In a fascinating exchange of views at this year’s VEITHsymposium, three experts on venous disease presented data on various treatments for varicose veins including; foam sclerotherapy, laser and open surgery. Dr John Bergan, Professor of Surgery, University of California, San Diego School of Medicine (La Jolla, CA), began by claiming foam sclerotherapy is the best choice: “It has ease and efficacy of treatment and follow-up, low procedure cost, and increased patient comfort.”
He stated that foam sclerotherapy provides the ultimate solution to these problems: it is non-invasive, requiring only local anesthetic and a short recovery time; it is already the therapy of choice for recurrent varicosities; and it does not have a high start-up or supply cost. “It is for these reasons that it can be expected that foam sclerotherapy will replace open surgery and the other minimally invasive techniques,” Bergan added,
Stripping the great saphenous vein is not without its limitations, Bergan noted. “Those who report results have not used the life table method which takes into consideration dropouts and early and mid-term failures.” He also raised other vital considerations, such as the initial and ongoing costs of equipment and disposables, reimbursement and procedure time, the availability of experienced ultrasound equipment operators, and the practitioner’s own level of expertise and comfort.
While agreeing that foam sclerotherapy is effective, Dr Jose I Almeida, Miami Vein Center and Voluntary Assistant Professor of Surgery at the University of Miami Miller School of Medicine, asserted that other therapies still have a vital place among varicose vein treatment options. “As a single modality, limitations do exist; common examples are saphenous veins greater than 12mm in diameter, perforating veins greater than 4mm in diameter and huge chronic varicosities on the skin surface. Foam sclerotherapy is inadequate for these conditions as a stand-alone treatment. When thermal ablation and phlebectomy are used in combination with foam therapy, most superficial venous problems can be treated successfully with a single treatment session,” Almeida said.
Almeida then went on to discuss the merits of using ultrasound mapping and laser therapy, most notably Laser Assisted Distal Stripping (LADS). This approach that directly treats the complex architecture of veins that run parallel to the great saphenous vein. Almeida and his team use LADS to deal with this specific anatomy. This hybrid technique combines ablation of the proximal thigh great saphenous vein using endovenous laser treatment (EVLT). EVLT works by heating the inside of the malfunctioning great saphenous vein at the point where it meets the superficial accessory saphenous vein by guiding a very thin fiber laser through an endovenous sheath. This painlessly seals the vein shut. The distal superficial accessory saphenous vein is then removed by invagination stripping.
“With the LADS procedure we remove a troublesome faulty vein adherent to the skin and obviate the problem of laser-induced-staining of the skin. It is simple and gives a satisfactory cosmetic result,” said Almeida. LADS enables patients to regain the smooth legs of their youth without suffering the invasive, painful procedures, risky anaesthetics or extended recoveries.
Finally, Dr Alun H Davies of the Imperial College at Charing Cross Hospital (London, UK), presented data on traditional open surgery vs. newer alternatives, and claimed that open surgery is still the superior ablation technique. He began by stating that the benefits of open surgery are well documented: “It is a well-studied procedure, having been performed for over a century; it is easy to teach to new doctors; and it is less expensive than newer procedures; and it generally needs to be performed only once,” he commented. Moreover, he added that general complications include deep vein thrombosis (0.15%), pulmonary embolus (0.06%), and wound complication, including infection (2.2%).
In direct contrast, he argued that alternative ablation treatments have only been in use for ten years, so there are few studies documenting long-term effects; they require more specialised training for new doctors; and the costly devices and training required keeps procedure costs high. Unlike open surgery, doctors cannot view the anatomy and must rely on ultrasound instead; as a result, follow-up sclerotherapy or phlebectomy is often required four to six weeks after the initial procedure.
General complications for radiofrequency ablation include bruising, burns, paraesthesia, clinical phlebitis, and slightly higher rates of deep vein thrombosis (0.57%) and pulmonary embolus (0.17%) than occur after open surgery. Endovenous laser ablation is associated with similar complications, including bruising (24%-100%), burns (4.8%), paraesthesia (1%-36.5%), and induration along the length of the saphenous vein (55%-100%). “The limited medical literature available for newer procedures also makes comparing recurrence rates difficult,” said Davies. “For traditional open surgery, recurrence rates have been tracked for as long as ten years, and range from 5%-60%.”
By contrast, the longest study of endovenous laser ablation available is only 39 months. Radiofrequency ablation is better documented; recent three-year study showed it had a significantly worse recurrence rate of 33% as compared to traditional open surgery, which showed a rate of only 23%. “These facts strongly suggest that newer endovascular procedures should be more thoroughly studied and compared with traditional open surgery, and that the best clinical practice is to empower patients with the information that they need to make a choice among them,” he commented.
“The jury remains out on the optimal way in which to treat patients presenting with primary venous incompetence; the endo-luminal techniques definitely have complications. The long-term recurrence rates have yet to be properly compared between the different modalities,” he added. “It is likely that all the modalities will have their own niche market and hence the physician treating patients with varicose veins needs to be able to either be able to offer all the potential modalities or be prepared to refer patients on to a physician who could offer that patient the optimal mode of treatment.”