Varicose veins are superficial veins in the subcutaneous tissue that become enlarged upon standing and are a common manifestation of underlying chronic venous disease. Chronic venous disease encompasses a spectrum, presenting as eczema, hyperpigmentation, telangiectasia, superficial thrombophlebitis, lipodermatosclerosis, atrophie blanche, and ulceration. Established risk factors include age, family history, obesity, and previous pregnancy. Other risk factors such as gender, smoking, history of injury to lower extremity and occupations that require prolonged standing, have not shown a strong or consistent correlation, and require further studies. Symptoms of chronic venous disease include leg heaviness, pedal swelling, and pain that can significantly diminish the quality of life.
The pathophysiology of venous disease is complex and poorly understood. What is known is that inflammation plays a central role in the development and progression of the disease. Mechanically, there is a hemodynamic dysfunction, such as hypertension, that causes valvular reflux resulting in hemostasis or blood pooling in lower extremities. This sets off a feed-forward cycle of venous wall remodeling and local inflammation. It is believed that high venous pressures cause shear stress, which is sensed by the endothelial cells. In response, growth factors such as vascular endothelial growth factor (VEGF), platelet-derived growth factor, and transforming growth factor-β1 (TGF-β1) are released and stimulate vascular smooth muscle cell proliferation. In addition, endothelial cells increase the production of adhesion molecules, which promote leukocyte attachment and transmigration. The result is a disruption of collagen homeostasis producing varicose veins, which are less elastic and unable to maintain structural conformation during high-pressure blood flow. Progression of the disease involves further VEGF and TGF-β1 mediated vascular remodeling with increased leukocyte infiltration. Ultimately, this pathology culminates in dermal changes and ulcer formation. Taken together, valvular reflux appears to be the critical factor that initiates the cascade of inflammatory cytokines disrupting collagen homeostasis resulting in structural changes to the venous wall.
Chronic venous disease is classified based on CEAP (clinical, etiologic, anatomic, and pathophysiologic) criteria:
Updated 2020 CEAP classification guidelines are as follows:
Etiologic classification is based on congenital (Ec), primary (Ep), secondary (Es), or unknown (En). Es is further differentiated into intravenous (Esi) or extra-venous (Ese). Combinations of etiologic states can coexist. Anatomic classification is differentiated based on the affected vein and laterality: superficial (As), perforator (Ap), deep (Ad), or unknown (An). Pathophysiology is defined by whether the cause is due to reflux (Pr), obstruction (Po), both (Pr,o), or neither (Pn).
Although there are many different approaches to treatment ranging from conservative (compression stockings) to invasive (vein stripping) for varicose veins depending on the severity of the disease, this article will focus on the use of endovenous laser ablation. The theory behind venous ablation is using heat to damage the vein wall, which causes fibrosis and collapse of the vein. LASER, which stands for “light amplification by stimulated emission of radiation,” is a device that focuses light energy. For endovenous laser ablation, a fiber optic laser is inserted into the vein and, when activated, will transmit light energy to the laser tip that is distributed radially by a prism and will heat the surrounding tissue. Heat injury to the vein wall will cause disruption to collagen, leading to fibrosis and collapse of the vessel. Tumescent anesthesia, which plays a critical role in this procedure, is given prior to ablation to decrease intravenous blood volume through venous compression, create a barrier between laser and surrounding tissue, and provide local anesthesia. The procedure can be performed outpatient and does not require general anesthesia. Advantages of endo-ablation include rapid recovery with return to work on average in 1 day and 96.7% of vein obliteration maintained at 3 and 5 years after the operation.
Commonly targetted/involved veins of the lower extremity include:
Patients with lower extremity venous disease should be evaluated with duplex ultrasound. Initial therapy for varicose veins in patients with CEAP classification of C3 or less is conservative with compression stockings for 3 to 6 months. However, there remains a need for a high-quality clinical trial comparing the efficacy of compression stockings. Failure of conservative therapy is an indication for interventional measures, including ablation with a radiofrequency catheter or endovenous laser, foam sclerotherapy, or venous stripping. Endovascular ablation is suitable for varicosities originating from the GSV or SSV.
