Procedure Guides
Venous

Superficial Venous Insufficiency

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Procedure Guide

  • Chronic venous insufficiency with CEAP >C2/C3. Some suggest trial of conservative therapy first for insurance coverage

  • Significant post-thrombotic syndrome (PTS) with Villalta score >=10

  • VCSS >=8

  • Cosmetic - varicose veins, spider veins

  • For insurance coverage, need to document above with symptoms, complications, effect on ADLs, and prior trial of compression therapy (20-30 mmHg for 6 wks to 6 mo)

  • Hypercoagulable states

  • DVT with inability to support superficial venous occlusion

  • INR >1.7, Plts <50K, or uncorrected coagulopathy

  • Sciatic vein reflux

  • Target etiology if identifiable

    • Central venous obstruction -> recanalization and stenting prior to ablation

    • Muscle pump dysfunction -> exercise program

    • Reflux  -> (deep) valve reconstruction vs (superficial) ablation

  • Conservative therapy should be trialed first, e.g., exercise, compression stockings, wound care, Vasculera (diosimplex), pentoxifylline

    • 20-30 mmHg for C2-3, 30-40 mmHg for C4-6, 40-50 mmHg for recurrent ulcers. May not prevent PTS according to the SOX trial.

    • Often tried first but limited for advanced disease (>C3). 

    • Need to exclude PAD as the etiology prior to compression stockings.

    • Essential for long term success - improves 60-70% but 50% will have recurrence in 1 year

  • Some data suggests horse chestnut seed extract and aqua therapy may be helpful

  • Vein stripping is effective but inferior to RFA in 3 randomized trials in terms of postoperative pain, recovery, and QoL scores. *No longer considered the standard of care* 

  • Endovenous ablation has 90-100% anatomical success; or 75-88% long-term clinical success

    • Most recurrence occurs in first 6 mo and all within 12 mo, similar efficacy and complication rates to surgery but faster recovery

    • For advanced venous disease, 6 mo trial of elevation, compression, and wound care

    • Thermal, tumescent ablation (RFS, laser): well-established, good for large veins (>10-12 mm) but potential for nerve injury and more patient discomfort due to tumescent anesthesia

    • Non-thermal, non-tumescent: less data, likely good for smaller veins, treatment near the malleolus, advanced disease where tumescent is hard to place, potentially less procedure time and pain

      • Clarivein - mechanicochemical ablation, spins hockey stick damaging the endothelium and sprays sclerosant, has dedicated CPT codes. Less painful. Good closure rates.

      • VenaSeal - often 2-3 mL glue, puts out a little glue with external compression, has dedicated CPT code, can treat below the knee, but 20% have transient phlebitis (resolves in 1 mo)

      • Varithena - polidocanol endovenous microfoam (PEM), more uniform than homemade foam, can only use max of 15 mL per patient but comes in 90 mL cannister and has 30d shelf life. Can access GSV at level of the knee, inject antegrade, and occlude at the SFJ once the foam reaches there under US monitoring. Can then inject with GSV compressed superior to catheter to reflux retrograde below the knee.

  • Spider or reticular veins - can be treated next in same or subsequent visit as ablation with ambulatory phlebectomy, US-guided foam sclerotherapy, or surface laser treatment. AP superior/quicker cosmetic result for limited surface varices. Otherwise, USGFS is superior.

  • Detailed skin exam and venous treatment history. Need to assess for evidence of a more central process such as May Thurner or pelvic congestion syndrome, particularly in severe disease in patient without prior DVT.

  • Physical exam needs to be while STANDING or you will miss things

  • DUS w/ 7.5-13 MHz probe - carefully map out venous system, perforators, reflux, any thrombosis

    • “HML rule,” need to assess high (suprainguinal), medium (infrainguinal), and low (near/under venous ulcers)

  • Plan approach accordingly:

    • SVR alone: ablation is indicated and perforator reflux is likely to resolve on its own without direct treatment of the perforators

    • SVR + DVR: most common pattern after DVT, DVR and ulcers tend to improve with treatment of SVR alone, perforators often DO NOT resolve and may need to be treated directly, e.g., sclerosis

    • SVR + DVO: consider venography to determine whether venous drainage relies on superficial system

      • No reliance (deep venous collaterals present) -> ablate symptomatic superficial veins

      • Reliance on superficial veins -> consider localized therapy of perforators and varicose veins

    • Central obstruction: present in 37% of pts with CVI, treatment of CVO can improve venous symptoms (one study saw this in 91%), treatment of SVR can be done at same time and is often required (safe and effective, required in 82%)

  • Hold ASA, Plavix, and Coumadin 5d

  • Some give cefazolin pre-op continued 5d post-op for ambulatory phlebectomy (AP), Ativan, often no conscious sedation needed except for AP

Venous Ablation

  • Mark veins on skin with patient standing prior to lying flat as they often collapse. Need to treat the most central extent of superficial venous insufficiency first to prevent recurrence. Often one of the saphenous veins via ablation.

