¶ … Endovascular Laser and Microphlebectomy for Treatment of Varicose Vein Venous insufficiency is a condition that affects hundreds and thousands of individuals each year, particularly women. Venous insufficiency often results in varicose veins, phlebitis and similar physiological conditions. In general these abnormalities are thought to result from a combination of gender and heredity among other things. Historically treatment for venous insufficiencies involved very aggressive and invasive surgery which stripped veins; this process resulted in a removal of the offending veins. Often the recovery time was in excess of two weeks, with patients often only minimally mobile.

Advances in technology and procedure however have resulted in a new minimally invasive procedure that combines the use of endovascular laser surgery and microphlebectomy to remove varicosities that occur below the knee (Pearce, 2003). The use of endovascular laser is limited primarily to the greater and minor saphenous veins, which are often implicated in venous disorders. The use of endovenous laser has greatly altered the manner in which patients currently receive care. Laser treatment typically involves a one day out of office procedure conducted using local anesthesia only, though intravenous sedation may also be utilized. Microphlebectomy is then utilized to remove the smaller varicose veins that often are fed by saphenous insufficiencies in the lower calf. Microphlebectomy is also minimally invasive, requiring only pinpoint incisions to be made in the lower calf. The bulging veins are subsequently removed. Patients are asked to wear high grade compression stockings for a two-week period to prevent clotting or recurrence. They are able however, to return to work or regular activities almost immediately.

ANALYSIS

Vein disorders for purposes of this study will be examined as a whole. Traditionally an individual suffering from venous disorder will experience pain and discomfort resulting from elongated, dilated and malfunctioning vessels, which have incompetent valves, allowing blood to pool in the veins; they may be of various size and shape (Arnoldi, 1957). Traditionally physicians have attributed venous disorders to genetic and hormonal influences, though "hydrodynamic factors" may also influence the severity of the disorder.

Gravitational hydrostatic force and hydrodynamic muscular compartment force have also been implicated in venous insufficiencies and contribute to complications associated with venous insufficiency in a large majority of cases. Many women find themselves affect by venous disorders during pregnancy, as a result of hormonal influences; studies suggest in fact that more than 70% of varicosities develop during the first trimester, some within 2-3 weeks of gestation, thus may be attributed to hormonal fluctuations rather than the increased weight and pressure of the mother (Struckmann, JR, et.al, 1990). Varicose veins are often implicated from a hereditary perspective, though the research currently available on hereditary causes has not been able to adequately assess the nature of the trait (Cornu-Thenard, et. al, 1994).

People seek treatment for varicosities for a variety of reasons. A common cause for consultation includes the misshapen appearance of the leg that often results from varicosities. Large, bulging veins are not uncommon among patients with venous insufficiencies. Varicose veins also prompt consultation for a variety of other symptoms, including the following: leg pain, heaviness, and external bleeding, phlebitis, ulcer and leg fatigue.

Surprisingly, a majority of non-specialized physicians are still unaware of new technologically advanced techniques that make seeking out treatment easy and efficient (Weiss & Goldman, 1992). Some patients also are not aware that there symptoms may be alleviated through treatment, and thus suffer through the discomfort needlessly. More than 85% of patients however, will realize relief of their symptoms as a result of medical care (Weiss & Weiss, 1990).

Recurrent varicose veins may be a problem for individuals seeking out traditional forms of therapy, such as saphenous ligation (McMullin, et. al, 1991). Stripping of the saphenous vein often results in relief, however the treatment can be very painful and invasive, and the risk of recurrence is still relatively high (Stonebridge, et. al, 1995).

Studies now show that microphlebectomy can be used to detach perforator vein tributaries, while endovenous laser treatment may successfully be utilized to seal off the saphenous vein in the upper thigh. Endovenous laser treats the saphenous vein by ablating (Munn, et. al, 1981).

Endovenous laser surgery is perhaps the most non-invasive mechanisms for removing the saphenous vein. Ultrasound scanning is used in conjunction with laser treatment to highlight and effectively remove the offending veins.

