What are the steps of endovenous radiofrequency (RF) ablation for varicose veins?

Detailed Steps of Endovenous Radiofrequency Ablation for Varicose Veins

Pre-Procedure Patient Selection and Preparation

Radiofrequency ablation is indicated for patients with documented saphenous vein reflux ≥500 milliseconds at the saphenofemoral or saphenopopliteal junction, vein diameter between 4.5-20 mm, and symptomatic varicose veins that have failed conservative management. 1, 2

• Confirm diagnostic criteria with duplex ultrasound performed within the past 6 months, documenting reflux duration, exact vein diameter at specific anatomic landmarks, deep venous system patency, and location/extent of refluxing segments 1
• Verify vein diameter is at least 4.5 mm (some protocols accept 2-20 mm range) and that the vein is located at least 5 mm from the skin surface or in a subfascial location 3, 2
• Document a minimum 3-month trial of medical-grade gradient compression stockings (20-30 mmHg) with persistent symptoms despite full compliance 1
• Ensure the vein is not excessively tortuous in the treatment area, as this may complicate catheter advancement 4

Procedure Setup and Access

The procedure is performed under local tumescent anesthesia with ultrasound guidance, allowing same-day discharge and immediate ambulation. 1, 5

Access Site Selection

• For great saphenous vein (GSV), access at or above the knee joint to ensure adequate treatment length 2
• For small saphenous vein (SSV), access above the mid-calf to avoid complications 2
• Perform percutaneous puncture or small skin incision under ultrasound guidance to access the target vein 5

Catheter Placement

• Position the radiofrequency catheter tip 2.0 cm inferior to the saphenofemoral junction (SFJ) or saphenopopliteal junction (SPJ) to avoid junctional thrombosis while ensuring complete treatment 2
• Verify catheter position with duplex ultrasound before initiating energy delivery 4, 2

Tumescent Anesthesia Administration

Tumescent anesthesia provides both pain control and thermal protection of surrounding tissues, reducing the risk of nerve injury and skin burns. 2, 5

• Prepare tumescent solution using 2% lidocaine 20 mL + 500 mL normal saline + bicarbonate 2.5 mL, with or without epinephrine 2
• Infiltrate tumescent solution circumferentially around the target vein under ultrasound guidance, creating a fluid cushion that separates the vein from surrounding structures 2, 5
• Infiltration can be performed from multiple directions to ensure complete perivenous coverage 2

Radiofrequency Energy Delivery

The ablation process uses controlled thermal energy to cause vein wall shrinkage and thrombus formation, resulting in permanent vein occlusion. 4, 6

Ablation Protocol

• Perform two cycles of ablation for the first proximal segment (near the SFJ/SPJ) and any segments with incompetent perforators 2
• Ablate all other segments one time as the catheter is withdrawn 2
• Apply external compression during radiofrequency energy delivery to enhance vein wall contact and improve treatment efficacy 2
• Withdraw the catheter slowly and continuously while delivering energy to ensure uniform treatment of the entire vein length 6

Expected Tissue Response

• Vein shrinkage occurs immediately, with reduction to 31.2% of original area at the saphenofemoral junction, 44% at the thigh, and 57.7% at the knee 4
• Thrombus formation accompanies vein shrinkage, contributing to permanent occlusion 4

Concomitant Procedures

Treating tributary veins and varicosities during the same session provides comprehensive treatment and reduces recurrence rates. 1, 2

• Perform ambulatory phlebectomy simultaneously for symptomatic varicose tributary veins to address visible varicosities 2
• Defer sclerotherapy for at least 2 weeks post-ablation to allow initial healing and reduce complications 2
• Treating saphenofemoral junction reflux is mandatory before tributary sclerotherapy, as untreated junctional reflux causes persistent downstream pressure and recurrence rates of 20-28% at 5 years 7

Post-Procedure Management

Immediate ambulation and compression therapy are essential to reduce thrombotic complications and optimize outcomes. 1, 2

Immediate Post-Procedure Care

• Encourage immediate post-procedural ambulation to reduce the risk of deep vein thrombosis (0.3% incidence) and pulmonary embolism (0.1% incidence) 1, 2
• Apply compression stockings for at least 7 days (some protocols recommend longer duration) to promote vein occlusion and reduce inflammation 1, 2
• Discharge patients 2 hours after the procedure once ambulation is confirmed 5

Activity Restrictions

• Minor daily activities are not limited, allowing quick return to work within 3-5 days 5, 8
• Avoid strenuous activities for 2 weeks to prevent complications 2
• Permit showers after 24 hours, but defer tub baths, swimming, or water soaking for 2 weeks 2

Follow-Up and Surveillance

Early postoperative duplex scanning is mandatory to detect endovenous heat-induced thrombosis (EHIT), while longer-term imaging assesses treatment success. 1, 7

Surveillance Protocol

• Perform duplex ultrasound at 2-7 days post-procedure to detect EHIT and confirm initial vein occlusion 7
• Treat EHIT ≥class III with low-molecular weight heparin to prevent propagation into the deep venous system 2
• Schedule follow-up ultrasound at 1 week, 1 month, 6 months, and 12 months to assess treatment durability 4, 5
• Evaluate for complete occlusion, which occurs in 91-100% of cases at 1 year when appropriate patient selection criteria are met 1, 6, 8

Expected Outcomes and Complications

Radiofrequency ablation achieves high technical success rates with minimal complications, providing superior quality of life compared to traditional surgery. 6, 8

Success Rates

• Total occlusion rates of 93% at 3 months and 91% at 12 months have been demonstrated in clinical studies 8
• Immediate occlusion rates approach 100% with modern radiofrequency systems 6
• Symptom improvement includes reduction in leg pain, fatigue, edema, and visible varicosities in the majority of patients 5, 8

Common Complications

• Superficial thrombophlebitis occurs in approximately 13% of cases, typically resolving with conservative management 4
• Temporary sensory nerve injury affects approximately 4-7% of patients, with most cases resolving spontaneously 1, 4
• Minor side effects include bruising, tenderness, and skin discoloration, which are less frequent than with surgical stripping 6

Rare but Serious Complications

• Deep vein thrombosis occurs in 0.3% of cases and requires anticoagulation therapy 1
• Pulmonary embolism occurs in 0.1% of cases, representing a rare but potentially life-threatening complication 1
• Skin burns and thermal injury to surrounding structures are minimized by proper tumescent anesthesia technique 2, 5