What is endovenous thermal ablation?

What is Endovenous Thermal Ablation?

Endovenous thermal ablation is a minimally invasive catheter-based procedure that uses heat—delivered via laser (endovenous laser ablation/EVLA) or radiofrequency energy (radiofrequency ablation/RFA)—to destroy and close incompetent superficial veins from the inside, causing blood to reroute through healthy veins. 1

Mechanism of Action

• Under ultrasound guidance, a laser optical fiber or radiofrequency catheter electrode is inserted into the diseased vein in a distal to proximal direction 1
• Heat from the laser or radio waves coagulates the blood in the vein, resulting in permanent closure of the vein and redirection of blood flow to functional veins 1
• The procedure destroys the vein wall through thermocoagulation, with hemoglobin absorbing the laser energy in EVLA 1

Clinical Application and Patient Selection

• Endovenous thermal ablation is recommended as first-line treatment for nonpregnant patients with symptomatic varicose veins and documented valvular reflux, and need not be delayed for a trial of external compression 1
• The procedure is appropriate for larger vessels, including the great saphenous vein, small saphenous vein, and accessory saphenous veins 1, 2
• Medical necessity requires vein diameter of at least 4.5mm and documented reflux duration ≥500 milliseconds at the saphenofemoral or saphenopopliteal junction 2, 3

Procedural Details

• The procedure is performed after local anesthetic is injected around the vein (tumescent anesthesia) 1
• Patients can walk immediately after the procedure and may be discharged home the same day 1
• Patients may return quickly to work and other activities with minimal recovery time 1
• Ultrasound guidance is essential for safe and effective performance, allowing accurate visualization of the vein and surrounding structures 2

Efficacy and Outcomes

• Endovenous thermal ablation achieves technical success rates of 91-100% occlusion within 1 year post-treatment 2, 3
• The procedure has largely replaced surgical ligation and stripping as the main treatment method for varicose veins due to similar efficacy, improved early quality of life, and reduced hospital recovery 2, 3
• Long-term follow-up demonstrates 86% overall satisfaction, symptom relief, and absence of varicosities at mean 6.7 years 4
• Both EVLA and RFA demonstrate comparable efficacy rates exceeding 80%, with EVLA showing slightly higher success rates (98.1% vs 98.4%) though clinical significance is uncertain 5, 6

Complications and Risks

• There is approximately 7% risk of surrounding nerve damage attributed to thermal injury; however, most nerve damage is temporary 1, 3
• Deep vein thrombosis occurs in approximately 0.3% of cases after endovenous ablation 2, 3
• Pulmonary embolism occurs in 0.1% of cases 2, 3
• Endovenous heat-induced thrombosis (EHIT) occurs in 5.9% of cases overall, but true EHIT (excluding class 1) occurs in only 1.16% 6
• RFA demonstrates lower thrombotic complication rates (7.7%) compared to EVLA (11.4%), though RFA shows slightly higher recanalization rates 5, 6
• RFA results in significantly less postoperative pain and bruising compared to EVLA 5

Comparison to Alternative Treatments

• Endovenous thermal ablation has fewer complications compared to surgery, including reduced rates of bleeding, hematoma, wound infection, and paresthesia 2, 3
• The procedure provides better long-term outcomes than foam sclerotherapy alone, which has occlusion rates of only 72-89% at 1 year and higher recurrence rates at 1-, 5-, and 8-year follow-ups 2
• Compression stockings alone have no proven benefit in preventing post-thrombotic syndrome or treating established venous insufficiency when significant reflux is present 2