Keywords
varicose vein - intervention - radiology
Introduction
A chronic venous disorder is a clinical condition characterized primarily by weakness
within the vein wall and associated with valvular dysfunction and venous reflux.[1] Chronic venous insufficiency (CVI) of the lower limb is a syndrome that includes
all the signs and symptoms occurring due to persistent venous hypertension. Patients
present with a spectrum of symptoms, including prominent leg veins (telangiectasias,
varicosities), heaviness, pain, itching, swelling, muscle cramps, discoloration, and
ulceration.[2]
The estimated prevalence of CVI is up to 73% in female population and up to 56% in
the male population.[3] The Framingham study showed that 77% of women older than 70 years and 10% of women
younger than 30 years had varicose veins.[4] Various risk factors associated with the condition include female sex, prolonged
standing/sitting, pregnancy, occupation (e.g., policemen, farmers, teachers), hormonal
influence, obesity, family history, and advanced age.[5] An excellent and thorough understanding of the lower limb venous anatomy and physiology
is warranted for an effective treatment. Different treatment options include traditional
surgical management and newer endovascular treatments. Endovascular options include
thermal ablation, mechanicochemical ablation (MOCA), and foam sclerotherapy.
Pathophysiology
Venous pressure in the lower limbs is dependent on the proper functioning of the normal
ability of the venous system and calf muscles to return blood, the absence of an upstream
venous obstruction, and inflow via the arterial system. Failure of these mechanisms
can lead to venous hypertension. CVI of the lower limb develops due to several reasons,
including valvular dysfunction, venous wall dysfunction, or deep venous hypertension
secondary to proximal venous obstruction. Primary valvular insufficiency develops
due to structural and intrinsic biochemical changes[2] in the vein wall, and secondary venous insufficiency develops due to venous thrombosis.
History and Clinical Examination
History and Clinical Examination
A detailed clinical history and physical examination are required for a patient presenting
with symptoms of varicose veins.[1]
[6]
[7] Posttreatment follow-up assessing the same clinical parameters helps in evaluating
the effectiveness of the procedure, the level of patient satisfaction, and complications
associated with the procedure. A clinical questionnaire with essential questions related
to how the symptoms of CVI affect the patient’s quality of life (QoL) is crucial and
is recommended. Such a questionnaire can be administered just before the consultation.
Availability of a questionnaire in languages other than English is highly recommended
to increase the yield and effectiveness of the questionnaire. We propose a simplified
questionnaire that addresses all the important questions ([Fig. 1]).
Fig. 1 A simplified proposed pre-consultation questionnaire to assess the patient’s condition.
Physical examination involves inspection and palpation of the extremity to look for
signs of edema, asymmetry, ulceration, and skin manifestations (rashes, hyperpigmentation).
Pelvis should be assessed to rule out any underlying pelvic vein insufficiency or
iliac vein obstruction. Arterial insufficiency should also be evaluated before deciding
any treatment. The findings collected from the patient’s history and physical examination
should be organized in various standardized disease severity classifications such
as the CEAP (clinical, etiologic, anatomical, pathophysiologic) and VCSS (venous clinical
severity score) to standardize the clinical findings and treatment outcomes.
Clinical Etiologic Anatomical Pathophysiologic Classification
The CEAP classification was proposed by the American Venous Forum and endorsed by
the Society for Vascular Surgery, which was published first in 1994 and later revised
in 2004.[8] The CEAP classification is a comprehensive assessment system that takes into account
the features such as clinical (C) aspects of venous disease, etiology (E) of the venous
disease, anatomical (A) location of the disease, and pathophysiologic (P) components
of the disease. The condition is clinically (C) classified as (a) C0: no visible or
palpable signs of venous disease, (b) C1: telangiectasia or reticular veins, (c) C2:
varicose veins, (d) C3: edema, (e) C4a: hyperpigmentation or eczema, (f) C4b: lipodermatosclerosis,
(g) C5: healed venous ulcer, (h) C6: active venous ulcer, (i) s: symptomatic, (ache,
pain, tightness, skin irritation, heaviness, muscle cramps), and (j) a: asymptomatic.
