Marcaine

St. Louis Park, Minn. -- A new minimally invasive treatment for varicose veins offers a higher success rate, with less pain and downtime than commonly performed stripping procedures, experts say.

The VNUS Closure technique (VNUS Medical Technologies; San Jose, Calif.) is indicated for patients with varicosities arising from the greater saphenous vein. It uses ultrasound-guided radiofrequency catheterization to close off areas of venous reflux.

"In my series, the success rate is 94 percent," says David Knighton, M.D., a specialist in vascular surgery and president of Knighton Clinic for Vein Care, who treated approximately 700 patients with the technique. "Nationwide, it's over 90 percent successful. Success is defined as successful ablation of the greater saphenous vein at one year follow-up."

To determine if the procedure can help a particular patient, Dr. Knighton first performs Duplex ultrasound. This procedure allows him to very precisely determine the source of the varicosities, which is usually the greater saphenous vein.

"That's a critical point for cosmetic surgeons because they do a lot of venous surgery without doing the ultrasound," he says. "So they tend to take care of the varicose branches they can see, but they haven't fixed the source. Then they have a very high recurrence rate."

Dr. Knighton performs the VNUS Closure procedure in his clinic using general anesthetic, although it can be done under local anesthetic in an outpatient setting. He begins by gaining access under ultrasound to the greater saphenous vein at the knee. Then he places an introducer, through which he introduces the catheter up the greater saphenous vein and through the sapheno-femoral junction, which is where the greater saphenous vein feeds into the common femoral vein. Still using ultrasound, he places the catheter's tips precisely at the sapheno-femoral junction.

"That's very critical because you need to close the varicosities right to the sapheno-femoral junction. If you don't, then you get a higher recurrence rate," he says.

After properly placing the catheter, he fills the fascial compartment that contains the greater saphenous vein with a solution of saline, Marcaine (bupivacaine, AstraZeneca) and epinephrine. This causes the vein to constrict around the catheter. Then he energizes the catheter, which allows him to heat the vein to 86 to 90 degrees C.

"Once it heats the vein to that temperature," Dr. Knighton says, "the vein constricts and the heat eliminates it from the circulation. Then we progress down the vein in 1 mm increments. There's a thermistor on the end of the catheter that measures the temperature of the vein wall. So we basically treat the whole vein 1 mm at a time. Then we pull out the catheter, put a little pressure on (the insertion site) until the bleeding stops, put a steri-strip on it and the procedure is complete. There are basically no incisions.

Patients can then walk out of the office. Dr. Knighton advises them to rest for one day after the procedure. Very few of them require pain medication.

"The biggest potential complication is misplacement of the catheter," he states. "That can be avoided by being very careful with the ultrasound and making sure everything is done correctly. The next biggest complication is recurrence, which happens in 4 percent of my cases. That's usually due to aberrant venous anatomy. Venous anatomy at the sapheno-femoral junction is not a very precise situation in that there are five branches there, and different people's vein branches come off in different places. So there's a variability in venous anatomy that you can't predict because you can't see it to that detail. Some patients recur because they have branches coming off the common femoral vein, which is higher up and feeds the varicosities. So you have to go in surgically and fix those with a simple ligation of the vein."

Coughing fits and nausea so severe that they pop open treated veins also can cause recurrences, although this has happened only twice in Dr. Knighton's experience. Embolization of clots that travel up the greater saphenous vein to the common femoral vein also can occur, but very rarely.

"Complications for VNUS Closure are very minor compared to those of stripping" Dr. Knighton says.

As for advantages, the closure procedure offers quicker recovery times and significantly less pain for patients (Lurie F, et al. J Vasc Surg. 2003 Aug;38 (2):207-214). "That's huge. The pain of vein stripping is excruciating. Anyone who's had a vein stripping probably will never get another one" he says.

In addition, insurance covers the closure procedure, provided a patient has ultrasound documentation that the greater saphenous vein is the culprit. Accordingly, Dr. Knighton says, "you have to be a good ultrasonographer. That's what takes time--learning how to do the ultrasound and manipulate the catheter. To be facile at it probably takes four to five procedures in a teaching situation. But my experience is that when people go on their own, the ultrasound is what they have difficulty with"

Cosmetic surgeons might do well to invest the time to master ultrasonography and the VNUS Closure.

"Cosmetic surgeons don't use it much at all" Dr. Knighton says. "That's one of the big problems. Cosmetic surgeons focus on the cutaneous manifestations of varicosities, which are spider veins and secondary varicose veins. They remove those, but not the greater saphenous, which is the cause."

VNUS Closure vs. Stripping

According to Dr. Knighton, using VNUS Closure is a significant improvement over stripping of the greater saphenous vein in the following ways:

* The veins are closed with a catheter inserted into the vein through a needle, so the surgery requires no incisions.

* Because the vein is closed and not removed, there is no bleeding into the tissues, resulting in minimal post-operative pain. Stripping produces significant bleeding into the tissues around the removed vein, causing significant pain, stiffness and bruising.

* With Closure, most patients can return to work in one or two days, whereas stripping often requires a two- to three-week recovery period.

* Closure can be done with regional or light general anesthesia, so the surgery can be done in an outpatient setting rather than the more expensive hospital operating room.

Disclosure: Dr Knighton consults with VNUS Medical Technologies regarding its patent and owns stock options in the company.

For more information: www.knightonclinic.com, www.vnus.com

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