From the Guidelines
The next best step in managing a patient with persistent left lower extremity venous reflux and symptoms despite conservative management is to consider endovenous ablation therapy, as recommended by the most recent and highest quality study 1. This minimally invasive procedure can be performed using either radiofrequency ablation (RFA) or endovenous laser treatment (EVLT), both of which effectively close the incompetent veins causing reflux. The procedure is typically performed under local anesthesia in an outpatient setting and takes approximately 45-60 minutes. Prior to the procedure, a detailed duplex ultrasound mapping should be performed to identify the specific veins requiring treatment, as suggested by 1 and 1. Post-procedure, patients should wear compression stockings (20-30 mmHg) for at least two weeks, maintain regular walking activity, and avoid prolonged standing. They may return to normal activities within 24-48 hours but should avoid strenuous exercise for 1-2 weeks. Endovenous ablation is recommended because it addresses the underlying pathophysiology by eliminating the abnormal retrograde flow in the affected veins, which conservative measures like compression therapy cannot correct, as noted in 1 and 1. This approach has a high technical success rate with significant symptom improvement and a lower complication rate compared to traditional surgical stripping. Key considerations for this procedure include:
- Patient selection: appropriate for patients with symptomatic varicose veins that do not respond to conservative management, as indicated by 1 and 1.
- Procedure technique: RFA or EVLT can be used, with the choice depending on the specific patient and vein characteristics, as discussed in 1 and 1.
- Post-procedure care: compression stockings, regular walking activity, and avoidance of prolonged standing are essential for optimal outcomes, as recommended by 1 and 1.
From the Research
Next Steps in Management
Given the patient's persistent left lower extremity venous reflux and symptoms despite conservative management, the next best step would be to consider endovenous ablation therapy.
- The patient has failed conservative management and continues to experience persistent swelling and pain, indicating the need for a more invasive approach.
- Endovenous ablation of the great saphenous vein (GSV) has been shown to be a safe and effective treatment for lower extremity varicose veins, with a high success rate in occluding the vein and improving symptoms 2.
- The patient's reflux is located at the level of the mid calf, which may involve the below-knee (BK) segment of the GSV. Studies have demonstrated that endovenous ablation of the BK-GSV can be performed safely with minimal complications 3.
- Factors associated with saphenous vein recanalization after endothermal ablation have been identified, including longer follow-up time and anatomic risk factors 4.
- Endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) have been compared to conventional surgery in the treatment of short saphenous varicose veins, with EVLA showing less frequent recanalization or persistence of reflux at six weeks and recurrence of reflux at one year 5.
- The clinical significance of below-knee GSV reflux following endovenous laser ablation of above-knee GSV has been assessed, with results indicating that persistent BK-GSV reflux may be responsible for residual symptoms and a greater need for sclerotherapy for residual varicosities 6.
Considerations for Endovenous Ablation
- The choice of endovenous ablation technique (e.g. EVLA or RFA) will depend on various factors, including the patient's anatomy, the extent of reflux, and the operator's preference.
- The patient should be informed of the potential risks and benefits of endovenous ablation, including the possibility of recanalization, nerve injury, and other complications.
- Post-procedure follow-up is essential to monitor for complications and assess the effectiveness of treatment.