Etiologic (E) classification of the disease includes Ec (congenital), Ep (primary),
Es (secondary), and En (no cause identified). Anatomical (A) classification of the
venous disease includes As (superficial veins), Ap (perforator vein), Ad (deep veins),
and An (no cause identified), and pathophysiologically as Pr (reflux), Po (obstruction),
Pr,o (reflux and obstruction), and Pn (no cause identified).[8] CEAP classification is the most widely used and accepted system to report chronic
venous disease.[9]
Venous Clinical Severity Score
The VCSS is a QoL score used to supplement the CEAP classification. The score allows
quantification of disease severity and how it affects the patient’s QoL. Ten clinical
characteristics are evaluated and graded between scores 0 and 3 to a total score of
30. The 10 clinical characteristics include (a) pain or discomfort, (b) varicose veins,
(c) edema, (d) pigmentation, (e) inflammation, (f) induration, (g) number of active
ulcers, (h) active ulcer size, (i) active ulcer duration, and (j) use of compression
therapy. It is useful in grading severity of a patient with a CEAP score of C2 and
higher, and more so in patients with CEAP class of C4 to C6. The VCSS score reduces
both intra- and interobserver variability and allows better assessment and comparison
of signs, symptoms before and after the procedure.[10]
[11] VCSS minus stocking (VCSS-S) score can be used to assess the effect of mechanical
compression on the angiogenesis post varicose treatment.[12]
Quality-of-Life Measure
Chronic venous disease is associated with depression in up to 30% of patients.[13] Assessment of the QoL is essential and integral allowing a thorough and a complete
evaluation of the condition. Improvement or deterioration in the disease is associated
with a change in the patient’s QoL score. Several tools are available to assess QoL;
however, they lack sensitivity. The CIVIQ-20 is a 20-item QoL questionnaire that was
created in 1996.[14] The questionnaire covers four aspects: physical, psychologic, social, and pain.
This questionnaire can be accessed on www.civiq-20.com. This questionnaire is disease-specific with high sensitivity and reliability.[15]
Duplex Ultrasound Study
Duplex scan is the most widely accepted and useful initial imaging tool in the diagnosis
of venous insufficiency, its extent, and the treatment planning. The use of both grayscale
imaging and pulsed wave Doppler together allows the assessment of both the anatomy
and the physiology (concerning the hemodynamics, valvular competency, and venous obstruction)
of the lower limb venous system. The addition of color Doppler improves and quickens
the ultrasound study. Duplex scan is considered a gold standard for chronic venous
disease. The noninvasive nature and the quick reproducibility have allowed the Duplex
scan to replace the more invasive procedures such as phlebography that is mainly reserved
for exceptional indications. Duplex scan is also a highly useful follow-up tool and
helps predict recurrence at saphenofemoral junction (SFJ) at 5 years.[16]
A complete duplex scan incorporates the following features: (a) anatomical information,
(b) assessment of flow dynamics, (c) morphology of the valves, and (d) assessment
of flow augmentation and venous compressibility ([Fig. 2]).
Fig. 2 Points to report for a complete and comprehensive duplex scan.
Scan Protocol
A standardized duplex evaluation should be performed in a relaxed standing position
with the examined leg externally rotated and the weight transferred onto the contralateral
limb. Patency of the iliac vein and common femoral veins should be checked in a supine
position, whereas femoral and popliteal vein should be investigated in standing position.
Deep veins should be examined with relaxed calf muscles. A high-frequency (7.5–10
MHz) linear array probe with pulse repetition frequency is set to detect low-velocity
flow and reflux. The cutoff values to define as reflux in various segments of the
venous system include more than 1 seconds in the popliteal vein and femoral vein,
more than 0.5 second in the deep femoral vein, superficial venous system, and calf
veins, and more than 0.35 second in perforating veins (all of which are in standing
position).[17] The superficial venous system includes the great saphenous vein (GSV), short saphenous
vein (SSV), anterior accessory saphenous vein (AASV), and posterior accessory saphenous
vein (PASV). Perforator diameter should be measured at the fascial level. The GSV
diameter should be taken in three locations: 3 cm below SFJ, at mid-thigh, and knee.
