Annals of Vascular Surgery
Volume 23, Issue 2 , Pages 207-211, March 2009

Endovenous Lasering Versus Ambulatory Phlebectomy of Varicose Tributaries in Conjunction with Endovenous Laser Treatment of the Great or Small Saphenous Vein

Department of Thoracic and Cardiovascular Surgery, Guro Hospital, Korea University Medical Center, Seoul, South Korea

published online 05 August 2008.

Article Outline

Endovenous laser treatment (EVLT) is a widely used minimally invasive alternative to stripping of varicose veins involving the great and small saphenous veins. We expanded the applications to tributary varicosities and compared EVLT alone with combined EVLT and ambulatory phlebectomy. The study included 132 patients (76 males, 56 females) who were treated with EVLT and ambulatory phlebectomy. In addition, 133 patients (67 males, 66 females) were treated only with EVLT. Perforating vein reflux was identified in 65 patients in the combination group (49.2%) and in 121 patients (91.0%) in the EVLT only group (p=0.000). Postoperative complications and reoperation rates were compared between the two groups and the risk factors for reoperation analyzed. Ecchymosis (about 85%) and pain (>20%) were the major postoperative complications for both groups. There were no significant differences in the complications noted between the combination and EVLT only groups. During the follow-up period (25.6±12.8 months, range 15.5-37.3, in combination group; 11.8±8.2 months, range 1.3-18.5, in EVLT only group), residual tributary varicosities were noted in 12 patients (9.1%) in the combination group and in 11 (8.3%) in the EVLT only group (p=0.813). For patients who had reflux in the perforating veins, the reoperation rate was significantly higher compared to the patients without reflux in the perforating veins in each group (p=0.015 in combination group, p= 0.006 in EVLT only group). The presence of perforating reflux was a significant risk factor (odds ratio=3.938, 95% confidence interval 1.05-14.78, p=0.042). EVLT as the sole therapy for the management of combined saphenous and tributary varicose veins was found to be safe and effective. However, longer follow-up is needed for confirmation of these findings.

 

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Introduction 

For patients with symptomatic varicose veins and substantial venous incompetence, surgery has been the optimal treatment for many years. The common surgical approach has been ligation of the saphenofemoral or the saphenopopliteal junction, stripping of the great or small saphenous veins, and ambulatory phlebectomy.1 Endovenous laser treatment (EVLT) is relatively new; it is a minimally invasive alternative to the stripping of varicose veins involving the great and small saphenous veins. This new approach avoids a groin incision and may lead to less bruising and faster recovery. It can be done in the outpatient setting under local anesthesia.2 However, it is generally thought that tributary varicosities cannot be treated during EVLT, meaning that patients require follow-up treatment with ambulatory phlebectomy or sclerotherapy; and this is usually done 4-6 weeks later.3, 4 Sadick and Wasser5 recently reported that combined saphenous vein and multiple truncal varicose vein incompetence could be treated safely and effectively with a combination of EVLT for obliteration of the saphenous veins and simultaneous hook avulsion of all tributary varicosities.

In our hospital, combined EVLT and ambulatory phlebectomy was the routine procedure for varicose vein surgery. However, recently, we attempted a single EVLT approach that used only EVLT to obliterate great and small saphenous veins and correct tributary varicosities. In the present study, we compared the outcomes of the combined EVLT with ambulatory phlebectomy and single EVLT approaches to the treatment of varicose veins.

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Materials and Methods 

The study included 132 patients (76 males, 56 females, combination group) with varicose veins as documented by Duplex ultrasound. They were treated with EVLT (980nm Multidiode Endo™ Laser; Intermedic Arfran, Barcelona, Spain) of the incompetent segments of the great and/or small saphenous veins, followed by ambulatory phlebectomy of the remaining associated tributary varicosities between August 2003 and February 2005. Since then, we began to use a modified technique. There were 133 patients (67 males, 66 females) with varicose veins treated only with EVLT of the incompetent saphenous veins and branch varicosities between March 2005 and July 2006. All patients signed an informed consent form before undergoing the procedure. All patients had the procedure in one leg. Patients with a history of deep vein thrombosis, previous varicose vein surgery, or injection sclerotherapy on the same side of the leg were excluded. The study design was a retrospective review of the patients' medical records.

The mean age at the time of surgery was 50.7±10.45 years in the combination group and 54.3±8.91 in the EVLT only group (p=0.065). All patients had saphenofemoral junction reflux. Saphenopopliteal junction reflux was present in 30 patients (22.7%) in the combination group and in 32 patients (24.1%) in the EVLT only group (p=0.383). Perforating vein reflux was identified in 65 patients in the combination group (49.2%) and in 121 patients (91.0%) in the EVLT only group (p=0.000). The data indicated that there was a gradual increase in the severity of the varicosities at our hospital.

