Varicose Vein Treatment Comparison of Thermal, Nonthermal, & Surgical Approaches

by VIP Specialists | May 2020
The Vein Specialists at VIP explain the treatment of varicose veins with laser, radiofrequency, foam sclerosant, glue, phlebectomy, and surgery; and compare the risks and benefits of each treatment method.
Varicose Vein Treatment Comparison: Thermal, Nonthermal, and Surgical Approaches

In This Article:

  • Overview of varicose vein treatments with thermal ablation, nonthermal ablation, microphlebectomy, and surgery
  • Comparison of treatment types for the removal of varicose veins
  • Benefits and drawbacks of:
    • Radiofrequency
    • Laser ablation
    • Foam sclerotherapy
    • Mechanochemical ablation (MOCA)
    • Cyanoacrylate vein glue
    • Microphlebectomy
    • Surgery
Thermal ablation – Heat from radiofrequency energy or a laser breaks down the proteins that form the structure of the vein wall. Due to the heat generated, a cold anesthetic saline mixture is injected locally to reduce pain and prevent skin burns or nerve injury.

Nonthermal ablation – A wire, chemical foam (sclerotherapy), glue, or a combination of these are injected into the varicose vein. The vein collapses on itself and eventually closes.

Microphlebectomy – A hooked instrument is used to remove the varicose vein through small, millimeter sized incisions on the skin surface.

Surgery – Varicose veins are detached and then removed through small cuts in the skin. The remaining veins are re-routed and tied together.

Thermal Ablation

Radiofrequency Ablation

A device that produces high frequency, alternating electrical current is delivered through a thin needle or catheter into the vein. High heat is generated by the electrical current, and causes damage to the vein wall [6]. Due to the heat generated, a cold anesthetic saline mixture called tumescent anesthesia is injected locally to reduce pain and to prevent nerve injury. The VNUS Closure procedure is a radiofrequency ablation treatment that can be done in the VIP office.

Benefits of Radiofrequency Ablation

● Effective in treating larger varicose veins with diameters of 5 to 8 mm.

Drawbacks of Radiofrequency Ablation

● Nerve injury is very rare, but possible
● It may be difficult to treat tortuous (twisted) veins or partially thrombosed (obstructed) veins.

Laser Ablation

Lasers emit light at a specific wavelength and frequency. Light absorbed by the vein wall generates heat that induces thermal injury to the varicose vein. The target vein structure, vein depth, and patient skin type determine the specifications of the laser. Due to the heat generated, a cold anesthetic saline mixture is injected locally to reduce pain and to prevent skin burns or nerve injury [5].

Benefits of Laser Ablation

● Laser ablation can treat large varicose veins and veins that are recurrent.

Drawbacks of Laser Ablation

● Skin discoloration, nerve injury, and skin burns are possible risks of laser ablation treatment.

Nonthermal Ablation

Foam Sclerotherapy

Foam sclerotherapy utilizes a chemical foam mixture which is injected into the varicose vein. The heavier foam displaces the blood in the vein while also dehydrating and damaging the vein. The procedure is usually done under the guidance of ultrasound imaging.

Benefits of Foam Sclerotherapy

● Foam sclerotherapy is effective in treating varicose veins that are large, lie deep below the surface of the skin, and are highly branched or twisted [2, 3].
● Because foam produces small bubbles, duplex ultrasound can be used to guide treatment [2].
● Partially occluded varicose veins can be treated.

Drawbacks of Foam Sclerotherapy

● Multiple treatment sessions may be necessary for complete vein clearance.
● Adverse reactions, such as ulceration, can occur following treatment.

Mechanochemical Ablation (MOCA)

MOCA, also called ClariVein, is a vein clearance technique where a wire is used to injure the vein and a chemical sclerosant is simultaneously injected. The mechanical energy from the wire irritates the varicose vein and enhances exposure to the sclerosant. The MOCA technique can be used for veins that are straight enough to allow wire placement [2,4].

Benefits of MOCA

● Superficial veins and veins below the knees are easily treated with MOCA.

Drawbacks of MOCA

● Tortuous (twisted) and partially thrombosed (obstructed) varicose veins are difficult to treat with MOCA.
● MOCA is not as effective on recurrent veins.

Cyanoacrylate Vein Glue

Small beads of cyanoacrylate glue are delivered into the varicose vein through a catheter. The vein glue that is commonly used is called VenaSeal. As a foreign body, the glue initiates an inflammatory reaction that leads to occlusion and eventual closure of the vein [2,4].

Benefits of Cyanoacrylate Vein Glue

● Works well for superficial and small veins.
● Can be used to treat recurrent veins.

Drawbacks of Cyanoacrylate Glue

● Patients with adhesive or tape allergies may be sensitive and have cross-reactivity.
● The glue remains in the vein permanently and stays there as a foreign body.

Microphlebectomy

Veins can also be extracted with microphlebectomy, where small incisions or punctures are made into the skin and the varicose vein is removed with a hooked instrument. This procedure can be done in the office or outpatient setting and is often used following ablation to remove any remaining segments of varicose veins [7].

