VARICOSE VEINS

RFA Closurefast

Introduction

Last updated: apr 5, 2023

  • Prevalence > 20% in Western population
  • 5% suffer from venous edema, skin changes or ulcerations
  • 0.5% active ulcers : 1.4% healed ulcers

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Anatomy

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Indications

  • Clinical symptoms
    • Aching
    • Throbbing
    • Heaviness
    • Fatigue
    • Pruritus
    • Night cramps
    • Restlessness
    • Generalized pain
    • Swelling
  • Objective reflux
    • 1 s reversed flow femoral or popliteal vein
    • Deep femoral and perforating veins
    • Perforators with a diameter > 3.5 mm
    • Perforators located underneath an ulcer
    • Refluxtijd ≥ 500ms (perforatoren ≥ 350ms)

 

Contra indications

Absolute

  • Deep vein thrombosis (DVT) in the past six months (caution for deep venous obstruction with secondary varices essential for venous drainage)
  • Acute superficial thrombophlebitis and migratory phlebitis
  • Allergy to acrylate (type 4 hypersensitivity)
  • Arterial insufficiency in Fontaine stages III and IV (Stage III marked by rest and nighttime pain; Stage IV with continuous pain and acral ulcerations). For arterial issues, adequate compression—crucial in sclerotherapy—cannot be used.
  • Severe systemic illnesses, especially those involving bed confinement (acute infections, liver or kidney dysfunctions, neoplasms, severe chronic cardiac or respiratory diseases)
  • Immobility due to musculoskeletal issues (typically accompanied by edema, intolerance to adequate compression, increased risk of thrombosis)
  • Pregnancy and breastfeeding: Varices are typically not sclerosed during pregnancy as aethoxysclerol lacks a "safe during pregnancy" label. Veins often revert to normal size 8–10 weeks postpartum. If symptomatic, treatment is better scheduled prior to a subsequent pregnancy to prevent progression.

Relative

  • History of recurrent DVT
  • Clotting disorders with hypercoagulability
  • Anticoagulant use
  • Severe edema
  • Complicating arteriosclerosis with risk of pressure necrosis
  • Angiodysplasia, such as varices associated with Klippel-Trénaunay syndrome, where Duplex ultrasound should exclude deep vein anomalies
  • Patient unable or unwilling to wear compression stockings

 

Workup

  • CEAP classification
  • Duplex/doppler

 

Pre procedural

  • Compression stocking fitting

 

Materials

Essentials

  • Sterile drape and square adhesive dressing
  • Ultrasound device with gel and sterile cover
  • Puncture needle and 7Fr sheath
  • Tumescent fluid (500 ml NaCl 0.9% with 25 ml Lidocaine 2% without adrenaline)
  • Infiltration pump with foot pedal, infusion system, and yellow needle (20G)
  • VNUS catheter (the short one is sufficient in >95% of cases)
  • VNUS RF generator

Non-Essentials

 

Positioning the patient

  • Supine for Great Saphenous Vein
  • Prone for Small Saphenous Vein
  • Table tilted anti-trendelenburg

 

The procedure in steps

  • TOP
  • Position the patient.
  • Disinfect the leg, including the groin area thoroughly.
  • Drape the area sterilely.
  • Under ultrasound guidance, puncture the insufficient vein.
  • Insert the sheath using the over-the-wire technique.
  • Advance the RFA wire to 1.5 cm below the saphenofemoral junction.
  • Administer tumescent anesthesia.
  • Start the RFA device.
  • Begin proximally with two ablations in the same position.
  • Proceed by retracting the RFA wire according to the markings.
  • When the shaded portion becomes visible, retract the sheath.
  • Perform one final ablation.
  • Ensure hemostasis.
  • Apply compression stockings.
  • SOP

 

Tips and tricks

  • https://www.huidziekten.nl/flebologie/scleroseren.htm
  • https://richtlijnendatabase.nl/richtlijn/veneuze_pathologie_varices/varices_-_korte_beschrijving.html

 

Complications

  • Skin burns or discoloration
  • Induration
  • Swelling
  • Paresthesia

 

Post-op

  • RFA: Wear compression stockings continuously for 24 hours, then only during the day for 1 week.
  • Convolutectomy: Wear bandages continuously for 24 hours, then switch to compression stockings only during the day for 1 week.

 

Follow-up

  • Follow-up typically unnecessary unless symptoms indicate otherwise

HIX
 

Report

Time out. Positioneren patient. Been wordt gedesinfecteerd, liesstreek goed mee desinfecteren. Na desinfecteren steriel afdekken. Onder echo aanprikken van de VSM rechts. Over-the-wire invoeren van de sheath, en opvoeren van de LASER tot aan de crosse. Inbrengen van tumescentie. 500 ml NaCl 0,9%met 25 ml Lidocaine 2% zonder adrenaline. Vervolgens ablatie van de vene. Hemostase. Compressie kous. Sign-out.

 

Patient folder

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Literature

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  10. Sildiroglu O, Muasher J, Arslan B, Sabri SS, Saad WE, Angle JF, Matsumoto AH, Turba UC. Outcomes of patients with acute upper gastrointestinal nonvariceal hemorrhage referred to interventional radiology for potential embolotherapy. J Clin Gastroenterol. 2014;48(8):687-92.