Two Doppler specialists evaluated the varicose veins and used the same protocol during this study. Color ultrasound mapping and marking of the affected varicosities were performed and recorded preoperatively. The patients selected anesthesia from the options of general, spinal, or local. After being placed in the reverse Trendelenburg position, access to the great or small saphenous vein was achieved at the ankle or just below the knee, by either needle puncture or a stab wound. A guidewire was introduced into the vein; it was maneuvered toward its junction with the deep vein under ultrasonographic guidance. A catheter was then introduced over the guidewire, which was then removed. Perivascular tumescent infiltration of local anesthetic along the length of the vein to be treated was performed to dissipate the heat generated during the procedure and reduce tissue damage. A diode laser fiber was inserted through the catheter to approximately 1-2cm below the saphenofemoral or saphenopopliteal junction; the position was confirmed by ultrasonography. Thermal laser energy (10W in continuous mode for great saphenous vein, 8W in continuous mode for small saphenous vein) was applied along the length of the vein by withdrawing the laser fiber in 3-5cm increments over time. Compression was applied to achieve vein wall apposition.6 In the combination group, all remaining tributary varicosities were removed utilizing toothed mosquito artery forceps or a Muller ambulatory phlebectomy hook. In the EVLT only group, several 18-gauge catheters were introduced percutaneously into the tributary varicosities and a diode laser fiber was inserted into these catheters (Seldinger technique). After perivascular tumescent infiltration, thermal laser energy (6-8W in continuous mode) was applied to all tributary varicosities under manual compression of the varicosities (Fig. 1). Graduated compression stockings were applied postoperatively, and the patients were instructed to resume normal activity other than heavy exercise immediately.

Statistical Analysis 

All statistical analyses were performed with SPSS version 12.0 (SPSS, Inc., Chicago, IL). The chi-squared test was used for comparison of proportions. Univariate analysis was performed with the chi-squared test and the independent sample t-test. Multivariate analysis was performed with the logistic regression test for risk factor analysis. Statistical significance was accepted at p<0.05.

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Results 

Two major procedure-related complications were identified (Table I).Mild ecchymosis was commonly noted at the EVLT-treated site and the phlebectomy-treated site (about 85% in each group). However, it was well tolerated by the patients and resolved spontaneously within 3 weeks. The second major side effect noted was a mild to moderate pain or paresthesia over the treatment site (>20% in each group). Some of the patients needed analgesics; however, no patient complained of pain or paresthesias at the last follow-up visit. Minor complications included edema, hyperpigmentation, skin burns, hematoma, and phlebitis. All patients except three with skin burns recovered spontaneously. The three patients with burns were in the EVLT only group; they required a long duration of wound care and finally underwent escharectomy successfully. There were no significant differences in the postoperative complications between the combination and the EVLT only groups.

Table I. Postoperative complications
Combination groupEVLT only groupp
Ecchymosis112 (84.8%)116 (87.2%)0.068
Pain/paresthesia33 (25.0%)28 (21.1%)0.076
Edema11 (8.3%)6 (4.5%)0.684
Hyperpigmentation5 (3.8%)4 (3.0%)0.752
Skin burn2 (1.5%)5 (3.8%)0.622
Hematoma2 (1.5%)0 (0%)0.247
Phlebitis2 (1.5%)3 (2.3%)0.622

During the follow-up period (25.6±12.8 months, range 15.5-37.3, in combination group; 11.8±8.2 months, range 1.3-18.5, in EVLT only group), follow-up duplex ultrasound did not identify reopening of the saphenofemoral or saphenopopliteal junction in either group. However, ultrasound scanning showed recurrent varicosities in 12 patients (9.1%) in the combination group and 11 patients (8.3%) in the EVLT only group (p=0.813) (Table II). For patients who had reflux of the perforating vein, the reoperation rate was significantly higher compared to patients who did not have reflux in the perforating vein, in both groups (p=0.015 in combination group, p=0.006 in EVLT only group). All patients with tributary varicosities underwent retreatment with percutaneous EVLT under local anesthesia 4-6 weeks after the initial procedure; all additional treatments were successful.

Table II. Reoperations according to the presence of perforating vein reflux in each group
Perforating vein refluxCombination groupEVLT only groupp
+9/65 (13.8%)11/121 (9.1%)0.175
-3/67 (4.5%)0/12 (0%)0.061
p0.0150.006
Total12/132 (9.1%)11/133 (8.3%)0.813

The factors associated with the risk for retreatment are shown in Table III. There were no variables identified that showed a statistically significant univariate association with retreatment, using the chi-squared and independent t tests. However, in the multivariate analysis with logistic regression, the presence of perforating reflux was a significant risk factor (odds ratio=3.938, 95% confidence interval 1.05-14.78, p=0.042), with an approximately fourfold increase in risk for retreatment.