  • Elevate head of the bed to 15-30*. Document no DVT prior to starting.

  • (Thermal ablation only) Mix tumescent anesthetic - 50 mL 1% lidocaine, 440 mL NS, and 10 mL sodium bicarbonate OR 50 mL 1% lidocaine in 450 mL LR

  • Obtain venous access at distal site - often knee for GSV and mid-calf for SSV unless using something like VenaSeal where you can access the GSV below the knee

    • If skin changes/ulceration, consider retrograde approach to avoid causing additional wounds trying to access through diseases skin

    • Traditional approach requires a 7 Fr short access sheath through which a 5 Fr sheath/catheter is advanced to or just beyond proximal starting point followed by the laser or RF ablation catheter, respectively - *2 cm below the saphenofemoral or saphenopopliteal junction*.

  • Confirm starting point with ultrasound

  • (Thermal ablation only) Inject tumescent anesthetic from entry to proximal starting point.

    • Skin marked at 5-10 cm increments along the length of the catheter and anesthetized at the leading ends of the marks.

    • Some place patient in 10-15* Trendelenburg 

  • Perform ablation

    • Thermal ablation

      • GSV: 140 J/cm @ 810 nm for first 10 cm pulling back at 1mm/sec -> 100 J/cm until upper calf -> 70-84 J/cm for remaining calf

      • SSV: 100 J/cm for first 4 cm -> 70-84 J/cm for enxt 4 cm -> 56-70 J/cm for remaining

    • ClariVein - gradually pull back monitoring with ultrasound

    • VenaSeal

      • Position catheter ~5 cm from SFJ

      • Compress probe 2 cm from SFJ -> inject 3s, withdraw 1cm, inject 3s, withdraw 3cm -> 3min compression

      • For remainder of treatment - Inject 3s, withdraw 3cm, compress 30s -> repeat until 5 cm from access (others go right to access site)

  • Obtain hemostasis

  • If spider or reticular veins are present, these can be treated next in same or subsequent visit with ambulatory phlebectomy, US-guided foam sclerotherapy, or surface laser treatment. AP superior/quicker cosmetic result for limited surface varices. Otherwise, USGFS is superior. note that AP require moderate sedation.

Foam Sclerotherapy

  • Mark varicosities to be treated and assess with US

  • Mix sclerosant into foam, e.g., 1 mL 1% STS or polidocanol with 4 parts air

  • Access varicosity with 25-27G butterfly needle at 30* angle. Can use 30G and bend needle for telangiectasia

  • Inject sclerosant

    • Various types and concentrations available.

    • Adjust concentration for vessels size, e.g., for STS 0.1-0.3% for 0.2-1 mm vessel, 0.25% foam for 1-3 mm, 0.5-1% foam for 3-5 mm, and 2-3% foam for >5 mm. Too high of concentration for vessel size can increase the risk of necrosis and hyperpigmentation

  • Hold pressure 10 min with limb elevated

  • Assess/document lack of foam entering the deep veins at end of procedure

  • NOTE: if sclerosing perforators, some always goes into the deep system. Can have patient “pump the break” with foot for 10-15 sec to help clear out. Good for advanced disease with ulcers. Not clearly helpful in patients without ulceration. Can also sclerose tortuous veins at edge of ulcer for faster ulcer healing.

Ambulatory Phlebectomy (AP)

  • Tumescent anesthesia (e.g., 0.1% lidocaine with 25 mg epinephrine). Make tiny incisions near varicosities (5-20).

  • Dissect tissue with blunt microspatula

  • Capture varicosity with #2 Mueller hook or similar device and pull through incision

  • Repeat process centrally and peripheral gently pulling the vein back and forth to disrupt it as much as possible. Veins scarred to the dermis can be difficult to remove.

  • Close incisions with steri-strips (less is more not to cause skin blistering)

Transient (1-2wk) bruising, tight sensation like strained muscle, superficial phlebitis (can treat with NSAIDs), infection, local nerve injury (e.g. saphenous or sural nerves)

Endothermal Heat-Induced Thrombosis (EHIT): SFJ thrombus in ~4% (IF >50% into CFV, should treat). Other DVT in ~0.7%.

Laser fiber fracture, skin burns

Transient hypersensitivity phlebitis with cyanoacrylate (VenaSeal). Some believe Benadryl may help prevent.

  • One leg at a time, usually ablation -> sclerotherapy -> ablation -> sclerotherapy

  • Walk 15 min in office/treadmill prior to discharge

  • 20-30 mmHg compression stockings (Chap) 24/7 for 4 days then only during the day for 10 days (Not needed with VenaSeal)

  • Limit lifting to <20 lbs

  • 600 mg ibuprofen TID/QID for 5-7 days

  • 20-30 min walking TID/QID for 2 weeks (no vigorous exercise or prolonged immobility)

  • Follow up in 1-2 weeks with DUS at 1 wk vs mo to ensure venous closure and periodically after until treated superficial vein is no longer visible or only a scar

    • *Additional exam at 72 hrs if extension across the SPJ or SFJ