One should proceed with caution in patients with post-thrombotic syndrome and venous reflux with superimposed arterial-venous fistula. Imaging to assess the patency of the deep veins is critical.
Medical providers range from vascular surgeons, pain physicians, interventional radiologists, and interventional cardiologists. Additional assistants may be helpful in utilizing ultrasound imaging and positioning.
All patients should have a pre-operative duplex ultrasound mapping of leg veins to identify the location of reflux, vein diameter, the velocity of reflux, and patency of vein. Reflux time greater than 500 milliseconds is considered abnormal. Ultrasound mapping can be used to reveal abnormal venous anatomy, the origin of venous varicosity, and perforating veins as well as to evaluate the deep venous system. This will help serve as a roadmap.
Thrombosis: Endovenous health-induced thrombosis occurs when thrombus extends from the ablated greater saphenous vein into the deep femoral vein. It is differentiated into four types: type 1 at the junction of a superficial and deep vein; type 2 located in deep vein with partial occlusion <50%; type 3 occlusion 50-99%; type 4 being complete occlusion. Incidence of endovenous health-induced thrombosis was found to be 1.4%, deep vein thrombosis 0.3%, and pulmonary embolus in 0.1% of cases.
Hematoma and ecchymoses: These are listed as complications of the procedure, but the impact on the patient is subjective depending on expectations. Furthermore, the use of higher wavelength lasers has been associated with decreased pain and ecchymoses due to better energy absorption by water and less by hemoglobin.
Skin burns: Ablating superficial veins close to the skin surface can cause full-thickness burns, but the frequency of complication significantly decreases to zero with better application of tumescent anesthesia. It can be treated with local wound care and monitoring for infection.
Nerve damage: GSV ablation can damage saphenous nerve causing transient cutaneous paresthesia in the medial leg. SSV ablation can damage sural nerve causing transient cutaneous paresthesia in the lateral foot. The majority of nerve injuries can be avoided with careful needle placement under ultrasound guidance and better tumescent anesthesia.
Recurrence: Meta-analysis showed that the five-year recurrence rate for laser ablation of GSV was found to be 36.6%, which is comparable to radiofrequency ablation and conventional surgery.
Varicose veins are caused by poorly functioning venous valves and decreased elasticity of the vein wall hindering flow and allowing the pooling of blood within the veins. These veins begin to pool and become engorged. Varicose veins affect up to 40% of adults and are more common in obese people and in multiparous women. Worsening varicose veins can present with pain and can contribute to decreased quality of life. Endovenous laser ablation is a minimally-invasive and well-tolerated procedure that can help to treat varicose veins and improve venous circulation.
Varicose veins arising from chronic venous disease is a highly prevalent disease that contributes to significant pain, debility, and quality of life reduction. Many patients will suffer from this disease and not seek treatment due to a lack of awareness. Educating the interprofessional team in the classification of chronic venous disease and indications for treatment can help motivate referrals for patients to seek treatment with a specialist, who can provide a plethora of options including endovascular ablation, which is a minimally invasive, same-day operation that has been proven to deliver consistent results with minimal complications. It is important to be aware that this is a chronic disease, and the procedure is by no means a cure. However, the physiologic and psychological benefit to the patient cannot be understated.
