Superficial Venous Disease: A primer for the Interventional Radiologist

1. Review indications and contraindications for GSV ablation
2. Review existing management for chronic venous disease (CVD)
3. Review current devices for endovascular ablation

Background:

The number of CVD cases continues to increase, along with burden on national healthcare budgets. CVD consists of a variety of clinical conditions involving valvular insufficiency within the superficial veins in the lower extremities, often resulting in venous leg ulceration, skin changes, and varicose veins. CVD can be treated by either surgical, phlebectomy or endovascular techniques. Endovenous treatments are favored due to similar or more effective results, shorter recovery times, lower complication rates, better cosmetic results, reduced postoperative pain and lower recurrence rate.

Clinical Findings/Procedure Details:

Indications for phlebectomy or ablation include patients’ symptoms, as well as anatomic or pathophysiologic deformities. Anatomic changes include reflux time of > 0.5 seconds, shallow location of the vein, or vein diameter within 2-20 nm. Symptoms may include cramps, pruritis, ankle swelling, or leg heaviness. Contraindications include acute deep vein thrombosis, acute skin infection at entry site, arterial insufficiency, or pregnancy.

Ambulatory phlebectomy is used on larger veins bulging above the surface of the skin and involves removing segments of veins through small incisions of the skin. Local anesthesia is used for procedural pain management.

Laser and radiofrequency ablation (RFA) are types of thermal ablation and have been deemed gold standard for management. Both are known for immediate technical success, long-term efficacy, and minimal complications. Both involve using a catheter to generate heat to close off the vein, however their heat sources differ. RFA is used in the great and small saphenous veins. Laser is used in patients with large, symptomatic varicose veins, and is known to have slightly more bruising than RFA.

 
Non-thermal ablations include ClariVein, VenaSeal and Varithena devices. ClariVein uses a thin oscillating wire which releases a sclerosing medication that coats the vein wall. VenaSeal utilizes a medical glue to close the vein. Varithena utilizes an injectable microfoam that will close off the vein

Conclusion and/or Teaching Points:

There has been a robust evolution in CVD treatments. Endovascular treatments have provided patients with additional options with shorter recovery times and lower complication rate. Trainees should be familiar with lower extremity vascular anatomy, indications for interventions, and post-intervention clinical management.