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  25. Nicholson AA, Ettles DF, Hartley JE, et al. Transcatheter coil embolotherapy: a safe and effective option for major colonic haemorrhage. Gut 1998; 43:79–84.

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  29. Loffroy R, Rao P, Ota S, De Lin M, Kwak BK, Geschwind JF. Embolization of acute nonvariceal upper gastrointestinal hemorrhage resistant to endoscopic treatment: results and predictors of recurrent bleeding. Cardiovasc Intervent Radiol. 2010 Dec;33(6):1088-100. doi: 10.1007/s00270-010-9829-7. Epub 2010 Mar 16.

  31. Eriksson LG, Sundbom M, Gustavsson S, Nyman R. Endoscopic marking with a metallic clip facilitates transcatheter arterial embolization in upper peptic ulcer bleeding. J Vasc Interv Radiol. 2006 Jun;17(6):959-64.

  32. Anthony S, Milburn S, Uberoi R. Multi-detector CT: review of its use in acute GI haemorrhage. Clin Radiol. 2007 Oct;62(10):938-49.

  33. Ernst O, Bulois P, Saint-Drenant S, Leroy C, Paris JC, Sergent G. Helical CT in acute lower gastrointestinal bleeding. Eur Radiol. 2003;13(1):114-7

  34. Mirsadraee S, Tirukonda P, Nicholson A, Everett SM, McPherson SJ. Embolization for non-variceal upper gastrointestinal tract haemorrhage: a systematic review. Clin Radiol 2011;66:500-509.

  35. Loffroy R, Guiu B, D'Athis P, Mezzetta L, Gagnaire A, Jouve JL, Ortega-Deballon P, Cheynel N, Cercueil JP, Krausé D. Arterial embolotherapy for endoscopically unmanageable acute gastroduodenal hemorrhage: predictors of early rebleeding. Clin Gastroenterol Hepatol. 2009 May;7(5):515-23.

  36. Aina R, Oliva VL, Therasse E, et al. Arterial embolotherapy for upper gastrointestinal hemorrhage: outcome assessment. J Vasc Interv Radiol 2001;12:195-200.

  37. Mirsadraee S, Tirukonda P, Nicholson A, Everett SM, McPherson SJ. Embolization for non-variceal upper gastrointestinal tract haemorrhage: a systematic review. Clin Radiol 2011;66:500-509.

  38. Loffroy R, Guiu B, Cercueil JP, Lepage C, Latournerie M, Hillon P, Rat P, Ricolfi F, Krausé D. Refractory bleeding from gastroduodenal ulcers: arterial embolization in high-operative-risk patients. J Clin Gastroenterol. 2008 Apr;42(4):361-7.

  39. Loffroy R, Guiu B, D'Athis P, Mezzetta L, Gagnaire A, Jouve JL, Ortega-Deballon P, Cheynel N, Cercueil JP, Krausé D. Arterial embolotherapy for endoscopically unmanageable acute gastroduodenal hemorrhage: predictors of early rebleeding. Clin Gastroenterol Hepatol. 2009 May;7(5):515-23.

  40. Poultsides GA, Kim CJ, Orlando R 3rd, Peros G, Hallisey MJ, Vignati PV. Angiographic embolization for gastroduodenal hemorrhage: safety, efficacy, and predictors of outcome. Arch Surg 2008;143:457-461.

  42. Gordon RL, Ahl KL, Kerlan RK, Wilson MW, LaBerge JM, Sandhu JS, Ring EJ, Welton ML. Selective arterial embolization for the control of lower gastrointestinal bleeding. Am J Surg. 1997;174(1):24-8.

  43. Funaki B, Kostelic JK, Lorenz J, Ha TV, Yip DL, Rosenblum JD, et al. Superselective microcoil embolization of colonic hemorrhage. AJR Am J Roentgenol 2001;177:829-836 7.

  44. Bandi R, Shetty PC, Sharma RP, Burke TH, Burke MW, Kastan D. Superselective arterial embolization for the treatment of lower gastrointestinal hemorrhage. J Vasc Interv Radiol 2001;12:1399-1405.

  45. Maleux G, Roeflaer F, Heye S, Vandersmissen J, Vliegen AS, Demedts I, et al. Long-term outcome of transcatheter embolotherapy for acute lower gastrointestinal hemorrhage. Am J Gastroenterol 2009;104:2042-2046

  46. Leitman IM, Paull DE, Shires GT 3rd. Evaluation and management of massive lower gastrointestinal hemorrhage. Ann Surg 1989;209:175-180

  47. Rosenkrantz H, Bookstein JJ, Rosen RJ, Goff WB 2nd, Healy JF. Postembolic colonic infarction. Radiology 1982;142:47-51.

  48. Koh DC, Luchtefeld MA, Kim DG, Knox MF, Fedeson BC, Vanerp JS, et al. Efficacy of transarterial embolization as definitive treatment in lower gastrointestinal bleeding. Colorectal Dis 2009;11:53-59

  49. Lipof T, Sardella WV, Bartus CM, Johnson KH, Vignati PV, Cohen JL. The efficacy and durability of super-selective embolization in the treatment of lower gastrointestinal bleeding. Dis Colon Rectum 2008;51:301-305

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