The SSV diameter should be taken 3 cm below saphenopopliteal junction (SPJ)[18] ([Fig. 3]).
Fig. 3 Venous screening worksheet.
Management
Conventional Surgery
Surgical intervention has historically been the treatment of choice for venous insufficiency
for more than half a century. Ligation, stripping, and avulsion have been some of
the older techniques used. The requirement of hospitalization, general anesthesia,
and associated postsurgical complication makes it less attractive for the patient.
About 25 to 50% of patients present with recurrence within 5 years[19]
[20]
[21] of surgery because of neovascularization, reendothelialization, or incomplete/inadequate/inappropriate
treatment.
Newer surgical methods include Cure conservatrice et Hémodynamique de l’Insuffisance
Veineuse en Ambulatoire (CHIVA) and ambulatory phlebectomy. Ambulatory phlebectomy
is a newer refined surgical technique used by avulsing tributaries under local anesthesia
using small stab-like incisions. CHIVA is a shunt ligation technique.
Compression Therapy
Compression therapy has been used in the management of ulcers and wounds for several
centuries and has undergone the process of evolution from the early days of an inelastic
bandage to elastic bandages. Compression therapy remains a crucial component in CVI
management because of its noninvasive nature and the ease of its use. Compression
therapy counteracts the effect of gravity by decreasing both venous hypertension and
interstitial pressure preventing venolymphatic disorder.[22] It is the Laplace’s law that dictates in compressive therapy were external pressure
(P) is inversely proportional to the radius of curvature (R) and directly to the tension
of the material (T). Various compression devices include graduated compression stockings,
bandages, pneumatic compression devices, etc. Graduated compression stockings are
the first line of management in venous insufficiency, in patients who cannot undergo
an ablative/surgical treatment, or in a postprocedure setup.[23]
[24] Some studies suggest that stockings do not provide added benefit over 1 week.[25] Progressively graduated compression stockings (higher pressure at calf than ankle)
are better than degressive graduated compression stockings (higher pressure at the
ankle) in terms of improvement in patient symptoms and ease of wearing.[26] In general, compression stockings are associated with poor patient compliance and
skin damage. For an effective treatment, the elastic compression stockings should
fit properly and be changed every 2 to 4 months as per the manufacturer’s advice.
Sclerotherapy
Sclerotherapy is a chemical ablation technique performed by injecting chemical irritants
into the venous lumen under ultrasound guidance leading to inflammation, thrombosis,
occlusion and eventually fibrosis. The chemical irritants, known as sclerosants, can
be injected as either liquid or foam. These include sodium tetradecyl sulfate (STS),
polidocanol, sodium morrhuate, glycerin, and hypertonic saline. Sclerosant causes
irreversible damage by attacking the lipid and cell wall within the endothelium. Sclerosants
are commonly used as foam is created by the Tessari technique. Tessari method uses
mixing of air and sclerosant using a three-way stopcock. Most commonly used mix is
a 4:1 combination of air:sclerosant.[27]
[28] Sclerotherapy is indicated in the treatment of truncal incompetence, large varicose
veins, reticular vein, telangiectatic veins, and incompetent perforators. Absolute
contraindications include allergy to sclerosant, acute deep venous thrombosis, active
infection at the site of treatment, or prolonged immobility. Post-sclerotherapy compression
stockings are necessary to prevent thrombophlebitis. Sclerotherapy is less time consuming,
easily repeatable, relatively painless, and inexpensive with a faster recovery. Studies
have reported up to 82% cosmetic improvement, 90% symptomatic improvement, and 85%
closure rates.[29] Complications are seen in up to 1.2% cases and include drug reactions, pain, venous
thrombosis, necrosis, hyperpigmentation, migraine-like headache, transient ischemic
attack, visual disturbance, and pulmonary embolism.[29] Foam sclerotherapy is associated with a 90% recurrence rate after 6 years, which
is a significant problem[30] requiring repeated sittings. Catheter foam sclerotherapy is a recently introduced
technique that is as effective as an ultrasound-guided procedure.
