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Endovenous Saphenous and Perforator Vein Ablation

Michael J. Singh, MD, and Cheryl Sura, LPN, RVT

enous insufficiency is a common disorder. Approximately 80 million people are affected; it is estimated that
30% of women and 10% to 20% of men have varicose veins.
Superficial varicosities are often caused by venous reflux because of failure of the valves in the saphenous vein and at the
saphenofemoral junction. This reflux increases superficial
venous pressure, which then leads to the development of
varicose veins. Transmission of pressure to the deep system
via incompetent perforators (or intrinsic deep reflux) leads to
classic venous insufficiency, which is manifested by ankle
edema, leg fatigue, aching, purities, stasis dermatitis, lipodermatosclerosis, or ulceration.
In a relatively short period of time, endovenous radiofrequency ablation has emerged as the standard of care for managing superficial and perforator vein reflux. For those who have
failed conservative treatment, endovenous ablation has been
shown to be an effective and efficient procedure for managing
venous insufficiency. Patients require minimal time for recovery
and pain is marked reduced when compared with traditional
surgical techniques offered for venous insufficiency. Endovenous laser ablation has similar success rates, but tends to
have a higher incidence of postoperative ecchymosis, thrombophlebitis, and pain that makes it a less attractive option.1-4

Radiofrequency ablation (RFA) is appropriate for virtually
any saphenous vein, although certain anatomic criteria must
be present. Most patients will have a Clinical Etiology Anatomy Pathophysiology classification score of 2 to 6.5 Obviously, the first requirement is that reflux exists in the saphenous vein. This is determined using duplex ultrasonography
with direct visualization of retrograde flow through incompetent valves in response to gravity, compression, or Valsalva
maneuver. Starting at the groin of the symptomatic leg, a
longitudinal view of the common femoral vein is obtained,
with blue assigned as antegrade venous flow. The patient
performs a valsalva maneuver and the color-flow and Doppler spectral changes are observed. The same steps are followed for the superficial femoral vein, saphenofemoral junction and both saphenous veins (greater and small).

Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY.

Address reprint requests to Michael J. Singh, MD, Division of Vascular Surgery, University of Rochester Medical Center, 601 Elmwood Avenue,
Rochester, NY 14642. E-mail: Michael_Singh@urmc.rochester.edu

1524-153X/08/$-see front matter 2008 Elsevier Inc. All rights reserved.


Finally, although not a medical requirement, most insurance companies will not provide coverage of venous procedures unless the patient has been compliant with a nonoperative treatment regimen for at least 3 months; this includes
the use of compression stockings, leg elevation, exercise,
weight loss, and anti-inflammatory medications.

Preoperative Evaluation
A preprocedure duplex ultrasound examination is initially
performed to document reflux in the system to be treated.
This is also required to determine whether the patient has the
proper anatomy for the procedure as discussed above; it
should assess patency of the entire lower extremity venous
system (deep, superficial, and perforator). Routine hematologic or other laboratory studies are not typically performed,
unless indicated by the health history (eg, anticoagulation
therapy would require checking an INR).

Procedure Technique
Endovenous procedures can be performed today in the office
setting, an outpatient surgical center, or operating room. In most
circumstances today, most procedures are performed in the office, in part because of insurance company incentives. Using an
oral anxiolytic combined with generous local tumescent anesthesia, patient comfort, safety, and acceptance are excellent.6-7
Patients are premedicated with two 5 mg doses of diazepam,
the first is administered 1 h before the procedure and the second
just before initiating the endovenous procedure. The patient is
placed in reverse Trendelenberg position (5-10), which dilates
the venous system and aids percutaneous access. The knee is
slightly flexed and externally rotated. After sterile preparation,
the greater saphenous vein (GSV) is marked, mapped, and measured with a portable ultrasound machine. A probe frequency of
7.5 MHZ or greater is beneficial during these procedures as a
shallow depth of field is helpful to optimize vessel resolution.
Areas of angulation, tortuosity, large branch vessels, and aneurismal dilation are marked on the skin overlying the vein. The
optimal access site is determined by ultrasound imaging and
often is below the level of the knee.
Percutaneous ultrasound guided access is obtained using a
micropuncture needle (Fig 1), and through a 7 Fr sheath the
radiofrequency ablation catheter (ClosureFast; VNUS Medical Technologies, San Jose, CA) is advanced to the saphenofemoral junction (SFJ) (Fig 2). In some cases, venous tortuousity or prior phlebitis may not permit catheter advancement.

