Interventions for Varicose Veins: Beyond Ablation

  • Raghu KolluriEmail author
Vascular Disease (I Weinberg, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Vascular Disease

Opinion statement

Minimally invasive endothermal treatments have replaced surgical ligation and stripping in the management of chronic venous insufficiency (CVI) and are now considered the standard of care. Newer techniques have emerged in the last few years in an attempt to further minimize the procedural discomfort associated with endothermal procedures. These new techniques are designed to avoid tumescent anesthesia (TA). These new non-thermal, tumescentless techniques are well tolerated and are shown to result in equivalent outcomes when compared to the thermal ablations. Since there is no data to support the argument that one of these therapies is truly superior to another, selection of a particular thermal or non-thermal technique is dependent on patient and physician preferences. Adoption of a particular non-thermal procedure is also dependent on other factors such as the learning curve, initial setup costs, overall cost-effectiveness and reimbursement. Once the reimbursement issues are resolved and durability is confirmed, these techniques have the potential to become the new standard of care for the management of CVI.


Vascular disease Minimally invasive endothermal treatments Tumescent anesthesia Endothermal treatments 


Compliance with Ethical Standards

Conflict of Interest

Raghu Kolluri reports personal fees from Medtronic, Bard, Cook, Boston Scientific, and Volcano.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.•
    Eklof B, Perrin M, Delis KT, Rutherford RB, Gloviczki P, American Venous F, et al. Updated terminology of chronic venous disorders: the VEIN-TERM transatlantic interdisciplinary consensus document. J Vasc Surg. 2009;49(2):498–501. Important consensus document to standardize venous nomenclature.CrossRefPubMedGoogle Scholar
  2. 2.
    Beebe-Dimmer JL, Pfeifer JR, Engle JS, Schottenfeld D. The epidemiology of chronic venous insufficiency and varicose veins. Ann Epidemiol. 2005;15(3):175–84.CrossRefPubMedGoogle Scholar
  3. 3.••
    Wittens C, Davies AH, Baekgaard N, Broholm R, Cavezzi A, Chastanet S, et al. Editor’s choice—management of chronic venous disease: clinical practice guidelines of the European society for vascular surgery (ESVS). Eur J Vasc Endovasc Surg. 2015;49(6):678–737. Important clinical practice guideline document for the management of venous disease.CrossRefPubMedGoogle Scholar
  4. 4.
    Graham ID, Harrison MB, Nelson EA, Lorimer K, Fisher A. Prevalence of lower-limb ulceration: a systematic review of prevalence studies. Adv Skin Wound Care. 2003;16(6):305–16.CrossRefPubMedGoogle Scholar
  5. 5.
    Yamaki T, Nozaki M, Fujiwara O, Yoshida E. Comparative evaluation of duplex-derived parameters in patients with chronic venous insufficiency: correlation with clinical manifestations. J Am Coll Surg. 2002;195(6):822–30.CrossRefPubMedGoogle Scholar
  6. 6.
    Abbade LP, Lastoria S. Venous ulcer: epidemiology, physiopathology, diagnosis and treatment. Int J Dermatol. 2005;44(6):449–56.CrossRefPubMedGoogle Scholar
  7. 7.
    McLafferty RB, Passman MA, Caprini JA, Rooke TW, Markwell SA, Lohr JM, et al. Increasing awareness about venous disease: The American Venous Forum expands the National Venous Screening Program. J Vasc Surg. 2008;48(2):394–9.CrossRefPubMedGoogle Scholar
  8. 8.
    Phillips T, Stanton B, Provan A, Lew R. A study of the impact of leg ulcers on quality of life: financial, social, and psychologic implications. J Am Acad Dermatol. 1994;31(1):49–53.CrossRefPubMedGoogle Scholar
  9. 9.••
    Gloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL, Gloviczki ML, et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011;53(5 Suppl):2S–48. American vascular/ venous society recommendations for treatment of venous disease.CrossRefPubMedGoogle Scholar
  10. 10.
    Rasmussen LH, Lawaetz M, Bjoern L, Vennits B, Blemings A, Eklof B. Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose veins. Br J Surg. 2011;98(8):1079–87.CrossRefPubMedGoogle Scholar
  11. 11.
    Varicose veins: diagnosis and management. NICE guidelines [CG168]: National Institute for Health and Clinical Excellence.; 2013 [Available from:
  12. 12.
    Sadek M, Kabnick LS. Are non-tumescent ablation procedures ready to take over? Phlebology. 2014;29(1 suppl):55–60.CrossRefPubMedGoogle Scholar
  13. 13.
    Elias S, Raines JK. Mechanochemical tumescentless endovenous ablation: final results of the initial clinical trial. Phlebology. 2012;27(2):67–72.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Pollak JS, White Jr RI. The use of cyanoacrylate adhesives in peripheral embolization. J Vasc Interv Radiol. 2001;12(8):907–13.CrossRefPubMedGoogle Scholar
  15. 15.