One of the more commonly utilized treatments in the U.S. now other than laser vein ablation is often use of the VNUS vein treatment system, developed by VNUS Medical Technologies.

Electrodes are designed specifically to monitor the electrical and thermal impulses delivered by a catheter that is inserted directly into the saphenous vein. The vein responds to the RF by shrinking and contracting. The procedure has been proven effective, with more than 90% of patients realizing continued closure rates after a two-year period (Kabnick & Merchant, 2001). Intravenous sedation and tumescent anesthesia are often the forms of anesthesia used in saphenous vein ablation therapy (Goldman, 2000) though general anesthesia is also utilized.
More advanced however, is the use of light energy. Laser light energy when delivered into the saphenous cavity often results in the least invasive and most promising results for veinous patients. Laser light energy is generally delivered via a 400-750µm "sterile bare-tipped quartz fiber" (Bone, 1999). Laser light surgery results in "non-thrombotic occlusion of the vein" with almost a 100% success rate (Navarro, 2001).

Laser vein ablation "challenges traditional thinking about varicose veins" (Pearce, 2003). Endovenous surgery works by ablating the saphenous vein from the groin area to just above the knee; saphenorfemoral branches are left in tact, and microphlebectomy is used to extract varicosities that occur below the knee (Pearce, 2003). Among the benefits of laser surgery include excellent cosmetic outcomes, though some reports have detailed possible complications with the procedure including the following: recannalization, arterialization and deep vein thrombosis (Pearce, 2003).

Traditionally laser therapy has been utilized to remove surface spider veins, including those present on the face and those in the leg if they were restricted in size to less than.3 mm in diameter, however the newer endovenous laser technique is now being used to effectively close veins that are 2 to 3mm in diameter and more (Kauvar, 2000). The endovenous laser technique utilizes a bare-tipped laser fiber; a catheter is used to guide the laser into the vein, while an ultrasound technician stands close by to guide the procedure (Kauvar, 2000). At this time the procedure has resulted in positive results for a majority of patients who have participated in trials (Navarro, 2001).

Microphlebectomy is also referred to as stab avulsion or ambulatory phlebectomy, and is a technique utilized to remove veins via use of several tiny incisions through which physicians can pull out varicosities.

The goals of treatment generally include reduction of symptoms including pain and discomfort; Also physicians aspire to reduce the potential for complications, as with any surgery. For some patients, and improved cosmetic outcome is highly desirable. Exercise is encouraged both before and after procedure.

More invasive or technologically advanced procedures are often the first line of defense for patients experiencing trouble with deep vain disease. The only disadvantage for microphlebectomy for surgeons is the tedious nature of the process. In general incisions must be made every two or three inches apart to reach veins; if the area that is affected includes veins that are scattered over a wide ranging area, then obliteration of those veins can take quite a bit of time. Microphlebectomy can be accomplished however under minimal expense, and rarely are complications a problem utilizing this technique.

Not all patients are good candidates for Endovenous Laser Closure treatment. This includes patients with a repeat history of varicose veins despite previous treatment of the saphenous veins. Also, patients whose varicose veins result from reflux of the lesser saphenous vein, which is located behind the knee, may not be good candidates for Endovenous laser. Saphenous veins that are larger than one inch in diameter and varicose veins that occur as a result of branch varicosities rather than the saphenous reflux are all typically considered poor candidates for laser. Laser procedures conducted too close to the surface of the skin may result in excessive burning of the tissue. However, despite these exceptions to the rule, this still leaves a majority of patients as exceptional candidates for the procedure.

The lasers utilized to close the saphenous vein are diode lasers that often fall in narrow ranges of the infrared electromagnetic spectrum.

There has been little impetus to conduct more in depth prospective studies regarding the outcome for such treatments, as many researchers still believe that these procedures are performed primarily for cosmetic reasons (Pearce, 2003).

A majority of patients also do not seek treatment because of the potential lack of insurance coverage for the procedures. Different health insurance policies currently have different rules and regulations regarding treatment. There are still several companies that will refuse treatment on the basis of classifying veinous insufficiency as primarily a cosmetic problem.

Aetna is an example however, of a new trend in…