M.J. Singh and C. Sura


Figure 1 Lidocaine (1%) is locally infiltrated at the chosen site. Percutaneous ultrasound guided access is obtained using
a micropuncture catheter system. Using B-mode imaging, the vein is centered on the transducer in a longitudinal plane
(parallel to the vein). The access needle is positioned bevel up at a 60 angle and the anterior wall of the vein penetrated.
A longitudinal image provides excellent visualization of the tissue planes and anterior vessel wall as the needled is
advanced. After access is obtained, the micropuncture system is exchanged for an 11-cm 7 Fr introducer sheath using
the modified Seldinger technique. Smaller veins and veins in spasm can be challenging. Access in these situations is aided by
the placement of an elastic tourniquet proximal to the access site. Alternatively, a small surgical cut down (3-4 mm) will
provide direct visualization of the vein and elevation with a blunt tipped stab phlebectomy hook utilized. v. vein.

These situations are handled by straightening the vein with

external compression using the skin stretch maneuver and
ultrasound imaging. Alternatively, an over-the-wire technique using a 0.018 or 0.025 angled hydrophilic guide wire
will aide the passage of the catheter. Longitudinal imaging
with the ultrasound probe will best define the location of the
epigastric vein and SFJ in relation to the catheter tip. The tip
of the catheter is drawn back and positioned 20 mm distal to
the SJF and distal to the superficial epigastric vein (Fig 3),
which is important to maintain flow through the SFJ after
saphenous closure.
Tumescent anesthesia, a large-volume, low-concentration
Lidocaine solution (0.10-0.25%) is commonly used for endovenous ablation. This is a combination of 50 mL 1% Lidocaine with epinephrine and 5 mL of sodium bicarbonate in
500 mL of 0.9% normal saline. The tumescent infiltration is

extremely important for procedural success: it compresses

the vein around the catheter for improved contact, increases
the distance from the skin to the vein to minimize (ideally
eliminate) thermal skin injury, and eliminates pain. Adequate
tumescent infiltration begins at the access site and extends
beyond the catheter tip. The 22-gauge spinal needle is positioned in the perivenous fascia and infiltration is guided by
ultrasound imaging. The goal is to circumferentially compress the vein within the perivascular compartment, thus
creating a halo around the catheter and vein. To protect the
skin, tumescent infiltration should separate the skin and
catheter by at least 10 mm.
The radiofrequency catheter tip position (20 mm distal
to the SFJ) is confirmed by ultrasound and direct pressure
along the course of the vein is applied. The procedure is
initiated as per recommended protocol. The catheter has a

Endovenous saphenous and perforator vein ablation


Figure 2 Percutaneous venous access is obtained at or below the level of the knee. The new 7 Fr radiofrequency ablation
catheter (ClosureFast; VNUS Medical Technologies) comes in two lengths (60 cm and 100 cm). The catheter length is
measured ex vivo and the catheter advanced to the saphenofemoral junction (SFJ). a. artery; v. vein.

7 cm long heater element that reaches 120C for 20 s at a

time; the tip is then drawn back at 6.5 cm increments and
the cycle repeated. At the completion of the procedure, a
final duplex scan is performed to confirm patency of the
epigastric vein, SFJ, and deep venous system. The rate of
immediate GSV occlusion at the SFJ is almost 100%; ultrasound imaging will show a thickened vein wall with
absence of a flow lumen.

Bilateral GSV ablation can easily be performed. Doubling the

amount of tumescent solution is necessary; this has been shown
to be safe at a concentration of 35 mg/kg. During bilateral VNUS
Closure procedures, percutaneous ultrasound guided GSV access is obtained in each leg before the catheter insertion. This
technique minimizes access problems in the contralateral leg
because of vasospasm. The more tortuous GSV is always ablated
first, which allows the use of the over-the-wire catheter advance-

M.J. Singh and C. Sura


Figure 3 Longitudinal imaging with the ultrasound probe will best define the location of the epigastric vein and SFJ in
relation to the catheter tip. The tip of the catheter is drawn back and positioned 20 mm distal to the SJF and distal to
the superficial epigastric vein, and the locking donuts are advanced to secure the catheter position. Preservation of the
SEV is of the utmost importance as it maintains flow through the SFJ after closing the GSV. a. artery; v. vein.

