Continuing Education Activity

Endovenous laser ablation is used in the treatment and management of varicose veins from chronic venous disease. The main indication for this treatment is disease that is refractory to conservative therapy with compression stockings. This activity reviews the treatment of varicose veins with endovenous laser therapy and highlights the role of the interprofessional team in the care of patients that undergo this procedure.

Objectives:

• Identify the indications of varicose vein endovenous laser therapy.
• Describe the technique involved in varicose vein endovenous laser therapy.
• Review the potential complications and clinical significance of varicose vein endovenous laser therapy.
• Outline interprofessional team strategies for improving care coordination and communication to enhance the care of patients that undergo varicose vein endovenous laser therapy and improve outcomes.

Introduction

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.[1] 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.[2] Symptoms of chronic venous disease include leg heaviness, pedal swelling, and pain that can significantly diminish the quality of life.[3]

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 the 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-beta 1 (TGF-beta 1) are released and stimulate vascular smooth muscle cell proliferation.[4][5] In addition, endothelial cells increase the production of adhesion molecules, which promote leukocyte attachment and transmigration.[6] 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-beta 1 mediated vascular remodeling with increased leukocyte infiltration. Ultimately, this pathology culminates in dermal changes and ulcer formation.[7] 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:[8]

Updated 2020 CEAP classification guidelines are as follows:

• C0: Without any visible or palpable signs of disease
• C1: Telangiectasia or reticular veins
• C2: Varicose veins
  • C2r: Recurrent varicose veins
• C3: Edema is present
• C4: Changes in skin and subcutaneous tissue
  • C4a: Pigmentation or eczema
  • C4b: Lipodermatosclerosis or atrophie blanche
  • C4c: Corona phlebectatica
• C5: Healed ulcers
• C6: Active ulcers
  • C6r: Recurrent active venous ulcer

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).[9]

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.[10] 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 in an outpatient setting 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 procedure.[11]

Anatomy and Physiology

Commonly targetted/involved veins of the lower extremity include:

• Greater saphenous vein (GSV)
• Small saphenous vein (SSV)
• Saphenofemoral junction (SFJ)
• Inferior epigastric vein (IEV)

Indications

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.[12] 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.

Contraindications

• Acute deep vein thrombosis
• Arterial insufficiency
• Acute skin infection at the site of entry
• Obstruction of the deep vein where the target vein serves as collateral
• Pregnancy

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.

Equipment

• Ultrasound (US) machine with probe cover
• Percutaneous venous access kit: lidocaine, a needle with syringe, guidewire, scalpel, dilator, and sutures
• Fiber-optic laser with appropriate eye protection and catheter sheath
• Tumescent anesthetic solution with injector pump. Maximum of 15 mg/kg of total lidocaine.[13]

Personnel

Medical providers that perform this procedure range from vascular surgeons, pain management clinicians, interventional radiologists, and interventional cardiologists. Additional assistants may be helpful in utilizing ultrasound imaging and positioning.

Preparation

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.

Technique or Treatment

1. Place the patient in prone, reverse Trendelenburg position and place monitors for EKG and pulse oximetry. Identify cannulation access site on the leg, usually below the knee. Prep with antiseptic
2. Drape patient and cover ultrasound probe with a sterile sheath
3. Gently sedate the patient.
4. Inject local 1% lidocaine superficial to the access site under US guidance. Access the vein with a needle. Thread the guidewire through the needle and advance to the saphenofemoral junction.
5. Remove the needle and replace it with a dilator. Using a scalpel, make an incision at the junction of guidewire and skin that allows the dilator to pass smoothly.
6. Replace dilator with catheter and advance to SFJ. Replace the guidewire with a laser fiber. Using the US in longitudinal view, advance the laser tip up until 2 cm distal to the SFJ, ensure that the IEV is visualized.
7. Place the patient in Trendelenburg position and inject tumescent anesthesia using an injection pump into the perivenous fascia beginning from the access site to SFJ. Typically, injections are spaced 3-5 cm apart.
8. Visualize under the US using transverse view the GSV with the catheter at the center surrounded by hypoechoic tumescent anesthesia. Activate the laser.
9. Withdraw fiber optic laser and catheter at a rate of 1-2 mm/s while confirming ablation with the US in the longitudinal view. Take care not to heavily compress the area superficial to the catheter.
10. Close percutaneous skin incision.
11. Return table to the neutral position. Monitor for any perioperative complications.[14]

Complications

Thrombosis: Endovenous health-induced thrombosis occurs when a 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 complete occlusion. Incidence of endovenous health-induced thrombosis was found to be 1.4%, deep vein thrombosis was 0.3%, and pulmonary embolus was in 0.1% of cases.[15]

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.[10]

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 the saphenous nerve causing transient cutaneous paresthesia in the medial leg. SSV ablation can damage the 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.[16]

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.[17]

Clinical Significance

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.

Enhancing Healthcare Team Outcomes

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 procedure 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 benefits to the patient cannot be understated.