Venous Insufficiency/Varicose Veins

Millions of American's suffer from Varicose Veins. Risk factors for varicose veins are obesity, prolonged sitting or standing, increasing age, female sex, family history, and pregnancy.

Varicose veins can become problematic if left untreated. They typically cause lower extremities to swell, ache, burn, or tingling depending on the severity of the venous insufficiency. They give the lower extremities a sensation of heaviness. If severe and untreated, they can lead to pooling of blood, ulceration, and phlebitis.

Symptoms of Varicose Vein Insufficiency

Any surgical treatment for varicose veins requires, at a minimum, that the patient is symptomatic with one or more of the following symptoms:

1. Persistent aching, cramping, burning, itching, swelling, or other symptoms significantly interfering with activities of daily living;

2. Significant and or recurrent episodes of superficial phlebitis;

3. Bleeding from a varicosity;

4. Refractory dependent edema;

5. Ulceration from venous stasis;

6. Stasis dermatitis and its variations (e.g., lipodermatosclerosis). The etiology of varicose veins is due to incompetent one way valve in the venous system.

Etiology

The venous system of the lower extremities consists of the superficial veins (this includes the great and small saphenous and accessory, or duplicate, veins that travel in parallel with the great and small saphenous veins), the deep system (popliteal and femoral veins), and perforator veins that cross through the fascia and connect the deep and superficial systems. One-way valves are present within all veins to direct the return of blood up the lower limb. Because venous pressure in the deep system is generally greater than that of the superficial system, valve incompetence at any level may lead to backflow (venous reflux) with pooling of blood in superficial veins. Varicose veins with visible varicosities may be the only sign of venous reflux, although itching, heaviness, tension, and pain may also occur. Chronic venous insufficiency secondary to venous reflux can lead to thrombophlebitis, leg ulcerations, and hemorrhage. The CEAP classification considers the clinical, etiologic, anatomic, and pathologic (CEAP) characteristics of venous insufficiency, ranging from class 0 (no
visible sign of disease) to class 6 (active ulceration).

Treatment

Treatment of venous reflux/venous insufficiency is aimed at reducing abnormal pressure transmission from the deep to the superficial veins. Conservative medical treatment consists of elevation of the extremities, graded compression, and wound care when indicated. Conventional surgical treatment consists of identifying and correcting the site of reflux by ligation of the incompetent junction followed by stripping of the vein to redirect venous flow through veins with intact valves. While most venous reflux is secondary to incompetent valves at the saphenofemoral or saphenopopliteal junctions, reflux may also occur at incompetent valves in the perforator veins or in the deep venous system. The competence of any single valve is not static and may be pressure-dependent. For example, accessory saphenous veins may have independent saphenofemoral or
saphenopopliteal junctions that become incompetent when the great or small saphenous veins are eliminated and blood flow is diverted through the
accessory veins.

Thermal Ablation (eg: Closurefast)

RFA is performed by means of a specially designed catheter inserted through a small incision in the distal medial thigh to within 1 to 2 centimeter of the saphenofemoral junction. The catheter is slowly withdrawn, closing the vein. Laser ablation is performed similarly; a laser fiber is introduced into the great saphenous vein under ultrasound guidance; the laser is activated and slowly removed along the course of the saphenous vein. Cryoablation uses extreme cold to cause injury to the vessel. The objective of endovenous techniques is to cause injury to the vessel, causing retraction and subsequent fibrotic occlusion of the vein. Technical developments since thermal ablation procedures were initially introduced include the use of perivenous tumescent anesthesia, which allows successful treatment of veins larger than 12 millimeters in diameter and helps to protect adjacent tissue from thermal damage during treatment of the small saphenous vein.

Cyanoacrylate Adhesive (e.g., VenaSeal®)

Cyanoacrylate adhesive is a clear, free-flowing liquid that polymerizes in the vessel via an anionic mechanism (i.e., polymerizes into a solid material on contact with body fluids or tissue). The adhesive is gradually injected along the length of the vein in conjunction with ultrasound and manual compression. The acute coaptation halts blood flow through the vein until the implanted adhesive becomes fibrotically encapsulated and establishes chronic occlusion of the treated vein. Cyanoacrylate glue has been used as a surgical adhesive and sealant for a variety of indications, including gastrointestinal bleeding, embolization of brain arteriovenous malformations, and to seal surgical incisions or other skin wounds.