Residency · Residency · Interventional Radiology

Chronic Venous Insufficiency and Varicose Vein Ablation

Pathophysiology

Chronic venous insufficiency (CVI) results from venous hypertension driven by three principal mechanisms: valvular incompetence causing reflux through incompetent valves in the superficial, deep, or perforator veins; venous obstruction from post-thrombotic stenosis or external compression; and calf muscle pump dysfunction related to immobility, obesity, or neuromuscular disease. Superficial venous reflux in the great saphenous vein (GSV) and small saphenous vein (SSV) is the most common treatable cause. Perforator vein incompetence connects the deep and superficial systems and exacerbates reflux.

CEAP Classification

The CEAP system provides a standardized classification for chronic venous disease. Clinical grades range from C0 (no visible or palpable signs) through C1 (telangiectasias or reticular veins), C2 (varicose veins greater than 3 mm diameter), C3 (edema), C4a (pigmentation or eczema), C4b (lipodermatosclerosis or atrophie blanche), C4c (corona phlebectatica), C5 (healed venous ulcer), and C6 (active venous ulcer). The remaining components classify etiology (congenital, primary, secondary, or no identifiable cause), anatomy (superficial, deep, perforator), and pathophysiology (reflux, obstruction, or both).

Clinical Assessment

Patients typically present with leg heaviness, aching, swelling that worsens at the end of the day, cramping, and pruritus. Physical examination reveals varicose veins, skin changes, edema, and ulceration typically located at the medial malleolus. Duplex ultrasound is the essential diagnostic study, performed with the patient standing and facing away from the examiner. Reflux is assessed using Valsalva or manual compression and release, defined as retrograde flow exceeding 0.5 seconds in superficial veins and exceeding 1.0 second in deep veins. The examination maps the GSV, SSV, anterior accessory saphenous vein, and perforators, measures vein diameter (which influences treatment choice), and rules out deep venous obstruction before treating superficial reflux.

Treatment Options

Conservative Management

Compression stockings (20-30 mmHg or 30-40 mmHg), exercise, weight loss, and leg elevation are indicated for all patients. A trial of conservative management is often required before insurance authorization for procedural treatment. These measures effectively manage symptoms but do not correct underlying reflux.

Endovenous Thermal Ablation (ETA)

Radiofrequency Ablation (RFA)

The ClosureFast system (Medtronic) uses a segmental radiofrequency heating element that delivers 120 degrees Celsius for 20 seconds per segment. The thermal damage to the vein wall causes collagen contraction, fibrosis, and eventual vein occlusion. Tumescent anesthesia is injected perivenously under ultrasound guidance, providing anesthesia, heat sink protection, and vein compression. Technical success (vein closure) exceeds 95%, and the procedure causes less pain and bruising than laser ablation.

Endovenous Laser Ablation (EVLA/EVLT)

Laser energy at various wavelengths (810 nm, 980 nm, 1320 nm, 1470 nm) is delivered via a fiber within the vein. Higher wavelengths (1470 nm) target water in the vein wall and produce less bruising and pain than lower wavelengths. Radial-tip fibers distribute energy circumferentially for more uniform ablation. Tumescent anesthesia is required. Technical success exceeds 95%, and while there is slightly more bruising and pain than with RFA, long-term efficacy is equivalent.

Non-Thermal Non-Tumescent (NTNT) Techniques

Cyanoacrylate Glue Closure (VenaSeal)

Medical-grade cyanoacrylate adhesive is injected into the vein under ultrasound guidance without tumescent anesthesia, requiring only a single needle stick at the access site. An inflammatory reaction causes vein wall adhesion and fibrosis. The VeClose trial demonstrated non-inferiority to RFA at 5 years. Advantages include no tumescent anesthesia, no compression stockings required post-procedure, and no thermal nerve injury risk. Disadvantages include a foreign body reaction with phlebitis in 15-20% of patients, potential for allergic reaction, and higher device cost. The technique is contraindicated in patients with cyanoacrylate allergy.

Mechanochemical Ablation (MOCA -- ClariVein)

A rotating wire tip causes endothelial damage while simultaneously infusing a liquid sclerosant (sodium tetradecyl sulfate or polidocanol). No tumescent anesthesia is needed. The dual mechanism combines mechanical endothelial disruption with chemical sclerotherapy. Closure rates are slightly lower than thermal ablation at 3-5 years. The technique is particularly useful for SSV ablation near the sural nerve, as no thermal energy is delivered near nerves.

Sclerotherapy

Liquid sclerotherapy injects sclerosant into varicose veins and reticular veins. Foam sclerotherapy mixes sclerosant with air or CO2 to create foam that displaces blood and increases contact time with the vein wall, making it useful for larger varicose veins and recurrent disease. Ultrasound-guided foam sclerotherapy (UGFS) targets deeper veins. Risks include deep vein thrombosis from foam migration, skin staining, and rare visual disturbance due to paradoxical embolism through a patent foramen ovale.

