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Why is EVLA recommended for a perforator vein?

This question was asked in Panther Creek, Texas and has 10 answer(s) as of 06/12/2013.
I had saline sclerotherapy done 10 years ago with great success It got rid of the green surface veins-they were not bulging though-just aching. I am having the same problem now, but with a few spider veins, so I wanted to have the sclerotherapy done again, so when vein specialist was offering a free ultrasound, I went to see him. Turns out I have a leaky valve in my GSV in lower calf (it's only a very small lump-not bulging yet). He is recommending that I have EVLA done and a MP done on a leaky perforator vein in right leg and then foam sclerotherapy for the surface and spider veins. I have no insurance and the cost will be around 2200 dollars, so I am hesitant. I hear there can be nerve damage/burning associated with the ELVA-is radiofrequency ablation better in terms of side effects? Could foam sclerotherapy be just as efficient in closing down the GSV if the veins aren't twisted and bulging yet? Couldn't I just have a MP done on both legs with less expense? Isn't a little bit of reflux normal to a certain decimal? I realize I need to take care of the bigger problem in order for the smaller veins to be fixed, but because of money, I need to find the least expensive treatment and if something can be avoided, that would be great too.


Doctors Answers (10)

Well, you have a lot in your question. Yes, EVLA (endovenous laser ablation) or RA (radiofrequency ablation) are the two types of thermal ablation available. They both yield the same result, a 'cooked' trunk vein that will turn into scar tissue and therefore no longer carry blood and cause you any more problems. EVCA (endovenous chemical ablation) is a technique that uses ultrasound to guide a needle into an abnormal trunk vein. It too causes the treated vein to become scarred and shut down. Costs can vary from office to office. Using thermal ablation techniques usually cost more because of the equipment and personnel needed to complete a safe procedure. EVCA doesn't use expensive generators to produce the 'heat", so therefore it is more cost effective in that sense. However, when it comes to long term success, thermal ablation is by far more effective. MP (microphlebetomy) is a mini surgical procedure where a small incision is made along a bulging vein, followed by the insertion of a hook to grasp the vein so it can be pulled above the skin. This exposed vein is gently tugged and pulled until it tears. Then other spots are chosen for a repeat of this procedure. This is a messy approach and may leave numerous scars; but this is very much dependent upon the physician's skill and how well the patient heals. I recommend that you have your physician explain in detail what he can offer and the cost differences. As to what is reflux, the cut off for how long venous back flow is considered normal is less than 0.5 sec. So, anything longer is considered medically necessary, abnormal and should be treated.

You have several options, including simply sclerotherapy or only microphlebectomy. I am not sure you need an ablation of your GSV. Talk with the doctor or seek a second opinion.

A dysfunctional perforating vein allows venous blood from a deep vein (in the muscles) to send high pressure venous blood to the connecting surface veins and produce varicose veins. Normally, there are one-way venous valves to prevent this, allowing low pressure venous blood to drain into the deep veins where it is lifted up to the heart by regular leg muscular movements such as walking. In your case, an endovenous laser ablation (EVLA) should be an excellent choice for closing the refluxing lower extremity vein(s). If an apparent bulging varicose vein is seen, then a micro-phlebectomy (MP) may be an option. The first step would be to review the ultrasound results. Foam sclerotherapy is definitely a second choice as it is not as effective and may just buy some additional time before a proper treatment is done to permanently close the perforating vein. A radiofrequency ablation is a first generation vein ablating procedure that is also an excellent alternative to the laser ablation either will work well. It sounds like you have significant venous reflux (abnormal blood back-flow) which is typically greater than 1/2 seconds of reflux on the ultrasound evaluation. The smaller surface reticular and spider veins are usually cosmetic and treatment may wait.

If it is just reflux in the lower (distal) GSV from a calf perforator, then foam sclerotherapy would be very effective. I wouldn't recommend EVLT in the calf perforator, especially for cosmetic purposes. The risks certainly outweigh the benefits and you can have significant nerve pain after. If you are having leg aching, large varicose veins, and/or discoloration or ulceration with a very large calf perforator, then treating the calf perforator may be beneficial. If you are describing just small veins that are not bulging yet, I do not believe EVLT and sclerotherapy would be very effective.

Endovenous laser ablation, also called endovenous laser therapy, is my preferred method of treating incompetent perforator veins. I believe it is more reliable than radiofrequency ablation or sclerotherapy. Incompetent perforator veins, as well as refluxing great saphenous veins, can feed veins on the surface of the skin, such as spider veins. It is a standard recommendation in phlebology to treat the deeper refluxing veins before treating the spider veins. The one exception would be for patients that have no symptoms, no bulging veins or skin changes, and just want some spider veins treated. In that situation I will offer sclerotherapy or surface laser therapy without necessarily treating the deeper veins.

If your primary complaint is that of some small spider type veins on the surface of your legs, then I agree with your concern about having laser procedures done on the saphenous vein or on a perforator. It is probably a good idea to seek out a second opinion and have a second ultrasound done to confirm what was originally presented to you. If your primary complaint is just some small veins, even if there is some saphenous veins then reflux injection sclerotherapy alone may be reasonable. If the veins you are concerned about are on the outside of your leg then even if the great saphenous vein is a problem it would not be influencing these veins. In addition, most perforators can be treated with injection sclerotherapy alone utilizing foam sclerosant. Also, typically foam is not used on surface veins but on deeper veins with the help of an ultrasound.

Once reflux is present, it will intensify with time. An MP will probably fix the local problem temporarily but not the source of the problem which is the refluxing valves. These are best addressed with ablation (either radio frequency or laser). Foam sclero therapy is not indicated for perforators as the sclerosant will get to the deep veins. It's a good adjunctive treatment for the superficial spider veins once ablation is performed. Finally, laser ablation does not cause the complications you mentioned if done by a vein specialist. Actually, the long term results are better with laser than any other modality.

I address perforating veins in one of two ways. If the perforator is smaller and just feeds non-bulging veins I would do foam sclerotherapy of that vein. If it is a large perforating vein that feeds bulging varicose veins I would perform an endovenous laser perforator ablation. I have had good success following this method. I have done both laser and radio frequency ablations and in my experience the risks are the same as far as nerve damage etc. With respect to the great saphenous vein, sclerotherapy if not a good option due to the large size and high flow in that vein. If the saphenous does not communicate with the areas that you can see or the symptomatic area, you do not need to treat it at this time. In the future you may need to address it but with the use of support stockings and exercise, it may never progress to that point.

I have no experience in using EVLT. I do not know anyone who uses it for perforator veins; I use rfa exclusively for the greater saphenous vein, however I am not sure that the degree of reflux present justifies any treatment at all. The spider veins are a side issue that can be postponed. Good luck to you.

Discuss the financial issues with your physician and work to set priorities regarding treatment.

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