The past two decades have seen a major revolution in the treatment of varicose veins and venous reflux — and we may be on the brink of the next big change. This is what Mark S Whiteley writes about Venous Newsin an overview of the developments that have taken place in this field since the advent of intravenous interventions introduced in the last 20 years, and the earlier techniques that made them possible.
In the 1890s, Friedrich Trendelenburg introduced the idea that visible varicose veins are caused by underlying tympanic valve dysfunction—and to treat it, he introduced the Trendelenburg ligation. Previously, treatments only targeted visible varicose veins. The next century showed little progress in the treatment of varicose veins, except for studies showing that stripping of the great saphenous vein was superior to ligation alone and that treatment of incompetent perforators helped heal venous leg ulcers. In contrast, the last 20 years or so has seen a tremendous increase in the advancement of treatments for varicose veins and venous reflux.
Although most people point to the introduction of endovenous surgery as the major turning point, all the new developments actually came from the development of dual-vein ultrasound in the mid-1980s and early 1990s. Only because this non- invasive imaging method that allowed us to see venous function in real time became widely available, our understanding of venous disease advanced.
The ability to recognize venous regurgitation, the different regurgitation patterns, the differences between passive (diastolic) regurgitation that everyone understands and active (systolic) regurgitation that many doctors struggle with, and the size of the target veins, has shaped many of new approaches to varicose veins. vein treatment. In addition, the identification of venous reflux in the varicose veins of the legs arising from the pelvic veins has revolutionized the idea that varicose veins can be considered a problem isolated to the lower extremity.
However, to think that everyone has come to the same conclusions since the advent of venous duplex ultrasound would be a mistake. While some have used the technique to improve understanding and therefore outcomes, most physicians use it simply to determine which apical vein they are going to treat, ignoring complex patterns, perforators, or pelvic venous reflux. It is not surprising that randomized trials of different treatment modalities are inconclusive if they focus only on treating incompetent apical veins and ignore the other causes of varicose veins.
The introduction of venous duplex ultrasound divided the venous world into two main factions. Unfortunately, many doctors who “do” varicose veins as a job and do not attend conferences or read about the subject, are unaware of this huge gap. In the English-speaking world, most doctors practice ablative surgery. Some are still attached and stripped, although most have now gone through some form of thermal ablation. Other non-thermal techniques Ablation techniques are widely used.
However, a large number of doctors are not aware of the hemodynamic approach to varicose veins and venous reflux, supported by the conservative hemodynamic method of venous insufficiency correction (CHIVA). Proponents of this approach, often called “saphenous surgery,” present series where results have been shown to be comparable to stripping. While those of us who treat all regurgitation routes view such outcomes as suboptimal, randomized studies performed where surgeons ignore venipuncture regurgitation and pelvic vein regurgitation seem to show that stripping is equivalent to thermal techniques. catalysis. Hence, the hemodynamic approach may begin to gain some traction.
The intravenous revolution
After venous duplex ultrasound, the biggest revolution in the treatment of varicose veins was the invention of successful intravenous thermal ablation. In the late 1990s, catheter-inhibited radiofrequency ablation and intravenous laser ablation proved successful, causing intravenous surgery to take off. Not only did these intravenous thermal techniques destroy the vein, but the catheters were inserted under ultrasound guidance into the peripheral vein and passed proximally, without the need for open groin surgery.
This minimally invasive approach allowed the development of anesthesia. With trunk removal and phlebectomies possible under anesthesia, true ambulatory “walk-in, walk-out” surgery has become possible for the treatment of varicose veins. More than a new vein treatment technique, this allowed for the creation of vein centers outside of hospitals, which could focus on ambulatory vein surgery.
In rapid succession, the treatment of incompetent perforators was developed in 2001 using the transluminal clusion of perforator (TRLOP) technique (reinvented in America in 2007 as percutaneous ablation of the perforator or PAPS), steam venipuncture and several different radiofrequency devices and laser became available for leg veins.
All of these thermal removal devices require lift-off due to the heat generated during processing. This has led to the investigation and development of ablation techniques that are non-thermal, and therefore non-swelling. In 1985, a patent was granted that allowed liquid sclerotherapy detergents to be mixed with gas to produce foam. This was then taken up by a British company that hopes to replace surgery with a chemical removal technique.
Although it has become clear over the past decade that foam sclerotherapy works well in small intramural veins, medium- and long-term results have been poor in apical veins, which are larger and have thicker walls. Therefore, although foam sclerotherapy is a basic technique that should be used by any physician providing venous treatments, it has been shown to have relatively poor results when used as a sole treatment modality.
To improve the results of sclerotherapy, the mechanochemical ablation intravenous catheter (MOCA, Clarivein) was developed to mechanically injure the vein wall and allow the sclerosant to penetrate deeper. Research has shown that this increases cell death within the vein wall, improving long-term clearance from foam sclerotherapy alone. Finally, in the non-thermal non-bulky area, cyanoacrylate glue is injected intravenously with good results in medium-term studies. This appears to use a different mechanism, as the vein wall is not removed in the same way as with the previously described techniques. However, patient satisfaction is high and clinical outcomes very good.
Pelvic venous reflux
Over the past decade, pelvic venous reflux and pelvic congestion syndrome have been increasingly recognized as part of the varicocele disease profile. Although we began investigating and treating this in 2000, it has been largely ignored by the venous community until more recently.
Paradoxically, many of the lessons learned in the 1990s about varicose veins of the legs need to be learned again in the veins of the pelvis. In the 1990s, doctors realized that examination of varicose veins with venography, especially in the supine position, is suboptimal compared with venous double-view ultrasound, where the patient is semi-upright or upright. However, many now use CT or MRI to examine the pelvic veins in a supine patient! With approximately 20% of female patients with leg varices having a significant contribution from pelvic vein reflux and 3% of men, it is now impossible to offer a full varicose vein service unless the pelvic veins are assessed and provision is made for treatment as part of the service.
So what does the future hold for varicose vein treatment?
New IV devices will undoubtedly appear. Indeed, I just had the first intravenous microwave treatment in Europe. This technique has all the advantages of intravenous laser and radiofrequency ablation, but without some of the disadvantages of both. However, it is still an intravenous thermal technique that requires agitation.
One of the most exciting new treatments for varicose veins and venous reflux is HIFU: high-intensity focused ultrasound. This new technique has only recently been presented at meetings, so only the beginnings and very early results are known. However, HIFU has been used in other clinical scenarios for non-invasive tissue removal and so the potential for success in veins is high.
By externally focusing ultrasound to cause ablation at a specific point that targets internally, HIFU is a truly non-invasive technique, a quantum leap forward from minimally invasive techniques. With the ability to externally target specific venous regions, those of us interested in vein research will be able to investigate whether ablation of all venous reflux is required, or whether a hemodynamic ‘CHIVA’ approach can be successfully used to target specific areas of venous reflux . By being able to use the same equipment to compare strategies, we should be able to determine the optimal way to treat veins: be it ablation, hemodynamics, or a combination of both.
Mark S Whiteley is a consultant vein surgeon, visiting professor at the University of Surrey in Guildford, UK, and founder of The Whiteley Clinicwith three centers in the UK