Surgical Options

High ligation and stripping was the traditional surgical treatment but has been largely replaced by endovenous techniques. Ambulatory phlebectomy removes varicose vein tributaries through small stab incisions and is often combined with truncal vein ablation. CHIVA (Conservative Hemodynamic Insufficiency Venous Ambulatory treatment) is a hemodynamic-based surgical strategy popular in Europe.

GSV vs. SSV Ablation Considerations

For GSV ablation, access is at or below the knee with ablation extending to the saphenofemoral junction, leaving 2 cm from the junction to avoid extension into the common femoral vein. For SSV ablation, treatment extends to the saphenopopliteal junction, but there is higher risk of sural nerve injury with thermal ablation because the nerve runs adjacent to the SSV. Non-thermal techniques should be considered for this location. Junction anatomy should always be confirmed with ultrasound before ablation.

Venous Ulcer Management

Active venous ulcers (C6) warrant aggressive treatment. The EVRA trial demonstrated that early endovenous ablation within 2 weeks for patients with venous ulcers resulted in faster ulcer healing compared with deferred ablation. Compression therapy remains essential for ulcer healing alongside ablation. Underlying superficial and perforator reflux should be treated.

<image>Illustration of endovenous thermal ablation of the great saphenous vein. Sequential panels: (1) Ultrasound-guided percutaneous access of the GSV below the knee with a micropuncture needle; (2) Laser or RFA catheter positioned 2 cm from the saphenofemoral junction under ultrasound guidance, with tumescent anesthesia being injected perivenously; (3) Cross-sectional ultrasound view showing the GSV surrounded by tumescent fluid (anechoic halo) with the ablation catheter centered within the vein; (4) Post-procedure ultrasound at 1 week showing the ablated GSV as a non-compressible, echogenic cord with no flow on color Doppler. Labels identify the GSV, common femoral vein, saphenofemoral junction, and tumescent fluid.</image>

<image>Comparison diagram of thermal versus non-thermal ablation techniques for varicose veins. Four panels: (1) Radiofrequency ablation (ClosureFast) showing segmental heating with tumescent anesthesia; (2) Endovenous laser ablation showing fiber tip and energy delivery with tumescent anesthesia; (3) Cyanoacrylate glue closure (VenaSeal) showing glue injection without tumescent anesthesia; (4) Mechanochemical ablation (ClariVein) showing the rotating wire and sclerosant infusion without tumescent anesthesia. A comparison table below lists closure rates, pain levels, need for tumescent anesthesia, compression stockings, and cost for each technique.</image>

<image>Photographic and schematic representation of the CEAP classification of chronic venous disease. Six panels arranged from C1 to C6: C1 showing telangiectasias and reticular veins; C2 showing tortuous varicose veins; C3 showing pitting edema of the lower leg; C4 showing pigmentation and lipodermatosclerosis; C5 showing a healed venous ulcer with scar tissue; C6 showing an active venous ulcer at the medial malleolus. Each panel includes a brief clinical description and the typical findings on duplex ultrasound.</image>

Clinical Pearls

Duplex ultrasound is mandatory before any venous intervention to map reflux patterns, measure vein diameter, and exclude deep venous obstruction. Endovenous thermal ablation (RFA or EVLA) has replaced surgical stripping as the standard of care with equivalent or superior outcomes and faster recovery. Non-thermal techniques (VenaSeal, ClariVein) eliminate the need for tumescent anesthesia and reduce the risk of nerve injury, making them particularly useful for SSV ablation. The EVRA trial supports early ablation within 2 weeks for patients with active venous ulcers rather than deferring until the ulcer heals. The ablation catheter should be positioned 2 cm from the saphenofemoral junction to avoid thermal extension into the common femoral vein, known as endovenous heat-induced thrombosis (EHIT). Foam sclerotherapy is a useful adjunct for tributaries and recurrent varicose veins but carries a small risk of DVT and visual disturbance.

References

• Defined by the NICE Guidelines on Varicose Veins: Diagnosis and Management. 2013 (updated 2020)
• Morrison N et al. Five-year extension study of patients from a randomized clinical trial (VeClose) comparing cyanoacrylate closure versus radiofrequency ablation for the treatment of incompetent great saphenous veins. J Vasc Surg Venous Lymphat Disord 2020
• Gohel MS et al. A randomized trial of early endovenous ablation in venous ulceration (EVRA trial). N Engl J Med 2018
• Defined by the AVF/ACP/SIR/SVS Clinical Practice Guidelines on Management of Varicose Veins. J Vasc Surg Venous Lymphat Disord 2024

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