ment technique. Often the catheter lumen occludes during the

first Closure procedure that prevents use of the over-the-wire
technique during the second procedure.
Short saphenous vein (SSV) ablation is similar to that of the
greater saphenous vein. If performed simultaneously the GSV
is addressed first, followed by repositioning the patient in the
prone position. The SSV is marked, mapped, and measured.
Percutaneous access is obtained in the mid to distal calf and
the catheter inserted and positioned 20 mm below the saphenopopliteal junction. Tumescent anesthesia is infiltrated and
the procedure started. Follow-up imaging and instructions
are identical to the GSV ablation.
After the procedure, access site(s) are covered with a sterile
bandage and thigh high 20 to 30 mm Hg compression stockings applied and left in place for 24 h. A follow-up Duplex
scan is performed 3 to 5 days after the procedure to document absence of thrombus central to the SFJ or SPJ as appropriate.

Perforator Vein Ablation

The traditional surgical Linton procedure has been replaced
by subfascial endoscopic perforator surgery (SEPS, see article
by Iafrati MD in this issue) for treatment of incompetent
perforators, and in turn SEPS may be soon replaced by percutaneous perforator ablation. The current treatment method
is a modification of GSV radiofrequency ablation, and can be
performed as a stand-alone procedure or along with GSV
ablation (Fig 4). A completion duplex scan should be performed to confirm successful perforator closure and patency

of the deep venous system. RF perforator ablation can effectively treat incompetent perforator veins with minimal morbidity and a closure rate of 70% to 80%.8

Since its inception in 1998, it is estimated that over 250,000
radiofrequency ablation procedures have been performed. As
with many industry-driven technologic procedures, hard
data are somewhat lacking. Early trials demonstrated an unacceptably high rate of cutaneous skin burns, but this problem has largely been eliminated with the technique of tumescent anesthesia. An immediate closure rate of approximately
85% is commonly quoted, but long-term follow-up is poor.
When subjected to Kaplan-Meyer analysis, most failures (recanalization) occur within the first year or so, and long-term
outcome after this is generally satisfactory. There is some data
suggesting that endovenous laser therapy has a slightly better
closure rate than radiofrequency ablation, but these data are
derived using the first-generation RFA device. The secondgeneration device, ClosureFast (VNUS Medical Technologies), has shortened pullback times to approximately 3 min
and is associated with 100% closure at 6 months in preliminary studies.9-11

Endoluminal radiofrequency ablation has many advantages
over the traditional high ligation and stripping procedures. In
a short period of time, it has become a viable alternative and

Endovenous saphenous and perforator vein ablation


Figure 4 The leg is positioned and the perforator veins marked and mapped with ultrasound imaging; distance from the
medial malleous is documented to guide follow-up imaging. The leg is prepped and draped and the perforator vein
longitudinally visualized. Placing the transducer parallel to the perforator vein and using B-mode imaging improves
visualization and simplifies vessel access. One percentage Lidocaine is locally injected and a 12 gauge angiocath
inserted at a 60 angle. Intraluminal placement is confirmed by noting dimpling of the anterior vessel wall and
aspiration of blood. The RFS catheter is inserted and beaded catheter tip advanced to a subfascial segment of the
perforator vein. The final position of the tip should be 5 mm from the deep system, which reduces the incidence of deep
vein thrombosis. Catheter placement is confirmed and tumescent anesthesia locally administered. Direct pressure is
applied over the catheter and vein using the ultrasound probe. A four-quadrant closure technique at 85 degree Celsius
is used. To ensure adequate wall contact, the closure is performed over 4 min (1 min per quadrant). Impedance levels
should range from 150 to 350 Ohms; levels over 400 Ohms suggest extraluminal catheter placement. After the 4-min
cycle is complete, the catheter is pulled back 5 to 10 mm and a second 2-min treatment performed. v. vein.

possibly standard of care for the management of saphenous

vein insufficiency. This less invasive technique has been
shown to have a high technical success rate, low morbidity if
performed properly, and high patient satisfaction, and is very
successfully performed in an office setting.

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