Benefits of Microphlebectomy

● Effective for removing large, bulging varicose veins that are close to the surface of the skin [7].
● Incisions are 1 to 3mm in length and usually require no sutures.

Drawbacks of Cyanoacrylate Glue

● Blood collected under the skin during the procedure can cause bruising or hematoma.
● Fragments of unremoved varicose vein can cause inflammation and irritation.
● Numbness and tingling may result if a sensory nerve is injured.

Varicose Vein Surgery

Surgical Ligation and Vein Stripping

Surgical varicose vein removal remains the standard to which minimally invasive techniques are compared. While minimally invasive techniques are now the preferred approach, some patients with large varicose veins or complications may be best managed with open surgery performed in the hospital inpatient setting. Minimally invasive surgical microphlebectomy can also be used to remove larger varicose veins in the office setting [7].

Large varicose veins, typically >1.5 cm, that are at risk of hemorrhaging or that have a history of recurrent ulceration, can be surgically excised while the patient is under anesthesia.

Benefits of Surgery

● Low vein recurrence and neovascularization (new veins).
● Can remove larger varicose veins that would otherwise be untreatable with other minimally invasive thermal or nonthermal ablation techniques.

Drawbacks of Surgery

● Can be invasive and patients may experience more postoperative pain.
● Recovery time can be longer with a higher rate of complications.

Which Varicose Vein Treatment is Best?

To summarize, there are many viable options when it comes to varicose vein treatment, and the most favorable treatment can depend on physician preference, patient preference, or on the complexity and extent of vein disease. We highlight the strengths, benefits and risks of each treatment in the table below [9]. You can schedule an appointment with one of our vein specialists in Visalia, CA today to discuss further.

 

Technique Types of Veins Treated Benefits Risks
Foam Sclerotherapy Tortuous varicose veins, superficial veins, recurrent veins, partially occluded varicose veins Can treat deeper varicose veins that branch Skin discoloration possible, brief tenderness
Mechanochemical Ablation (MOCA) Smaller, superficial varicose veins Combines mechanical and chemical techniques, sclerosant is well distributed Local adverse reaction possible
Glue Superficial veins, recurrent varicose veins, varicose veins with <1 cm diameter Glue is well distributed into deeper veins and throughout varicosities Allergic reaction, immune reaction to foreign body
Laser Ablation Larger varicose veins, recurrent varicose veins Laser parameters can be altered to tailor treatment Nerve injury possible, skin burn possible
Radiofrequency Ablation Larger varicose veins, recurrent varicose veins Large, superficial varicose veins can be targeted Nerve injury possible
Microphlebectomy Short varicose vein segments near the surface of the skin Can treat isolated varicose veins, large varicose veins often have quicker and better cosmetic results than with foam sclerotherapy Nerve injury possible, may require second stage treatment with another technique
Surgery Large varicose veins >1.5 cm in diameter, veins with potential to hemorrhage or that are very occluded Best treatment for large veins that cannot be removed with minimally invasive techniques Infection, postoperative pain

 

References
[1] Patient education: Vein ablation (The Basics). UpToDate. Accessed March 2020.
[2] Scovell, S. Liquid, foam, and glue sclerotherapy techniques for the treatment of lower extremity veins. UpToDate. Accessed March 2020.
[3] Morrison, N., Gibson, K., Vasquez, M., Weiss, R., Cher, D., Madsen, M., & Jones, A. (2017). VeClose trial 12-month outcomes of cyanoacrylate closure versus radiofrequency ablation for incompetent great saphenous veins. Journal of Vascular Surgery: Venous and Lymphatic Disorders, 5(3), 321–330.
[4] Passman, MA. Approach to treating symptomatic superficial venous insufficiency. UpToDate. Accessed March 2020.
[5] Lupton JR, Alster TS, Romero P. Clinical comparison of sclerotherapy versus long-pulsed Nd:YAG laser treatment for lower extremity telangiectases. Dermatol Surg 2002; 28:694.
[6] Scovell, S. Radiofrequency ablation for the treatment of lower extremity chronic venous disease. UpToDate. Accessed March 2020.
[7] Eidt, JF. Open surgical techniques for lower extremity vein ablation. UpToDate. Accessed May 2020.
[8] Biemans AA, Kockaert M, Akkersdijk GP, van den Bos RR, de Maeseneer MG, Cuypers P, Stijnen T, Neumann MH, Nijsten T. Comparing endovenous laser ablation, foam sclerotherapy, and conventional surgery for great saphenous varicose veins. J Vasc Surg. 2013 Sep;58(3):727-734.e1. Epub 2013 Jun 13.
[9] Dillavou, E., Kiguchi, M. Comparison of methods for endovenous ablation for chronic venous disease. UptoDate. Accessed March 2020.

Medical Disclaimer
The Materials available on visaliavips.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients.

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