompetence is beneficial. However, it should be administered with caution to avoid overloading the deep venous system. Treating the superficial venous system may exacerbate symptoms of deep venous insufficiency. Therefore, the recommended approach is to treat one system and then monitor the patient's response before proceeding further.
Follow-up and Surveillance
- For patients with superficial venous incompetence undergoing treatment of a saphenous trunk, duplex ultrasound surveillance should be considered 1 to 4 (one to four) weeks after the initial treatment (such as endovenous ablation or surgery) to ensure the intervention's success and check for post-operative deep vein thrombosis (DVT).[1]
- For patients undergoing endovenous thermal ablation (EVTA), follow up 5-7 days after the procedure is recommended to check for endothermal heat-induced thrombosis (EHIT).
- For those undergoing sequential treatments, interval DUS is conducted before the next treatment stage. Repeat DUS assessments are generally needed only if there is a suspected clinical recurrence.
- For patients with symptomatic reflux in the major superficial venous trunks and associated varicosities undergoing initial ablation alone, clinical practice guidelines recommend follow-up for >3 months to assess the need for staged phlebectomy or ultrasound- guided sclerotherapy for persistent or recurrent symptoms. Longer follow-up is recommended for those with recurrence or more advanced CEAP class.[2]
Sample Surgical Intervention Protocol
Table 2 shows a sample Surgical Intervention Protocol for Incompetent Truncal Vein, for reference. Of note, protocols/procedures need to be reviewed/approved by each individual facility prior to implementation.
Table 2. Sample Surgical Intervention Protocol for Incompetent Truncal Vein
Sample Surgical Intervention Protocol for Incompetent Truncal Vein
|
1. Initial Consultation - Patient Assessment:
- Conduct a thorough medical history and physical examination, with documentation of CEAP and VCSS.
- Discuss symptoms, previous treatments, and any relevant medical conditions.
- Ensure the surgical intervention is addressed and supported in the plan of care, for a 90 day episode of care, that includes a specific treatment plan determined by the assessment and evaluation of the lower extremity venous incompetence.[5][6]
2. Non invasive arterial studies to rule out peripheral arterial disease (PAD) 3. Venous Duplex Ultrasound (DUS): - Performed by a licensed qualified physician, OR a technician who is certified in vascular technology, OR in facilities with laboratories accredited in vascular technology.
- Preparation for DUS:
- No compression stockings on the day of the DUS.
- Ensure the patient is well-hydrated to maximize reflux detection, which can be decisive for borderline cases.
- Ensure surgical intervention is indicated, based on DUS results
4. Standard Care/Conservative management: - Advise on compression therapy, leg elevation, exercise, and weight management for the overweight and obese
- Recommend trial of compression therapy to meet insurance eligibility.
- If unsure about the required compression level, wait for DUS results.
5. Insurance Considerations: - Note that insurance may not cover compression therapy to be used during trial of compression therapy to meet surgical eligibility requirements.
- Every insurance company is different, therefore respective coverage eligibility requirements for surgical interventions should be verified. For CMS, to meet eligibility requirements for treatment of CVI of the lower extremities, each MAC may have different requirements (see MAC's local coverage determinations for "chronic venous insufficiency" or "varicose veins" in topic " Medicare Coverage Determinations for Wound Care")
6. Day of the Procedure - Pre-Procedure Preparation:
- Confirm clinical and insurance eligibility.
- Obtain informed consent, explaining the procedure, risks, and benefits.
- Perform surgical intervention for incompetent truncal vein
7. Post-Procedure Care - Immediate Post-Procedure:
- Monitor the patient for any immediate complications.
- Provide post-procedure instructions, including the use of compression stockings and activity restrictions.
- Follow-Up:
- Schedule a follow-up visit 5-7 days post-procedure to check for deep vein thrombosis (DVT) using ultrasound.
