Abstract
Objective
This study presents the efficacy of ultrasound-guided percutaneous laser ablation of tributary varicose veins using a slim-type radial 2-ring fiber.
Methods
One thousand consecutive patients who underwent endovenous laser ablation (EVLA) of incompetent saphenous veins were included. The tributary varicose veins were punctured with a 16G venule needle and ablated with a 1470 nm laser system and a slim-type radial 2-ring fiber with a diameter of 1.27 mm. The EVLA was performed with a power of 5W and linear endovenous energy density of around 30 J/cm.
Results
Percutaneous varicose ablation was safely performed in 939 legs with an average of 5.9 times punctures per leg. No skin burn or nerve injury was observed after varicose ablation. Ultrasonography revealed complete occlusion of the treated veins 1 month after EVLA.
Conclusions
This study suggests that percutaneous varicose ablation with a slim-type radial 2-ring fiber is a safe and effective alternative to cover the weak point of ambulatory phlebectomy.
Objective
Ambulatory phlebectomy is a standard procedure concomitantly used with endovenous laser ablation (EVLA) of incompetent saphenous veins. However, phlebectomy may cause surgical trauma and cosmetic problems after the procedure.1–4 Furthermore, it is not always available for patients with anticoagulation therapy or severe congestive dermatitis because of high surgical risks.
To overcome the weak points of phlebectomy, we recently started to treat tributary varices by EVLA.5–7 The present study introduces a novel approach to varicose vein treatment besides phlebectomy. The technique and clinical results are presented.
Patients and methods
Clinical data of 1000 patients.
Before EVLA, varicose veins are marked in a standing position (Figure 1). At first, the incompetent saphenous vein is treated. A 16G venule needle punctures a truncal vein with ultrasound (US) guidance. A fiber is inserted into the lumen and reaches the saphenofemoral or saphenopopliteal junction. TLA solution is infiltrated around the trunk, then the incompetent above-knee great saphenous veins (GSV), anterior accessory saphenous veins (AASV), or small saphenous veins (SSV) are ablated by the power of 7W and linear endovenous energy density (LEED) between 50 and 70 J/cm. If the below-knee GSV has reflux, it is ablated by the power of 5W and LEED between 20 and 25 J/cm. A: Preoperative marking and postoperative appearance of the leg at one month. B: Varicose veins were punctured in a prone position with a short-axis view of the ultrasound monitor to ensure the venous lumen and treated ablation six times.
Next, the tributary varicose veins are treated. A short-axis view of the US monitor is used to secure the venous lumen (Figure 2). The procedure of each step is shown in Figure 3. A 16G venule needle is bent before puncture, the target vein is accessed with a bent needle, the fiber is inserted into the lumen, TLA solution is infiltrated around the vein, and then laser ablation is performed by the power of 5W and LEED around 30 J/cm. This procedure is repeated one after the other. For the target size, varicose veins with a diameter of 3 mm and over are the subject of laser ablation. A bandage covers the leg for 1–2 days. After removing the dressing, a compression stocking is recommended for a month after EVLA. One month later, treated veins were examined by the US. A varicose vein is punctured with a short-axis view of the ultrasound monitor to ensure the venous lumen. The monitor shows a high echo signal of the 16G needle reflected in the center of the huge varicose lumen. a: First, a 16G venule needle is bent with fingers. b: A bent needle. c: A target vein is punctured with ultrasound guidance. d: The inner cylinder is removed. e: A fiber is inserted into the lumen. f: The outer cylinder is removed. g: TLA infiltration around the vein. h: Laser ablation starts.
Results
From January 2021 to the present, 1000 patients (1079 legs) underwent EVLA of the incompetent saphenous veins (Table 1). The treated trunk was 829 legs of GSV, 39 legs of AASV, and 211 legs of SSV. A total of 939 legs (87%) underwent concomitant varicose laser ablation. The ablation was repeated 1–32 times, an average of 5.9 times. As for the length of ablation, each puncture resulted in an average ablation length of 4 cm, and the total ablation length per leg averaged approximately 24 cm. Each 20–30 ml TLA was applied for one puncture site of varicose ablation. The total volume of TLA used in the EVLA averaged 494 ml. No patients underwent concomitant phlebectomy or sclerotherapy. The mean operation time was 26.4 min. All patients walked home within 30 min after the EVLA.
Postoperative complications such as nerve injury, skin burn, or thrombophlebitis were not observed in patients after varicose ablation. Figures 4–7 show the perioperative appearance of varicose veins. Skin pigmentation and scarring were less when compared to cases that underwent a traditional surgical method of stab avulsion phlebectomy as a historical control.5–7 One month after EVLA, the US revealed complete occlusion of the treated veins. Subdermal induration was noticed after varicose ablation in most patients. There was no pain, tenderness, redness, or signs of infection. The average diameter of the induration was 4.4 mm at 1 month. The indurations were gradually sized-down and disappeared 6–12 months after the EVLA. Recanalization has not been noticed in any patients after varicose ablation for an average 1 year observation period. The perioperative appearance of varices. After GSV ablation, varicose veins were treated six times with puncture and ablation. The perioperative appearance of varices. After GSV ablation, varicose veins were treated with puncture and ablation eight times. The perioperative appearance of varices. After GSV ablation, varicose veins were treated with puncture and ablation eleven times. The perioperative appearance of varices. After GSV ablation, varicose veins were treated with puncture and ablation nine times in a prone position.
Discussion
Ambulatory phlebectomy is a standard concomitant procedure of truncal EVLA. The technique is simple but may cause some adverse events such as bleeding, lymphatic injury, nerve damage, infection, and cosmetic disorder.1–4 In addition to causing complications, its clinical indication is limited. It is not always available for some patients with anticoagulation and severe skin diseases because of high surgical risks.
Several clinical trials of tributary varicose ablation have been attempted.8–10 However, the results of the previous studies were not satisfactory. Those were supposed because of old-fashioned techniques used with laser equipment and ablation fibers, resulting in a high incidence of complications and poor clinical performance.
In 2020, we started to use the present EVLA technique for varicose vein treatment and compared clinical outcomes with stab avulsion phlebectomy.4–7 We evaluated clinical parameters such as postoperative pain, bleeding, lymphatic injury, nerve damage, pigmentation, and scarring. The results showed that laser ablation was superior in all these aspects, and based on these findings, we discontinued phlebectomy in 2021.
Since a slim-type fiber with a diameter of 1.27 mm has been available, it becomes easy to smoothly access tributary veins by puncturing with a 16G venule needle. A short-axis view of the US monitor helps accurately puncture the venous lumen. Ensure the venous lumen is also helpful to avoid “extra”-venous laser ablation, which may cause nerve injury or skin burn. In addition, we can prevent thermal damage to the surrounding tissue by infiltrating the TLA solution around the vein. Varicose ablation is appropriately performed without any harmful events by setting low energy conditions of the power (5W) and LEED (30 J/cm).
In our daily practice, concomitant varicose treatment has been completely switched from phlebectomy to this type of varicose ablation because of fewer adverse events and excellent cosmetic results. Although the Japanese government’s health insurance system doesn’t cover the extra cost of concomitant varicose ablation, it is worthful for patients to have high-quality one-term treatment. For example, in the future, our EVLA technique for tributary varicose veins might be a feasible alternative to cover the weak point of ambulatory phlebectomy.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