Endovenous Thermal Ablation
Percutaneous endovenous thermal ablation has emerged as a proven, safe, and effective
alternative procedure to conventional surgical stripping. The procedure is associated
with several advantages, including minimally invasive nature, outpatient procedure,
requirement of only local anesthesia, immediate discharge and ambulation, faster recovery,
and less periprocedural morbidity. Two forms of endovenous thermal ablation are commonly
used: endovascular laser ablation (EVLA) or radiofrequency ablation (RFA). These techniques
mainly require an injection of tumescent liquid around the target vein as a protective
cushion for the perivenous tissue by the heat sink effect. The principle of RFA is
based on heat that is generated by high-frequency alternating current whereas laser
ablation is based on the principle of emission of a monochromatic single wavelength
wave (ranging from < 420 to 10,600 nm). The technique for both procedures is same;
the procedure is performed percutaneously under ultrasound guidance. The probe is
placed 1 to 2 cm distal to the saphenous junctions, followed by which tumescent fluid
made of saline, local anesthesia, sodium bicarbonate, and epinephrine is injected
along the full course of the vein. The fiber is withdrawn as the energy is emitted
that causes an irreversible intraluminal endothelial damage. Post-procedure compression
is recommended.[6] Laser ablation is associated with an occlusion rate ranging from 77 to 100%.[31]
[32]
[33] Laser ablation and RFA have almost the same occlusion rates, except the fact that
patients treated with RFA have less postoperative bruising and pain.[34] Postprocedure complications include pain, thrombophlebitis, thromboembolism, skin
burns, bruising, hyperpigmentation, paresthesia, and pulmonary embolism.[35]
[36]
[37]
Newer Techniques
Nonthermal Ablative Techniques
The success of thermal ablative techniques and medical advances led to the development
of various nonthermal ablative techniques that completely obviate the need of tumescent
anesthesia, further reducing procedure time and post-procedure pain, bruising, and
sensory nerve damage. It mainly includes three techniques: endovenous microfoam sclerotherapy,
endovenous MOCA, and cyanoacrylate embolization.
Endovenous Microfoam Sclerotherapy
Varithena is a preformed polidocanol foam canister that is of pharmaceutical grade
and the Food and Drug Administration (FDA) approved for the treatment of incompetent
GSV. It is a low-density injectable that contains polidocanol, ultra-low amount of
nitrogen, oxygen, and carbon dioxide producing a 1% microfoam solution.[38]
Mechanochemical Endovenous Ablation
Mechanochemical endovenous ablation (MOCA) is a hybrid endovascular procedure that,
as the name suggests, has two components: (1) mechanical abrasion via a special catheter
and (2) chemical ablation by injecting foam sclerosant. Sodium tetradecyl sulfate
or polidocanol can be used as the sclerosant agent of choice ([Fig. 4]). The mechanical damage of the endothelium is caused by the catheters rotating element/sharp
tines and the chemical damage by the sclerosants. The mechanically damaged endothelium
activates coagulation and causes vasospasm with the sclerosant damaging the lipid
cell wall. These together lead to occlusion of the vein.[39] The procedure is associated with faster recovery and less post-procedure pain and
discomfort.[40] The procedure has several advantages over other ablative techniques, including (a)
reduced pain, bruising and discomfort, (b) no tumescent anesthesia, (c) no risk of
nerve and skin damage, and (d) rapid return to regular activity. No major complication
is associated with this technique. Minor complications such as local site hematoma,
thrombophlebitis, and ecchymosis can occur.[41] Tang et al noted no major complications within their study. Approximately 4% of
the patients presented with thrombophlebitis.[42] MOCA has shown a closure rate of 87 to 96%.[39]
[43] A randomized controlled trial comparing MOCA and RFA showed a closure rate of 92%
at 4 weeks.[44] Tang et al reported no difference in occlusion while treating GSV and SSV.[42]
Fig. 4 A 63-year-old male patient first presented with complaints of itching and dull aching
pain in the right leg. On screening venous Doppler, there was reflux across the saphenopopliteal
junction (SPJ) with a dilated short saphenous vein. Patients CEAP score was C4a and
VCSS score was 7. (A–H) Sequential procedure images. (A) Punctured SSV with a 6F sheath within the SSV. (B, C) Flebogrif catheter with opened tines. (D) Foam sclerosant syringe connected to the Flebogrif catheter hub. (E, F) Catheter tip seen in axial section in the SSV (black arrow in E) and in sagittal section (yellow arrow in F). (G, H) Catheter tines are opened (black arrows in G) with occlusion postmechanical ablation.
