Alert Topic: Varicose Veins
Venous disease worse among obese, study shows; radiofrequency ablation best option for everyone
For your overweight patients who need further convincing to shed those dangerous extra pounds, try this: The clinical severity of venous disease is often worse in obese patients.
Researchers from the Dunedin School of Medicine at New Zealand’s University of Otago report in the June 2008 issue of European Journal of Vascular and Endovascular Surgery that the worsening of venous disease in those with a far-above normal body-mass index may be the result of raised intra-abdominal pressure which then leads to greater reflux, increased vein diameter and venous pressures.
The university’s team of investigators arrived at this conclusion after assessing venous function using air plethysmography and duplex scanning in 934 consecutive patients presenting for assessment of venous disease. Foot vein pressures and femoral vein diameter were measured standing, sitting, lying down and ambulating.
Investigators observed that venous disease was more clinically severe in the obese limbs. In particular, they found that foot venous pressure in all positions was significantly greater among the obese.
Traditional approach
Venous disease – or, more properly, venous insufficiency – involves failure of the primary valves at the saphenofemoral junction. The condition often manifests itself in the form of varicose veins, which, untreated, can progress in a relentless manner and, in extreme instances, become life-threatening.
The traditional treatment for venous disease entails surgical ligation at the groin crease and division of the saphenous trunk and all proximal tributaries, followed either by a process of vein stripping or avulsion phlebectomy.
Unfortunately, vein stripping and avulsion phlebectomy are less than optimal techniques. Stripping, for instance, requires additional incisions at or below the knee, is associated with a high incidence of complications and is known to not prevent recurrence of varicose veins. Stripping also is very painful and – inasmuch as it must be performed on an inpatient basis – largely confines the patient to bed rest for several weeks postoperatively. Moreover, stripping leaves unsightly scars, making it problematic from a purely cosmetic standpoint.
Meanwhile, avulsion phlebectomy carries with it all the downsides of vein stripping, plus the added risk of damage to adjacent nerves and lymphatic vessels owing to the need for multiple 2 mm to 3 mm incisions along the entire course of the vein.
Advantages aplenty
A superior alternative to vein stripping and avulsion phlebectomy is endoluminal radiofrequency ablation. This newer procedure is less invasive (it can be performed in-office, which makes it more convenient and cost-effective) and is well-tolerated by patients (they are typically back to normal activities within 24 to 48 hours postoperatively). Endoluminal radiofrequency ablation also yields good cosmetic results, one reason why patient satisfaction with it is so high: Some studies suggest that as many as 95% of patients would recommend the procedure to a friend.
Studies have shown that in the absence of significant complications – such as deep vein thrombosis and pulmonary embolism, severe neuritic sequelae and skin burns – there are significant early advantages to endoluminal radiofrequency ablation compared with conventional vein stripping.
For example, a published investigation by the Straub Clinic and Hospital, Honolulu, compared procedure related complications, patient recuperation and quality-of-life outcomes between patients undergoing vein stripping with high ligation and patients undergoing greater saphenous vein obliteration with temperature-controlled radiofrequency ablation without adjunctive high ligation. In this study – appearing on the pages of The Journal of Vascular Surgery (2003) – a total of 85 patients from five domestic and international sites were randomly allocated to undergo either endoluminal radiofrequency ablation or stripping with high ligation. Follow-up examinations were performed at 72 hours, one week, three weeks and four months.
Researchers found that time to return to normal activities was significantly less in the endoluminal radiofrequency ablation group (mean 1.15 days) compared with the stripping-and-ligation group (mean 3.89 days). In the endoluminal radiofrequency ablation group, 80.5% of patients returned to routine activities of daily living within 1 day (versus 46.9% of patients in the other group). Endoluminal radiofrequency ablation patients went back to their jobs an average of 4.7 days postoperatively (compared to 12.4 days for those who underwent stripping and ligation).
How it works
The way endoluminal radiofrequency ablation works is by safely heating and denaturing venous tissues. This is accomplished by passing through the tissues electrical energy in the form of high-frequency alternating current, which, in turn, converts to heat of approximately 85 degrees centigrade – hot enough to cause tissue damage within a proximity of 2 mm but insufficient to harm tissues beyond that point or even to cause the vein wall to carbonize.
The high-frequency current is delivered through an electrode-tipped endoluminal catheter. When the electrodes come into contact with the vein walls, energy is channeled directly into the tissues. The heat causes the vessel to shrink in the treated area but does not coagulate blood.
Studies have shown that this procedure results in a significant reduction in the size of the vein lumen (in more than 90% of patients, biopsy specimens demonstrate complete occlusion of the vein lumen six weeks after treatment). Additionally, the procedure delivers an adequately stripped endothelium, good thrombus formation, thickened vessel walls and loss of collagen birefringence.