- Subsequent Treatments:
- Wait at least 1 month before addressing any associated tributaries. Note that certain insurance companies may require a 3-month wait and another DUS to confirm persistent tributary reflux.
8. Insurance-Specific Requirements: - Be aware that each insurance company has different requirements.
9. Long-Term Follow-Up - Ongoing Monitoring:
- Schedule regular follow-up visits to monitor for recurrence or complications.
- Adjust treatment plans based on patient progress and any new symptoms.
|
Case: Non-Healing Venous Leg Ulcer
Table 3 illustrates a case of a non-healing VLU successfully treated with surgical interventions.
Table 3. Case: Non-Healing Venous Leg Ulcer
Case: Non-Healing Venous Leg Ulcer
|
Patient Background - Condition: The patient presented to the vein clinic with a non-healing venous leg ulcer (VLU), which had been treated with compression therapy and local wound care for 2.5 years.
Clinical Presentation - Ulcer Location: Medial malleolus
- Ulcer Size: 2.5 cm x 3 cm
- Healing Status: Non-healing despite 2.5 years of treatment
- Diagnostic Procedure: Duplex Ultrasound (DUS)
- DUS Finding: The DUS revealed significant venous reflux in the great saphenous vein, with reflux duration exceeding 0.5 seconds. Deep venous obstruction was ruled out.
Eligibility - Eligibility for Endovenous Laser Therapy (EVLT): Based on the DUS results showing venous reflux, the patient was found eligible for EVLT.
Outcome - Time to Healing: Within a week post-EVLT, the patient's VLU healed.
Key Takeaway - Easy access to DUS results facilitated the timely implementation of appropriate interventions, significantly speeding up the healing process.
- This case highlights the importance of timely diagnostic procedures such as DUS in identifying suitable interventions like EVLT, which can lead to rapid healing of non-healing VLUs.
|
Interventions for Deep Venous Pathology
Suspicion of deep venous pathology warrants a referral to vascular surgery. This section provides a brief summary on surgical interventions for deep venous pathology.
Deep vein reflux and/or obstruction poses a significant burden on both patients and healthcare systems. Initial therapy should typically begin with non-invasive treatments, with compression therapy as the cornerstone. If there is no clinical improvement, invasive treatment options may be considered. An appropriate assessment, confirming clinically significant deep vein reflux and/or obstruction, is essential before initiating any treatment.[1]
The largest group of patients eligible for deep venous interventions are those suffering from post-thrombotic syndrome, which presents as a set of symptoms and signs of CVD, caused by impaired venous outflow due to deep venous obstruction and/or reflux following a DVT.[1]
Clinical practice guidelines are summarized below [1]:
Iliac vein outflow obstruction (proximal chronic total venous obstruction/severe stenosis)
- For patients with iliac vein outflow obstruction, management by a multidisciplinary team is recommended.
- 2CFor patients with iliac vein outflow obstruction without severe symptoms, neither endovascular nor surgical interventions are recommended (Grade 2C).
- 1CFor patients with iliac vein outflow obstruction and severe symptoms/signs, endovascular treatment should be considered, as the first choice treatment (Grade 1C). [1]
- 2CFor patients with iliac vein outflow obstruction suffering from a recalcitrant venous ulcer, severe post-thrombotic syndrome, or disabling venous claudication, surgical or hybrid deep venous reconstruction may be considered when endovascular options alone are not appropriate (Grade 2C).[1]
Deep venous incompetence of the lower limbs
- 2BFor patients with extensive axial deep venous incompetence and severe persistent symptoms and signs, where previous management has failed, surgical repair of valvular incompetence may be considered in specialized centers (Grade 2B).
Combined superficial and deep venous pathology
- 2CIn patients with chronic venous disease, caused by combined superficial and deep venous incompetence, treatment of incompetent superficial veins should be considered (Grade 2C).
Official reprint from WoundReference® woundreference.com ©2024 Wound Reference, Inc. All Rights Reserved
NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.