    Almeida JI, Javier JJ, Mackay EG, Bautista C, Cher DJ, Proebstle TM. Two-year follow-up of first human use of cyanoacrylate adhesive for treatment of saphenous vein incompetence. Phlebology. 2015;30(6):397–404.CrossRefPubMedGoogle Scholar
  16. 16.
    Proebstle TM, Alm J, Dimitri S, Rasmussen L, Whiteley M, Lawson J, et al. The European multicenter cohort study on cyanoacrylate embolization of refluxing great saphenous veins. J Vasc Surg: Venous Lymph Disord. 2015;3(1):2–7.Google Scholar
  17. 17.••
    Morrison N, Gibson K, McEnroe S, Goldman M, King T, Weiss R, et al. Randomized trial comparing cyanoacrylate embolization and radiofrequency ablation for incompetent great saphenous veins (VeClose). J Vasc Surg. 2015;61(4):985–94. Most important CAC related trial.CrossRefPubMedGoogle Scholar
  18. 18.
    Toonder IM, Lam YL, Lawson J, Wittens CH. Cyanoacrylate adhesive perforator embolization (CAPE) of incompetent perforating veins of the leg, a feasibility study. Phlebology. 2014;29(1 suppl):49–54.CrossRefPubMedGoogle Scholar
  19. 19.•
    Mueller RL, Raines JK. ClariVein mechanochemical ablation: background and procedural details. Vasc Endovasc Surg. 2013;47(3):195–206. Important paper to understand the procedural steps of MOCA.CrossRefGoogle Scholar
  20. 20.
    Boersma D, van Eekeren RR, Werson DA, van der Waal RI, Reijnen MM, de Vries JP. Mechanochemical endovenous ablation of small saphenous vein insufficiency using the ClariVein((R)) device: one-year results of a prospective series. Eur J Vasc Endovasc Surg. 2013;45(3):299–303.CrossRefPubMedGoogle Scholar
  21. 21.
    Bishawi M, Bernstein R, Boter M, Draughn D, Gould CF, Hamilton C, et al. Mechanochemical ablation in patients with chronic venous disease: a prospective multicenter report. Phlebology. 2014;29(6):397–400.CrossRefPubMedGoogle Scholar
  22. 22.•
    Bootun R, Lane T, Dharmarajah B, Lim C, Najem M, Renton S, et al. Intra-procedural pain score in a randomised controlled trial comparing mechanochemical ablation to radiofrequency ablation: The Multicentre Venefit versus ClariVein(R) for varicose veins trial. Phlebology. 2014. The RCT comparing MOCA to RFA.Google Scholar
  23. 23.
    Moore HM, Lane TR, Franklin IJ, Davies AH. Retrograde mechanochemical ablation of the small saphenous vein for the treatment of a venous ulcer. Vascular. 2014;22(5):375–7.CrossRefPubMedGoogle Scholar
  24. 24.
    Sullivan LP, Quach G, Chapman T. Retrograde mechanico-chemical endovenous ablation of infrageniculate great saphenous vein for persistent venous stasis ulcers. Phlebology. 2014;29(10):654–7.CrossRefPubMedGoogle Scholar
  25. 25.
    Lane TR, Moore HM, Franklin IJ, Davies AH. Retrograde inversion stripping as a complication of the ClariVein mechanochemical venous ablation procedure. Ann R Coll Surg Engl. 2015;97(2):e18–20.CrossRefPubMedGoogle Scholar
  26. 26.
    Coleridge SP. Foam and liquid sclerotherapy for varicose veins. Phlebology. 2009;24 Suppl 1:62–72.Google Scholar
  27. 27.
    Davies HO, Popplewell M, Darvall K, Bate G, Bradbury AW. A review of randomised controlled trials comparing ultrasound-guided foam sclerotherapy with endothermal ablation for the treatment of great saphenous varicose veins. Phlebology. 2015.Google Scholar
  28. 28.
    Carugo D, Ankrett DN, Zhao X, Zhang X, Hill M, O’Byrne V, et al. Benefits of polidocanol endovenous microfoam (Varithena®) compared with physician-compounded foams. Phlebology. 2015:0268355515589063.Google Scholar
  29. 29.•
    Todd III KL, Wright DI, Group V-I. The VANISH-2 study: a randomized, blinded, multicenter study to evaluate the efficacy and safety of polidocanol endovenous microfoam 0.5% and 1.0% compared with placebo for the treatment of saphenofemoral junction incompetence. Phlebology. 2014;29(9):608–18. This is one of the 2 pivotal PEM studies.CrossRefPubMedGoogle Scholar
  30. 30.
    Todd KL, Wright DI, Group V-I. Durability of treatment effect with polidocanol endovenous microfoam on varicose vein symptoms and appearance (VANISH-2). J Vasc Surg: Venous Lymp Disord. 2015.Google Scholar
  31. 31.•
    King J, O’Byrne M, Vasquez M, Wright D. Treatment of truncal incompetence and varicose veins with a single administration of a new polidocanol endovenous microfoam preparation improves symptoms and appearance. Eur J Vasc Endovasc Surg. 2015;50(6):784–93. This is one of the 2 pivotal PEM studies.CrossRefPubMedGoogle Scholar
  32. 32.
  33. 33.
    Farber A, Belenky A, Malikova M, Brenner O, Brandeis Z, Migdal M, et al. The evaluation of a novel technique to treat saphenous vein incompetence: preclinical animal study to examine safety and efficacy of a new vein occlusion device. Phlebology. 2014;29(1):16–24.PubMedGoogle Scholar
  34. 34.
    Kolvenbach RR. A novel approach to closing the great saphenous vein: V-Block trial. VEITHsymposium; November 19; New York, NY.2013.Google Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  1. 1.System Medical Director – Vascular MedicineOhioHealth Heart and Vascular/ Riverside Methodist HospitalColumbusUSA

Personalised recommendations