Major advances have occurred in three respects:
- where the procedures are performed
- minimally invasive
- the risks and down-time associated with the procedures
Modern vein procedures are performed outside of the hospital, either in an office or ambulatory outpatient surgery setting. Incisions required are few and very small, and typically do not leave a lasting scar. General anesthesia is not required, but oral or intravenous sedation is an option. Short-term post-procedure discomfort is minimal, typically a bruisy soreness, and only requires over-the-counter as-needed oral analgesics and topical creams or salves. Patients require only a couple days after procedure for reduced, light activity, then can resume usual activities while wearing compression hose for 2 weeks to aid/speed healing.
This compares to the old way of vein stripping, requiring hospital operating room procedure with increased risk of general anesthesia, larger incisions that usually left visible scars, much post-operative discomfort, much higher risk of major complications, and a very lengthy recovery with delay returning to work (often out of work for 6 weeks).
EVLT: Endovenous Laser Treatment
Also referred to as EVLA (Endovenous Laser Ablation). This is one of the two cornerstone thermal ablation methods of modern vein treatment that replaced the vein stripping procedure. EVLT was invented in 2000, is FDA approved, and has been tweaked for the better through several generations of lasers. From the initial consult with necessary ultrasound, if a main trunk vein is diseased, it is usually amenable to laser heat destruction. The heat at the laser tip (intense light energy) is slowly withdrawn through the length of the bad trunk vein, destroying it on the inside. Numbing shots are required to avoid feeling the intense heat. The bad segment of trunk vein is not removed at all (in contrast to prior stripping), but becomes non-functional when thermally destroyed, and the body slowly reabsorbs it over several months.
Vein Treatment Informational Video:
RFA: Endovenous Radiofrequency Ablation
This technology was invented in 1999 to destroy a bad vein with intense heat delivered inside of the vein. It is the other of the two FDA-approved thermal technologies developed that replaced the vein stripping procedure. The technology has gone through several permutations for the better. RFA is most simply described as intense electrical heat, like uncoiling an element on a stove and putting it inside a vein and turning it on. The RFA heating coil reaches a temperature near 300 degrees Fahrenheit. Numbing shots are required to avoid feeling the intense heat. The same as laser, the treated vein is not removed, but is rendered ineffective by heat destruction and then the body slowly reabsorbs it over several months.
Also referred to as Chemical Ablation. Some veins are not amenable to EVLT or RFA. Ultrasound delineates whether a bad vein is amenable to laser or not. Sclerotherapy, often performed by ultrasound guidance, uses FDA approved chemicals (sclerosants). Rather than thermally ablating a diseased vein, injecting the sclerosant causes a chemical irritation that similarly induces scarring of the bad vein and eventual reabsorption of that vein by the body. Sclerotherapy is not quite as precise as laser or radiofrequency, but is a close second when needed. On occasion, repeat sclerotherapy is necessary to fully destroy a problem vein.
Microphlebectomy (a.k.a. Ambulatory Phlebectomy)
Also sometimes referred to as Stab Avulsion Phlebectomy. This is usually employed as the preferred method to eradicate diseased branch veins that are varicosed (diseased and lumpy on the surface due to a back-flowing trunk vein). The varicosed branch veins on the skin surface are numbed with a mild numbing agent, very small incisions are made, and with a hook device, the lump segments of the bad branch vein are actually removed. The very small incisions heal very quickly, rarely need a suture, and rarely leave a visible scar. This is different from a stripping since only small segments of the bad branch vein are removed, yet the end result is that the remaining segments of the bad branch die and are reabsorbed by the body over a few weeks-months.
The two newest advances that are alternatives to thermal (RFA and EVLT) ablation:
Mechano-Chemical Ablation (MOCA)
MOCA can be used in place of EVLT or RFA. It uses the typical sclerosants used in vein medicine combined with a patented endovenous device that is FDA approved. The device is inserted in to the bad trunk vein. The tip of the device is battery powered and spins at very high revolution to induce mechanical injury to the inner vein wall while simultaneously delivering the sclerosant to contact the injured vein wall via a small port at the tip of the device, while the device is slowly pulled back through the vein. 2 year published studies indicate a success rate at eradicating the bad trunk vein similar to EVLT and RFA. An advantage to this technique is most cases do not require using local numbing shots, therefore avoiding the pain of multiple needle sticks. As with the other endovenous ablation methods, the treated vein is not removed but scars and is slowly reabsorbed by the body.
The downsides of this technology are: 1) many medical insurance companies do not yet cover MOCA, and 2) we do not have 15+ year compelling success data as we do for the thermal ablation modalities. So, will MOCA hold up over the long-run in success rates compared to EVLT and RFA?
VenaSeal is the newest kid on the block for endovenous ablation that is FDA approved. It can be used in place of EVLT or RFA. VenaSeal involves placing a catheter in the bad trunk vein, then slowly delivering a patented cyanoacrylate (“superglue”) through the tip of the catheter while the catheter is slowly withdrawn through the vein. The glue causes the vein to close and eventually scar. 2 year published studies indicate a success rate at eradicating the bad trunk vein similar to EVLT and RFA. An advantage to this technique is only one numbing shot at catheter insertion site is needed.
The downsides of this technology are: 1) many medical insurance companies do not yet cover VenaSeal, and 2) we do not have 15+ year compelling success data as we do for the thermal ablation modalities. So, will VenaSeal hold up over the long-run in success rates compared to EVLT and RFA?