Reported complications of the procedure are rare. The greatest current area of concern is deep vein thrombosis: One 2004 study documented incidence of deep vein thrombus in 16% of 73 limbs treated with endoluminal radiofrequency ablation.
Conclusions
Venous disease and its manifestation of varicose veins is not just a cosmetic concern – it is a clinical problem that carries with it significant risk if left untreated.
The traditional approach of treating venous disease involves vein stripping or avulsion phlebectomy, neither of which are as favorable as the relatively new approach of endoluminal radiofrequency ablation.
Published studies show that endoluminal radiofrequency ablation has a high early success rate with a very low subsequent recurrence rate up to 5 years after treatment. The outpatient procedure is less painful and allows patients to get back to participating in activities of daily living within 24 to 48 hours postoperatively.
Like laser therapy, endoluminal radiofrequency ablation works by heating tissues. However, wholly unlike laser therapy, endoluminal radiofrequency ablation generates a mere one-tenth the heat of a laser (a key reason for the reduced risk of complications).
Endoluminal radiofrequency ablation for treatment of venous insufficiency is a procedure best performed by a board-certified pain doctor for the reason that this type of specialist possesses the training to deal on-the-spot with complications and to provide the most complete follow-up care.
Here at Oregon Pain Associates, we are highly adept at endoluminal radiofrequency ablation for treatment of venous insufficiency. However, we believe that it is not the only procedure that can and should be utilized. Varicose vein treatment requires a comprehensive approach that also incorporates sclerotherapy, injection therapy and cosmetic plastic surgery. And, with us, all of these treatments are provided in a relaxed, inviting spa-like atmosphere.
Our success rate with the treatment of venous disease is very high: We are able in more than 95% of cases to deliver a good to excellent result.
We welcome your referrals of patients who suffer from varicose veins. Oregon Pain Associates can on your behalf perform evaluations of these patients and make intervention recommendations or, if you prefer, initiate treatment and perform follow-up. Whichever path you choose, we will keep you apprised every step of the way. Satisfied by the high-quality services and interactions delivered at each encounter, your patients will return to you as willing as ever to continue entrusting you with their ongoing care.
For more information, please call Oregon Pain Associates in Portland or Salem at 503-238-7246 or toll-free 866-785-7246.
BACK
Alert Topic: Varicose Veins
Venous disease worse among obese, study shows; radiofrequency ablation best option for everyone
For your overweight patients who need further convincing to shed those dangerous extra pounds, try this: The clinical severity of venous disease is often worse in obese patients.
Researchers from the Dunedin School of Medicine at New Zealand’s University of Otago report in the June 2008 issue of European Journal of Vascular and Endovascular Surgery that the worsening of venous disease in those with a far-above normal body-mass index may be the result of raised intra-abdominal pressure which then leads to greater reflux, increased vein diameter and venous pressures.
The university’s team of investigators arrived at this conclusion after assessing venous function using air plethysmography and duplex scanning in 934 consecutive patients presenting for assessment of venous disease. Foot vein pressures and femoral vein diameter were measured standing, sitting, lying down and ambulating.
Investigators observed that venous disease was more clinically severe in the obese limbs. In particular, they found that foot venous pressure in all positions was significantly greater among the obese.
Traditional approach
Venous disease – or, more properly, venous insufficiency – involves failure of the primary valves at the saphenofemoral junction. The condition often manifests itself in the form of varicose veins, which, untreated, can progress in a relentless manner and, in extreme instances, become life-threatening.
The traditional treatment for venous disease entails surgical ligation at the groin crease and division of the saphenous trunk and all proximal tributaries, followed either by a process of vein stripping or avulsion phlebectomy.
Unfortunately, vein stripping and avulsion phlebectomy are less than optimal techniques. Stripping, for instance, requires additional incisions at or below the knee, is associated with a high incidence of complications and is known to not prevent recurrence of varicose veins. Stripping also is very painful and – inasmuch as it must be performed on an inpatient basis – largely confines the patient to bed rest for several weeks postoperatively. Moreover, stripping leaves unsightly scars, making it problematic from a purely cosmetic standpoint.
Meanwhile, avulsion phlebectomy carries with it all the downsides of vein stripping, plus the added risk of damage to adjacent nerves and lymphatic vessels owing to the need for multiple 2 mm to 3 mm incisions along the entire course of the vein.
Advantages aplenty
A superior alternative to vein stripping and avulsion phlebectomy is endoluminal radiofrequency ablation. This newer procedure is less invasive (it can be performed in-office, which makes it more convenient and cost-effective) and is well-tolerated by patients (they are typically back to normal activities within 24 to 48 hours postoperatively). Endoluminal radiofrequency ablation also yields good cosmetic results, one reason why patient satisfaction with it is so high: Some studies suggest that as many as 95% of patients would recommend the procedure to a friend.
