Saphenectomy or stripping has been the technique of choice for the treatment of varicose veins for almost a century. Classic varicose vein surgery had two objectives: to eliminate varicose veins and to correct venous hypertension, basing the procedure on two fundamental concepts: exeresis and radicality. However, in the mid-1990s, other objectives appeared, such as minimizing complications, reducing social and work-related sick leave and obtaining the best possible cosmetic result.
Today there are different techniques and modalities.
Endoablative techniques: the endolaser
Laser technology is used in medicine in many fields. Under the concept of selective photothermolysis, the laser emits a wavelength of light directed at the chromophore of the target tissue. The first generation of lasers used a wavelength of between 800 and 1000 nm, mostly directed at the hemoglobin chromophore, while the new ones have a wavelength of between 1300 and 1600 nm, and mainly target water chromophores and endothelial wall cells, causing injury to the vein wall.
Since the beginning of its use, laser technology has been involved in numerous controversies. In fact, the choice of wavelength is still a matter of debate. There is a clear tendency that lasers with longer wavelengths, as well as the use of fibers with radial wave emission have better results on the patient’s quality of life.
Endoablative techniques: radiofrequency
The use of radiofrequency for the treatment of superficial venous insufficiency has been known since 1998 in Switzerland. The first effect of radiofrequency is the concentration of collagen and subsequent denaturation of its matrix. Other factors intervene in the evolution towards fibrotic closure of the vessel, such as venous spasm, endothelial denudation and wall edema.
There are many studies that have compared radiofrequency with other techniques, initially with conventional surgery, and subsequently with endolaser. Radiofrequency and the 1470 endolaser are the most effective and least harmful modalities, offering very similar results.
Endoablative techniques: water vapor
The system of pulsed application of water vapor at 120 degrees Celsius to cause occlusion of insufficient saphenous shafts has been the latest thermal ablation technique to be incorporated. Although the procedure had been discussed for some years, it was characterized from the beginning by a scarce bibliographical support.
However, subsequent scientific evidence has shown one-year occlusion rates similar to other means.
Steam is a thermal ablation system that requires, or is recommended, the use of tumescent anesthesia, a local anesthetic technique that consists of the infusion of a large volume of a low-concentration solution of local anesthetic and adrenaline.
Although there are numerous enthusiastic publications regarding its efficacy, it has not reached the level of diffusion of other endovascular techniques. The system, devised in France, first appeared as an alternative to endolaser and radiofrequency for cases of tortuous and superficial saphenous shafts. The catheter is clearly thinner than the radiofrequency catheter, and allows navigation through non-rectilinear veins.
Endoablative techniques: echo-guided sclerotherapy
As early as 1939, McAusland injected air in the form of foam in patients with varicose veins for therapeutic purposes. However, sclerotherapy raises a host of questions: what sclerosant to use, at what concentration, how to prepare the foam, how to inject the foam, whether by withdrawal catheter or direct puncture? There are many questions without definitive answers.
In general, truncal sclerotherapy offers less local morbidity than thermal ablation in terms of nerve lesions, although it carries higher rates of thrombophleblitis and pigmentation. Although its results can be considered acceptable, it is the modality with the highest failure rates.
Endoablative techniques: mechanical-chemical ablation
Through a minimally invasive catheter with a double action on the one hand, mechanical, with a guide that rotates at 3500 rpm causing a spasm of the venous endothelium, and on the other hand, chemical, through the infusion of the sclerosing agent that induces fibrosis of the vein, eliminating the need to apply tumescent anesthesia.
Mechanical-chemical ablation has proven to be a safe and effective process in its initial studies.
But not everything is reduced to occlusion rates; Van Eekren’s study compares radiofrequency and mechanical-chemical ablation for patients with varicose veins, with favorable results for the MOCA system in terms of perioperative pain, improvement in quality of life and recovery of daily activity. In a multicenter study, Bootun also found advantages of the MOCA system over radiofrequency.
Endoablative techniques: adhesive sealing
Cyanoacrylate adhesive (Venaseal) has a long life in medical applications, especially in cerebral arteriovenous malformations. The adhesive properties of cyanoacrylate and its first medical applications date back to 1951. The derivatives used in medicine are the n-butyl esters, which provide strong and rigid bonds. Their application in chronic venous insufficiency has been achieved after planning some modifications, such as giving the glue greater flexibility to tolerate dynamic movement of the legs, rapid polymerization in contact with blood and tissues, and especially greater viscosity in order to eliminate the risk of embolization to the deep venous system and pulmonary circulation.
The procedure does not require tumescent anesthesia or postoperative elastic compression. Given that there is no need to use elastic compression stockings, this obviates one of the points where there is no consensus on the ideal postoperative compression therapy.
Analysis of the procedures in endoablative techniques
In an attempt to make a global and personal evaluation of each of the techniques, some parameters have been selected that could be grouped into different categories. However, a complete cost analysis has not been made, since it is difficult to include all the concepts, aspects such as the personnel necessary for the procedure, the time employed for each one, the location in an operating room or treatment room or the economic repercussion of the social and labor leave are difficult to quantify and compare.
The categories are:
- Literature support and scientific evidence: older techniques (EVLA and Radiofrequency) will have greater scientific support.
- Reproducibility: this section assesses whether the procedure is applicable to as many patients as possible. Thus, situations such as trying to avoid MOCA and sclerotherapy in large veins, thermal ablation in very thin patients, extrafascial veins, etc., must be taken into account.
- Simplicity: aspects such as the learning curve or the average time consumed per procedure are evaluated. In this case, radiofrequency would be the best. The Venaseal device consumes a little more average time. Sclerotherapy and endolaser have a certain variability factor, and the MOCA system requires a higher learning curve.
- Patient comfort: aspects such as treatment site, whether or not tumescent anesthesia or sedation is necessary, the pain generated by the procedure, etc. are important.
- Initial success: only occlusion rates are taken into account, where all procedures are very similar.
- Postoperative complications: pain, tombophlebitis, nerve damage… Radiofrequency seems to have shown superiority over laser, although the latest developments seem to outperform radiofrequency.
- Postoperative comfort: need for elastic containment, prohibition of sun exposure, risk of pigmentation… The Venaseal device brings advantages in this area.
- Medium-term success: occlusion rate, recanalization, need for re-treatment… Echo-guided sclerotherapy offers the worst results in this section.
- Direct cost: although this is an unrealistic section, since we only focus on the price of the devices and material required, the Venaseal device is expensive in comparison with the others, with sclerotherapy and endolaser being the most economical in terms of direct cost of the material.
- Glamour: fascination, seduction… In short, its capacity for diffusion is valued. In this case, lasers are the most popular, although radiofrequency and foam have gained ground in recent years.
Endoablative techniques, constant advances and a promising future
If endovascular techniques in the treatment of superficial venous insufficiency due to incompetence of saphenous shafts were already a great advance over conventional surgery or other open techniques, in concepts such as less aggressiveness and faster socio-labor recovery, they are evolving even more to eliminate cosmetic complications and side effects such as paresthesia and ecchymosis, in addition to avoiding the classic operating room as a place for the realization.
No paresthesia, no pigmentation, no operating room, no stockings… These are attractive aspects for patients.