Evaluation Of Endovenous Laser Ablation As A Treatment Of Varicose Veins - A One Year Hospital Based Observational Study

Abstract

Background & objectives “Varicose veins are defined as dilated and tortuous subcutaneous veins of diameter more than 3 mm when measured in the standing position with demonstrable reflux on valsalva.” In a study done in north India on 1012 subjects, 46.7% & 49.3% of females and 27.8% & 18.9% of males were found to be having varicose veins & venous symptoms respectively. The symptoms of varicose veins are due to venous hypertension resulting from reflux in one or more of veins of the saphenous system and in their tributaries. The pathophysiology is mainly related to the changes in vein wall leading to venous dilatation and secondary valvular incompetence. Duplex ultrasound imaging is the mainstay of investigation of varicose veins. Duplex imaging can evaluate valve incompetency, extent of reflux, thrombosis, and number, location & diameter of incompetent perforators. Several methods have been used to treat varicose veins. Traditional open surgical methods include ligation of GSV near its drainage and stripping. With advances in science and technology, modalities such as “foam sclerotherapy, EVLT and endovenous radiofrequency ablation (RFA), Mechanochemical endovenous ablation (MOCA) and Glue therapy” are being used commonly as they are less invasive. EVLT was first introduced by Carlos Bone, a Spanish phlebologist, in 1998. It is a minimally invasive procedure for treating varicose veins performed usually on veins that are still fairly straight and less tortuous with the use of catheters & lasers and ultrasound guidance for insertion of catheter & administration of local anaesthesia. The objectives of this study are to assess the postoperative pain, complication rates and improvement in symptoms post endovenous laser ablation. Materials and methods One year prospective observational study was done in Department of Radio-diagnosis at the KLE’S Dr. Prabhakar Kore hospital & MRC, Belagavi. 50 patients with varicose veins diagnosed clinically and further confirmed by Doppler ultrasound scanwere included in the study. After considering the inclusion and exclusion criteria, the patients were subjected to: 1. Preoperative Doppler scan of the lower limb to assess the superficial & deep veins and sapheno-femoral junction competence and 2. Venous clinical severity score (VCSS) Following the operative procedure they were again subjected to VCSS on post-op day1, day 3, week 1, week 2 and at 3months. Doppler scan using standard protocol was performed immediately after the procedure to check for GSV thrombosis & to rule out deep vein thrombosis and at the end of 3 months to check for recurrences. Results The mean age in our study was 45.24 ± 12.81 years with 39 (78%) males and 11 (22%) females. Among the study population, 1 (1.8%) participant did not have any incompetent perforator in his lower limb, 19 (33.3%) lower limbs had only 1 incompetent perforator, 24 (42.1%) had only 2, 9 had only 3, 2 of the lower limbs had 4 and 2 of the lower limbs had 5 incompetent perforators each. Among the study population, 28(49.1%) of lower limbs had Perimalleolarpigmentation,19 (33.3%) had Diffuse, lower 1/3 calf pigmentation and 3(5.3%) of lower limbs had Wider, above lower 1/3 calf pigmentation. Among the study population, 4(7.0%) lower limbs had single active ulcer and 1(1.8%) of the lower limbs had two active ulcers. The mean of pre-operative VCSS score was 12.42 ± 3.42 in the study population, minimum level was 8 and maximum level was 22, it was 11.79 ± 3.15 in post-operative day 1, it was 10.93 ± 3.13 in the post-operative day 3, it was 9.98 ± 3.1 in post-operative 1st week, it was 8.3 ± 2.49 in post-operative 3rd week and it was 6.91 ± 2.07 in Post-Operative 3rd month.The differences in the total score at day 1, day 3, week 1 and week 3 follow up period with baseline value (pre-operative) were statistically significant (P value <0.001). No patient in our study had developed Deep vein thrombosis or recanalization of superficial veins on Doppler study at 3 months follow-up. Interpretation and conclusion Endovenous approach is advantageous in being able to do the procedure under local tumescent anaesthesia, having smaller number of complications postoperatively like pain, nerve injury, hematoma and also has the added advantage of early discharge. Whereas, Traditional surgery for varicose veins will have major/ minor complications including wound infections (most common), nerve injury, venous thromboembolic complications etc. Traditional surgery is related with higher postoperative pain scores. Recanalisation or persistence of reflux are less common with EVLA compared to conventional surgery. Thus the study concluded that endovenous laser ablation is one of the best treatment modality for varicose veins with lesser complications and early discharge.