Studies have shown that in the absence of significant complications – such as deep vein thrombosis and pulmonary embolism, severe neuritic sequelae and skin burns – there are significant early advantages to endoluminal radiofrequency ablation compared with conventional vein stripping.
For example, a published investigation by the Straub Clinic and Hospital, Honolulu, compared procedure related complications, patient recuperation and quality-of-life outcomes between patients undergoing vein stripping with high ligation and patients undergoing greater saphenous vein obliteration with temperature-controlled radiofrequency ablation without adjunctive high ligation. In this study – appearing on the pages of The Journal of Vascular Surgery (2003) – a total of 85 patients from five domestic and international sites were randomly allocated to undergo either endoluminal radiofrequency ablation or stripping with high ligation. Follow-up examinations were performed at 72 hours, one week, three weeks and four months.
Researchers found that time to return to normal activities was significantly less in the endoluminal radiofrequency ablation group (mean 1.15 days) compared with the stripping-and-ligation group (mean 3.89 days). In the endoluminal radiofrequency ablation group, 80.5% of patients returned to routine activities of daily living within 1 day (versus 46.9% of patients in the other group). Endoluminal radiofrequency ablation patients went back to their jobs an average of 4.7 days postoperatively (compared to 12.4 days for those who underwent stripping and ligation).
How it works
The way endoluminal radiofrequency ablation works is by safely heating and denaturing venous tissues. This is accomplished by passing through the tissues electrical energy in the form of high-frequency alternating current, which, in turn, converts to heat of approximately 85 degrees centigrade – hot enough to cause tissue damage within a proximity of 2 mm but insufficient to harm tissues beyond that point or even to cause the vein wall to carbonize.
The high-frequency current is delivered through an electrode-tipped endoluminal catheter. When the electrodes come into contact with the vein walls, energy is channeled directly into the tissues. The heat causes the vessel to shrink in the treated area but does not coagulate blood.
Studies have shown that this procedure results in a significant reduction in the size of the vein lumen (in more than 90% of patients, biopsy specimens demonstrate complete occlusion of the vein lumen six weeks after treatment). Additionally, the procedure delivers an adequately stripped endothelium, good thrombus formation, thickened vessel walls and loss of collagen birefringence.
Reported complications of the procedure are rare. The greatest current area of concern is deep vein thrombosis: One 2004 study documented incidence of deep vein thrombus in 16% of 73 limbs treated with endoluminal radiofrequency ablation.
Conclusions
Venous disease and its manifestation of varicose veins is not just a cosmetic concern – it is a clinical problem that carries with it significant risk if left untreated.
The traditional approach of treating venous disease involves vein stripping or avulsion phlebectomy, neither of which are as favorable as the relatively new approach of endoluminal radiofrequency ablation.
Published studies show that endoluminal radiofrequency ablation has a high early success rate with a very low subsequent recurrence rate up to 5 years after treatment. The outpatient procedure is less painful and allows patients to get back to participating in activities of daily living within 24 to 48 hours postoperatively.
Like laser therapy, endoluminal radiofrequency ablation works by heating tissues. However, wholly unlike laser therapy, endoluminal radiofrequency ablation generates a mere one-tenth the heat of a laser (a key reason for the reduced risk of complications).
Endoluminal radiofrequency ablation for treatment of venous insufficiency is a procedure best performed by a board-certified pain doctor for the reason that this type of specialist possesses the training to deal on-the-spot with complications and to provide the most complete follow-up care.
Here at Oregon Pain Associates, we are highly adept at endoluminal radiofrequency ablation for treatment of venous insufficiency. However, we believe that it is not the only procedure that can and should be utilized. Varicose vein treatment requires a comprehensive approach that also incorporates sclerotherapy, injection therapy and cosmetic plastic surgery. And, with us, all of these treatments are provided in a relaxed, inviting spa-like atmosphere.
Our success rate with the treatment of venous disease is very high: We are able in more than 95% of cases to deliver a good to excellent result.
We welcome your referrals of patients who suffer from varicose veins. Oregon Pain Associates can on your behalf perform evaluations of these patients and make intervention recommendations or, if you prefer, initiate treatment and perform follow-up. Whichever path you choose, we will keep you apprised every step of the way. Satisfied by the high-quality services and interactions delivered at each encounter, your patients will return to you as willing as ever to continue entrusting you with their ongoing care.
For more information, please call Oregon Pain Associates in Portland or Salem at 503-238-7246 or toll-free 866-785-7246.
BACK