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Endovenöse thermische Therapie der Stammveneninsuffizienz

Endovenous thermal treatment of trunk vein insufficiency

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Zusammenfassung

Die endovenösen thermischen Verfahren zur Ablation und hämodynamischen Ausschaltung insuffizienter Stammvenen sind etablierte und wissenschaftlich gut untersuchte Therapieoptionen der Varikose. Zahlreiche Studien und Metaanalysen dokumentieren eine geringere Schmerzbelastung und eine raschere postoperative Rekonvaleszenz im Vergleich zu offenen Operationen mit Krossektomie und Stripping. Außerdem weisen die endothermischen Prozeduren ein niedriges Risikoprofil und eine dauerhafte Effektivität auf. Internationale Leitlinien empfehlen die Verfahren als Therapieoption der ersten Wahl bei symptomatischer Stammveneninsuffizienz. Die Sonographie ist integraler Bestandteil der endovenösen Prozeduren, um die exakte Platzierung der Therapiesonden und sichere Ausschaltung der Stammvene zu gewährleisten. Die thermische Energie soll eine irreversible Denaturierung, vollständige Ablation und dauerhafte hämodynamische Ausschaltung der therapierten Venensegmente bewirken, ohne das tiefe Venensystem oder perivenöses Gewebe zu alterieren. Während die Systeme zur Radiofrequenzablation (RFA) Feedback-Mechanismen mit automatischer Regulation der thermischen Energie aufweisen, müssen bei der Endovenösen Laserablation (EVLA) die thermischen Gewebeeffekte durch die Wahl der Laserleistung und Rückzugsgeschwindigkeit abgeschätzt werden. Wie bei allen invasiven Prozeduren ist eine adäquate theoretische und praktische Weiterbildung und Einweisung erforderlich, um Risiken zu minimieren und um das Potenzial dieser Therapieoptionen auszuschöpfen. Die Bedeutung der Positionierung der Therapiesonden zur Realisierung eines möglichst kurzen Saphenastumpfes und der simultanen Mitbehandlung nicht refluxiver akzessorischer Venen sind Gegenstand der aktuellen wissenschaftlichen Diskussion.

Abstract

Endovenous thermal procedures for ablation and hemodynamic elimination of insufficient saphenous veins are well established and scientifically confirmed treatment options for varicose veins. Numerous randomized controlled trials and meta-analyses document a lower pain burden and faster postoperative convalescence compared to open operations with crossectomy and stripping. In addition, the endothermal procedures are associated with a low risk profile and high long-term effectiveness. International guidelines recommend these procedures as the first-line treatment option for symptomatic saphenous vein insufficiency. Sonography is an integral part of the endovenous procedures in order to ensure the exact placement of the treatment probes and the safe elimination of the trunk vein. The thermal energy is intended to cause irreversible denaturation, complete ablation and permanent hemodynamic elimination of the treated venous segments without altering the deep venous system or perivenous tissue. While the systems for radiofrequency ablation (RFA) have feedback mechanisms with automatic regulation of the thermal energy, with endovenous laser ablation (EVLA) the thermal tissue effects must be estimated through the choice of laser power and retraction speed. As with all invasive procedures, the endovenous thermal procedures also require adequate theoretical and practical training and instruction in order to minimize risks and to exploit the potential of these treatment options. The importance of positioning the treatment probes to achieve the shortest possible saphenous stump and the simultaneous treatment of non-refluxing accessory veins are the subject of current scientific discussion.

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Authors and Affiliations

  1. Klinik für Gefäßchirurgie, Diakonie-Klinikum Schwäbisch Hall, Diakoniestr. 10, 74523, Schwäbisch Hall, Deutschland

    Claus-Georg Schmedt

  2. Klinik für Gefäß- und endovaskuläre Chirurgie, Krankenhaus Martha-Maria, Nürnberg, Deutschland

    Thomas Noppeney

  3. Universität Regensburg, Regensburg, Deutschland

    Thomas Noppeney

  4. Gefäß- und Endovascularchirurgie, Universitätsklinikum Frankfurt, Frankfurt am Main, Deutschland

    Thomas Schmitz-Rixen

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  1. Claus-Georg Schmedt
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Correspondence to Claus-Georg Schmedt.

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T. Noppeney gibt Beratertätigkeit für Medi Bayreuth und Vortragstätigkeit für Medtronic an. C.-G. Schmedt und T. Schmitz-Rixen geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Schmedt, CG., Noppeney, T. & Schmitz-Rixen, T. Endovenöse thermische Therapie der Stammveneninsuffizienz. Gefässchirurgie 27, 82–93 (2022). https://doi.org/10.1007/s00772-022-00880-7

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