Cyanoacrylate Embolization
The VenaSeal Sapheon Closure System is a proprietary n-butyl-2-cyanoacrylate–based formulation. This is injected into the lumen to treat
varicose veins. It polymerizes when it comes in contact with blood leading to occlusion
of the vessel.[45]
Laser-Assisted Foam Sclerotherapy
Laser-assisted foam sclerotherapy (LAFOS) is characterized by foam injection that
precedes a low-energy laser ablation. No tumescent anesthesia is necessary for this
technique. A study showed a 100% occlusion rate.[46]
Guidelines
The NICE (National Institute for Health and Care Excellence) guidelines for varicose
veins, first issued in 2013, make several recommendations (all recommendations are
for patients aged > 18 years).[47] Guidelines have also been proposed by a few other vascular societies such as the
American Venous Forum, the Society for Vascular Surgery, and the European Society
for Vascular Surgery. Most of the available guidelines are in agreement with the guidelines
proposed by NICE.
Treatment Comparison
With the availability of several treatment options choosing the right treatment for
the right patient is a crucial decision that needs to be taken. Kheirelseid et al
in their meta-analysis noted that 36.6% patients who underwent EVLA presented with
recurrence in comparison with 33.3% patients who underwent conventional surgery at
the end of 5 years.[48] Xiao et al found no difference in the results of EVLT versus surgery.[49] One study showed that 50% of recurrences occurred after 2 years of surgery whereas
recurrence was seen in 12% of patient within 6 months of laser ablation.[50] Kheirelseid et al found no significant difference in recurrence rate when comparing
surgery over RFA.[48] Luebke et al found that on comparing RFA over surgery, radiofrequency has several
short-term benefits; however, there was an increasing rate of recanalization at 1
year.[51] Studies comparing surgery and endothermal procedure found both to have the same
results over the long term; however, the endothermal procedure had several advantages,
including it being a safe and effective procedure with faster recovery.[52] RFA and laser ablation had similar outcomes on both short- and long-term follow-up.[53] Several studies have found minimally invasive procedures as effective and safe,[54]
[55] with one study reporting endothermal ablation being superior to surgery.[56] As suggested by the NICE guidelines,[47] endothermal treatment is the first line of treatment. In patients not suitable for
endothermal ablation, ultrasound-guided foam sclerotherapy must be offered as the
next treatment option. Only patients in whom both endothermal treatment and foam sclerotherapy
are not a suitable treatment option should surgery be offered.
Conclusion
Venous insufficiency of the lower limb is a widespread condition that, when diagnosed
and treated early, can prevent disease progression and complications associated with
the procedure. Principles of ultrasound and intervention are well understood by the
interventional radiologist giving them the skills to treat the condition with utmost
accuracy ideally. Studies have shown that endovascular treatment offers equal long-term
efficacy similar to surgery. Nonthermal endovenous ablations are newer techniques
but are in need of long-term outcome data.
