What is the role of cyanoacrylate in treating venous insufficiency?

Role of Cyanoacrylate in Treating Venous Insufficiency

Cyanoacrylate endovenous ablation (CAA) is an effective non-thermal, non-tumescent technique for treating venous insufficiency that offers comparable closure rates to thermal ablation methods with faster procedure times, less periprocedural pain, and no requirement for compression stockings. 1, 2

Mechanism and Efficacy

Cyanoacrylate works through a chemical adhesive mechanism that:

• Causes immediate closure of the treated vein through an adhesive reaction
• Does not require tumescent anesthesia (unlike thermal methods)
• Achieves high occlusion rates comparable to endovenous laser ablation (EVLA)
  • 12-month closure rates of 95.8-96.6% for CAA versus 92.2-94.1% for EVLA 1, 2

Advantages Over Thermal Ablation

Cyanoacrylate offers several benefits compared to radiofrequency ablation (RFA) and EVLA:

• Significantly shorter procedure time (13-15 minutes vs. 31-33 minutes) 1, 2
• Lower periprocedural pain scores 1, 2
• No requirement for compression stockings post-procedure 1
• Reduced rates of:
  • Ecchymosis (bruising)
  • Paresthesia
  • Enduration 1, 2

Patient Selection

While not specifically addressed in the current guidelines for cyanoacrylate 3, appropriate patient selection should consider:

• Patients with symptomatic venous insufficiency confirmed by duplex ultrasound
• Those seeking alternatives to thermal ablation methods
• Patients who may benefit from avoiding compression therapy
• Patients who prefer a procedure with less periprocedural pain

Potential Complications

Despite its advantages, cyanoacrylate is associated with specific complications:

• Phlebitis-like reactions (12% of patients)
• Induration (4.7%)
• Hyperpigmentation (1.3%)
• Rare but serious complications:
  • Deep vein thrombosis (DVT) (0.8%)
  • Pulmonary embolism
  • Abscess formation (1%)
  • Cellulitis (0.8%) 4

Position in Treatment Algorithm

While the American Venous Forum and other societies recommend endovenous thermal ablation (radiofrequency or laser) as first-line treatment for saphenous vein reflux 3, cyanoacrylate has emerged as an important alternative:

1. First-line options:

   • Endovenous thermal ablation (RFA or EVLA) 3
   • Cyanoacrylate ablation (as an alternative non-thermal option) 5

2. Adjunctive treatments:

   • Ultrasound-guided foam sclerotherapy for tributary veins 3
   • Microphlebectomy for visible varicosities 3

Technical Considerations

The American Vein and Lymphatic Society has provided guidance on cyanoacrylate use 5:

• Careful technique is essential to avoid deep venous extension of cyanoacrylate
• Proper positioning of the catheter tip at the saphenofemoral junction is critical
• Monitoring for potential deep vein thrombosis is recommended

Clinical Outcomes

Both cyanoacrylate and thermal ablation methods demonstrate:

• Significant improvements in Venous Clinical Severity Score (VCSS)
• Enhanced quality of life as measured by Aberdeen Varicose Vein Questionnaire
• No significant differences in clinical improvement between methods 1, 2

Practical Considerations

• Cyanoacrylate may be particularly beneficial for patients who:

  • Cannot tolerate compression therapy
  • Have concerns about post-procedure pain
  • Prefer faster procedure times
  • Want to avoid the discomfort of tumescent anesthesia

• Follow-up ultrasound is recommended to confirm successful closure and rule out complications 3