|||Matić M,Matić A,Gajinov Z,Golušin Z,Prćić S,Jeremić B, Major risk factors for chronic venous disease development in women: is childbirth among them? Women [PubMed PMID: 30907276]|
|||Lacroix P,Aboyans V,Preux PM,Houlès MB,Laskar M, Epidemiology of venous insufficiency in an occupational population. International angiology : a journal of the International Union of Angiology. 2003 Jun; [PubMed PMID: 12865883]|
|||Branisteanu DE,Feodor T,Baila S,Mitea IA,Vittos O, Impact of chronic venous disease on quality of life: Results of vein alarm study. Experimental and therapeutic medicine. 2019 Feb; [PubMed PMID: 30679979]|
|||Tisato V,Zauli G,Voltan R,Gianesini S,di Iasio MG,Volpi I,Fiorentini G,Zamboni P,Secchiero P, Endothelial cells obtained from patients affected by chronic venous disease exhibit a pro-inflammatory phenotype. PloS one. 2012; [PubMed PMID: 22737245]|
|||Tisato V,Zamboni P,Menegatti E,Gianesini S,Volpi I,Zauli G,Secchiero P, Endothelial PDGF-BB produced ex vivo correlates with relevant hemodynamic parameters in patients affected by chronic venous disease. Cytokine. 2013 Aug; [PubMed PMID: 23664275]|
|||Pocock ES,Alsaigh T,Mazor R,Schmid-Schönbein GW, Cellular and molecular basis of Venous insufficiency. Vascular cell. 2014; [PubMed PMID: 25520775]|
|||Mansilha A,Sousa J, Pathophysiological Mechanisms of Chronic Venous Disease and Implications for Venoactive Drug Therapy. International journal of molecular sciences. 2018 Jun 5; [PubMed PMID: 29874834]|
|||Porter JM,Moneta GL, Reporting standards in venous disease: an update. International Consensus Committee on Chronic Venous Disease. Journal of vascular surgery. 1995 Apr; [PubMed PMID: 7707568]|
|||Lurie F,Passman M,Meisner M,Dalsing M,Masuda E,Welch H,Bush RL,Blebea J,Carpentier PH,De Maeseneer M,Gasparis A,Labropoulos N,Marston WA,Rafetto J,Santiago F,Shortell C,Uhl JF,Urbanek T,van Rij A,Eklof B,Gloviczki P,Kistner R,Lawrence P,Moneta G,Padberg F,Perrin M,Wakefield T, The 2020 update of the CEAP classification system and reporting standards. Journal of vascular surgery. Venous and lymphatic disorders. 2020 May; [PubMed PMID: 32113854]|
|||Yamamoto T,Sakata M, Influence of fibers and wavelengths on the mechanism of action of endovenous laser ablation. Journal of vascular surgery. Venous and lymphatic disorders. 2014 Jan; [PubMed PMID: 26992971]|
|||Lawson JA,Gauw SA,van Vlijmen CJ,Pronk P,Gaastra MTW,Tangelder MJ,Mooij MC, Prospective comparative cohort study evaluating incompetent great saphenous vein closure using radiofrequency-powered segmental ablation or 1470-nm endovenous laser ablation with radial-tip fibers (Varico 2 study). Journal of vascular surgery. Venous and lymphatic disorders. 2018 Jan; [PubMed PMID: 29248107]|
|||Shingler S,Robertson L,Boghossian S,Stewart M, Compression stockings for the initial treatment of varicose veins in patients without venous ulceration. The Cochrane database of systematic reviews. 2013 Dec 9; [PubMed PMID: 24323411]|
|||Nandhra S,Wallace T,El-Sheikha J,Leung C,Carradice D,Chetter I, A Randomised Clinical Trial of Buffered Tumescent Local Anaesthesia During Endothermal Ablation for Superficial Venous Incompetence. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2018 Nov; [PubMed PMID: 30392525]|
|||Vuylsteke ME,Klitfod L,Mansilha A, Endovenous ablation. International angiology : a journal of the International Union of Angiology. 2019 Feb; [PubMed PMID: 30465420]|
|||Healy DA,Kimura S,Power D,Elhaj A,Abdeldaim Y,Cross KS,McGreal GT,Burke PE,Moloney T,Manning BJ,Kavanagh EG, A Systematic Review and Meta-analysis of Thrombotic Events Following Endovenous Thermal Ablation of the Great Saphenous Vein. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2018 Sep; [PubMed PMID: 29895399]|
|||Dexter D,Kabnick L,Berland T,Jacobowitz G,Lamparello P,Maldonado T,Mussa F,Rockman C,Sadek M,Giammaria LE,Adelman M, Complications of endovenous lasers. Phlebology. 2012 Mar; [PubMed PMID: 22312066]|
|||Kheirelseid EAH,Crowe G,Sehgal R,Liakopoulos D,Bela H,Mulkern E,McDonnell C,O'Donohoe M, Systematic review and meta-analysis of randomized controlled trials evaluating long-term outcomes of endovenous management of lower extremity varicose veins. Journal of vascular surgery. Venous and lymphatic disorders. 2018 Mar; [PubMed PMID: 29292115]|