What is it about?

According to international guidelines, the best way to treat varicose veins is by destroying them with heat from the inside. This is performed by passing a laser fibre or a radiofrequency fibre into the vein to be treated. Local anaesthetic can then be injected around the vein, and the vein heated sufficiently both to make it shrink away and also to kill all of the cells in the vein wall. This process is called "endovenous thermal ablation" which literally means permanently closing the veins using heat from inside the vein. Usually, an endovenous laser device or radiofrequency device is passed into the vein under ultrasound control from a point in the thigh, knee, lower leg or even ankle. The catheter is then passed up the vein to the groin. In some cases, it is either difficult or impossible to do this. It might be because there is scar tissue in or around the vein or blood around the vein caused by failed attempts to get the device into the vein, or sometimes the vein goes into spasm. In these cases, doctors often either make an incision to cut down onto the vein, or cancel a case allowing the patient to go home and bring them back in the future to try again. In the past, some experts have suggested passing the laser backwards down the vein to be treated. However, the difficulty with this is how to get the device into the vein in a way it can be passed backwards down the vein. One publication has suggested to enter the vein in the groin, accepting that this approach will leave the top few centimetres of the target vein untreated. Another publication has suggested putting the device into the vein in other groin and, under x-ray control, passing the device up into the pelvis to where the veins meet, and then back down the other pelvic vein and then into the varicose vein. However, this is complex and makes a simple procedure much more difficult. In this publication, we have demonstrated a much simpler way to get around these problems at The Whiteley Clinic. In patients where it is needed, we have shown that there is a small vein that joins the great saphenous vein in the groin. This small vein comes from the abdominal wall, and is called the superficial inferior epigastric vein. It joins the vein that needs treatment (the great saphenous vein) right at the point we would normally start the ablation. Using ultrasound, we have shown how we get the laser device into this vein under local anaesthetic. The laser is then passed backwards down the great saphenous vein and the treatment performed as it normally would be, but in reverse. The ablation starts at the lower end of the vein and then continues up the vein as the laser is withdrawn. The treatment continues right up to the point where this superficial inferior epigastric vein joins a great saphenous vein, completing the treatment.

Featured Image

Why is it important?

This technique allows doctors an opportunity to complete a varicose vein operation in situations where normally they might have to either abandon the operation or start making larger incisions. Although most endovenous treatments of varicose veins proceed without a problem, occasionally it is difficult or impossible to pass the treatment device up the vein to the groin as is necessary. Previously described ways around this either result in the top of the vein not being treated increasing the risks of clots, or requiring specialised x-ray skills to pass the device up into the pelvis and back down into the vein to be treated. This simple new technique allows any doctor with the skills to perform endovenous surgery a way to treat these difficult veins under local anaesthetic, ensuring that the whole of the vein that needs treatment can be treated.


Ever since I performed the first endovenous surgery for varicose veins in the UK in March 1999, my team and I have been developing different and improved ways to treat varicose veins. Before we started using endovenous surgery, varicose veins were treated by "open surgery", which means cutting through the skin, tying off the veins and often stripping them away. We now know that this doesn't work very well, is very painful and tends to cause the veins to grow back in the long term. Because open surgery requires surgical incisions, venous surgery was determined by where we could get to the vein. Hence incisions were made behind the knee or in the groin. Many doctors who start performing endovenous surgery merely replicate the open surgery approach but using the new devices. However, those of us who have been in endovenous surgery since the early days have discovered that we do not have to respect these old approaches. We can now pass treatment devices into veins anywhere in the legs that we wish and in whichever direction is needed, provided we can see the vein with ultrasound. Simple local anaesthesia allows us to put a needle into the vein, through which we can pass a wire and then an access port to start treatment. This is now allowing us to treat not only the usual great saphenous vein and small saphenous vein, but also perforating veins, abnormal sections of veins that have developed in some patients, veins that have regrown due to previous stripping called neovascular tissue, as well as any other abnormal vein. Not surprisingly this has resulted in far better medium and long-term results for our patients. This latest publication is just one of the many techniques we have developed to ensure that our patients get the best possible treatment of their leg varicose veins and associated conditions such as venous leg ulcers.

Professor Mark S Whiteley
The Whiteley Clinic

Read the Original

This page is a summary of: Retrograde endovenous laser ablation of the great saphenous vein using the superficial inferior epigastric vein as access vessel illustrated by a case report, SAGE Open Medical Case Reports, January 2021, SAGE Publications,
DOI: 10.1177/2050313x21994993.
You can read the full text:




The following have contributed to this page