From the Guidelines
For a patient with an incompetent great saphenous vein (GSV) with a diameter of 3.5mm and reflux time of 2.5 seconds, endovenous thermal ablation is the recommended first-line treatment. This recommendation is based on the most recent and highest quality study available, which suggests that endovenous thermal ablation has largely supplanted surgical ligation and stripping as the main invasive method to treat varicose veins with similar efficacy, improved early quality of life, and reduced hospital recovery 1.
The procedure can be performed using either radiofrequency ablation (RFA) or endovenous laser ablation (EVLA), both of which have high success rates and similar efficacy. The choice between RFA and EVLA may depend on various factors, including patient preference and physician expertise. However, a recent meta-analysis showed no statistically significant difference in long-term outcomes between RFA and EVLA or conventional surgery 1.
The procedure is typically performed under local anesthesia with tumescent solution (a mixture of lidocaine, epinephrine, sodium bicarbonate, and saline) injected around the vein to provide anesthesia, compress the vein, and protect surrounding tissues from thermal injury. Post-procedure, compression stockings (20-30 mmHg) should be worn for 1-2 weeks, and patients should be encouraged to ambulate immediately. Non-steroidal anti-inflammatory drugs like ibuprofen (400-600mg three times daily) can be used for pain management.
This recommendation is based on the significant reflux time (>0.5 seconds is considered pathological) and the moderate vein diameter, which makes it suitable for thermal ablation techniques. These minimally invasive procedures offer advantages over traditional surgical stripping, including faster recovery, less post-operative pain, and excellent cosmetic outcomes while effectively eliminating venous reflux and improving symptoms of chronic venous insufficiency. The most recent study available supports the use of endovenous thermal ablation as the first-line treatment for patients with symptomatic varicose veins and documented valvular reflux 1.
Some studies have reported conflicting data regarding procedural complications, with some showing higher rates of phlebitis, tightness, and dyspigmentation with EVLA, while others have found no significant difference in postprocedural complications between EVLA and high ligation and stripping 1. However, the overall evidence suggests that endovenous thermal ablation is a safe and effective treatment for patients with incompetent great saphenous veins.
Key points to consider when performing endovenous thermal ablation include:
- Patient selection: Patients with symptomatic varicose veins and documented valvular reflux are ideal candidates for endovenous thermal ablation.
- Procedure technique: The procedure should be performed under local anesthesia with tumescent solution injected around the vein to provide anesthesia and protect surrounding tissues.
- Post-procedure care: Compression stockings should be worn for 1-2 weeks, and patients should be encouraged to ambulate immediately.
- Pain management: Non-steroidal anti-inflammatory drugs like ibuprofen can be used for pain management.
Overall, endovenous thermal ablation is the recommended first-line treatment for patients with incompetent great saphenous veins, and it should be performed by experienced physicians using proper technique and post-procedure care to minimize complications and optimize outcomes 1.
From the Research
Patient Details
- Sapheno-femoral junction is patent and competent
- Great saphenous vein is patent and incompetent, diameter 3.5mm and reflux time 2.5sec
- Short saphenous vein is patent and competent
Recommended Treatment
- Endovenous ablation therapy (EVAT) is a suitable treatment option for incompetent great saphenous vein 2, 3
- The patient's great saphenous vein diameter of 3.5mm and reflux time of 2.5 seconds are within the treatable range for EVAT 2
- Combined endovenous laser treatment and ambulatory phlebectomy can be a safe and effective treatment modality for saphenous vein incompetence 4
Considerations
- The patient should be informed about the potential complications of EVAT, such as thrombus extension into the femoral vein 3
- Routine postoperative duplex scanning is recommended to monitor for potential complications 2, 3
- The patient's age and other comorbidities should be taken into account when considering treatment options 5, 6