A new way to pass a laser into varicose veins in difficult cases where varicose veins need treatment

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.

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Photo by Ale Romo Photography on Unsplash

Photo by Ale Romo Photography on Unsplash

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.

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