What about non-thermal closure methods, such as Venaseal, for treating varicose veins?

Non-Thermal Closure with VenaSeal for Varicose Veins

VenaSeal (cyanoacrylate glue) is an effective non-thermal, non-tumescent endovenous closure technique for treating symptomatic varicose veins, with comparable efficacy to thermal ablation methods but with increased patient comfort and no need for tumescent anesthesia. 1, 2

Treatment Algorithm for Varicose Veins

• First-line treatment for symptomatic varicose veins with documented valvular reflux is endovenous thermal ablation (radiofrequency or laser) 3, 1
• Second-line treatment is sclerotherapy, particularly for small to medium-sized veins (1-5 mm) 4
• Third-line treatment is surgery, according to clinical guidelines 4
• Non-thermal closure methods like VenaSeal can be considered as an alternative to thermal ablation, particularly for patients who cannot tolerate tumescent anesthesia or where thermal damage to surrounding structures is a concern 1, 2

VenaSeal (Cyanoacrylate Glue) Closure

Mechanism and Procedure

• VenaSeal uses n-butyl-2-cyanoacrylate (NBCA) glue, which is injected into the vein under ultrasound guidance, causing inflammation of the endothelium, resulting in fibrosis and occlusion of the vein 2, 5
• The procedure is non-thermal and non-tumescent, eliminating the need for tumescent anesthesia and reducing the risk of thermal damage to surrounding tissues 2, 6
• The procedure can be readily performed under local anesthesia only, making it feasible for in-room treatment 2

Efficacy

• Five-year data from the VeClose trial demonstrates that cyanoacrylate closure has a freedom from recanalization rate of 91.4% compared to 85.2% for radiofrequency ablation, demonstrating non-inferiority 6
• Real-world studies show closure rates of 99.6% at initial follow-up and 97.2% at 16-month follow-up 2
• Two-year occlusion rates are 93.7% for VenaSeal, compared to 90.9% for radiofrequency ablation and 91.5% for endovenous laser ablation 5

Patient Benefits

• Patients treated with VenaSeal experience sustained improvements in symptoms and quality of life, lower CEAP class, and high levels of satisfaction 6
• Recovery time is slightly reduced with non-thermal procedures compared to thermal ablation 7
• The procedure does not require compression stockings post-treatment, which may improve patient compliance and satisfaction 5

Safety Considerations

• Major complications are rare with VenaSeal 2, 6
• Potential complications include phlebitis, cellulitis, and deep vein thrombosis in rare instances 8
• There has been one reported case of cyanoacrylate extravasation with chronic foreign body reaction nine months after initial treatment, requiring surgical intervention 8
• No clinically symptomatic or occlusive deep vein thromboses have been reported in large studies 2

Patient Selection for VenaSeal

• Ideal candidates include patients with symptomatic varicose veins (CEAP class C2-C4b) and documented saphenous vein incompetence 6
• VenaSeal may be particularly beneficial for patients who:
  • Cannot tolerate tumescent anesthesia 2, 7
  • Have concerns about thermal damage to surrounding structures 7
  • Prefer a procedure with minimal discomfort and quick recovery 2, 7
  • Have veins in locations where thermal ablation might risk nerve damage 1

Cost-Effectiveness

• When considering cost-effectiveness at a willingness-to-pay threshold of $50,000 per QALY gained, the probabilities of being cost-effective were 55.6% for EVLA, 18.8% for CAC (VenaSeal), 15.6% for MOCA, 10.0% for RFA, and 0% for surgical vein stripping 7
• At a willingness-to-pay threshold of $100,000 per QALY gained, the probabilities shifted to 40.2% for EVLA, 30.0% for CAC, 17.7% for RFA, 12.1% for MOCA, and 0% for surgical vein stripping 7

Common Pitfalls and Caveats

• VenaSeal is primarily indicated for treating the main saphenous trunks rather than tributary veins, which may still require adjunctive treatments like foam sclerotherapy 2
• The long-term effects of leaving cyanoacrylate glue in the body are still being studied, though 5-year data shows good safety profiles 6
• The procedure is relatively new compared to thermal ablation techniques, so vigilance for rare complications is necessary 8
• Patients on anticoagulation may have different outcomes, though further studies are needed to assess this effect 5

VenaSeal represents an important advancement in the treatment of varicose veins, offering comparable efficacy to thermal ablation methods with the advantages of being non-thermal and non-tumescent, thus increasing patient comfort and eliminating the need for tumescent anesthesia.