Table III. Risk factor analysis for retreatment
UnivariateMultivariate
pOdds ratiop95% CI
Gender0.5371.2990.5570.540-3.106
Age0.6431.0090.6860.97-1.06
Group0.8131.8010.2160.71-4.57
SPR0.3411.5860.3260.63-3.98
Perforating reflux0.0663.9380.0421.05-14.78

CI, confidence interval; SPR, saphenopopliteal reflux.

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Discussion 

Because ambulatory phlebectomy is an economical, safe, and effective surgical procedure, assuring definitive extraction of all types of varicose and perforating veins of the legs,7 it can be effectively used for treating remnant tributary varicosities after EVLT.

However, it can be—and is argued—that complete eradication of all varicose veins at the initial operation is the preferred treatment method. Many studies2, 8, 9, 10 have shown that eliminating the source of the venous reflux can be effective in relieving patients of the symptoms of varicose veins, and further treatment can be deferred in many patients.

However, historically, the complete extirpation of visible varicose veins has been a fundamental tenet in the optimal treatment of varicose veins arising from great or small saphenous vein insufficiency. Actually, many practitioners routinely perform stab phlebectomy of branch varicose veins in conjunction with endovenous ablation.11, 12, 13, 14 In addition, Sadick and Wasser5 recently reported that very low recurrence rates were noted with combination EVLT with ambulatory phlebectomy (0% at 4 years, 3.4% at 3 years, 3.6% at 2 years, and 5.9% at 1 year).

In our hospital, combined EVLT with ambulatory phlebectomy had been the routine procedure for varicose vein surgery for the past 18 months. However, phlebectomy requires multiple stab wounds and is associated with complications such as matting, lymphatic pseudocysts, dysesthesia, hematoma, wound infection, keloid, traumatic neuroma, localized superficial thrombophlebitis, and telangiectasia.15, 16, 17, 18

Since February 2005, we have modified our practice of repair for tributary varicosities by performing the EVLT using a small catheter. When this method was introduced, the procedure was confined to the remaining tributary varicosities that were small and had competent perforating veins in primary and reoperative varicose surgery cases. As our experience increased, the combined procedure was gradually replaced by this new technique. Currently, this technique is being used for all varicose vein surgeries. This procedure is a technically simple one, with reduced scarring compared to ambulatory phlebectomy. However, it does not focus on the perforating veins but, rather, the superficial tributary varicosities. Therefore, EVLT as the sole method may have some limitation in treating the tributary varicosities which are connected to the incompetent perforating vein.

Blomgren et al.19 reported that surgical correction of a main stem saphenous vein reflux has profound effects on the venous hemodynamics of the leg. In particular, surgery for primary varicose veins was found to result in competence of the perforating veins without perforator interruption when the total venous overload of the leg was reduced. However, this beneficial effect of surgery was partly counteracted by the formation of new incompetent vessels at the surgically obliterated sites and the progression of venous disease in previously normal vessels. These recurrences, without improved knowledge of their etiology, cannot be prevented, even with improved surgical techniques. Therefore, Blomgren et al.19 insisted that specific surgery for perforators which can cause to deep vein thrombosis can be omitted in most patients at the primary surgery and that one possible indication for perforator surgery is the prevention of recurrence.

In the present study, although the EVLT only procedure did not treat the incompetent perforating vein, there was no statistical difference between the two groups in the rates of reoperation. The only risk factor identified for reoperation was the presence of perforating vein reflux. Therefore, a meticulous operative technique is required when perforating vein reflux exists.

All patients who needed reoperation, due to recurrent tributary varicosities, were treated by EVLT using a small catheter in both study groups. No other methods were used, such as sclerotherapy, subfacial endoscopic perforator surgery, and ambulatory phlebectomy. The technical problems encountered were caused by marked tortuosity and dilation of the tributary varicosities. This made it impossible to advance the laser fiber in one individual at the originally intended puncture site, necessitating multiple secondary intravascular access points. Therefore, careful attention and a great deal of experience are necessary to prevent procedure-related complications, such as ecchymosis and skin burns, during the modified procedure.

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Conclusion 

Laser ablation appears to have been as effective as ambulatory phlebectomy in eliminating superficial tributary varicosities, at short-tem follow-up, when used in conjunction with EVLT of the great or small saphenous vein, although this study had a limitation of time difference between the two procedures. Need for retreatment of residual or newly appearing superficial varicosities was significantly associated with persistence of perforator vein incompetence. A longer follow-up study should be performed.

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This study was supported by a Korea University Grant.

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References 

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 Presented at the 35th Annual Symposium of the Society for Clinical Vascular Surgery, Orando, FL, March 21-24, 2007.

PII: S0890-5096(08)00205-7

doi:10.1016/j.avsg.2008.05.014

Annals of Vascular Surgery
Volume 23, Issue 2 , Pages 207-211, March 2009

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