Initial Study Of Vnus Closure Treating Small Saphenous Vein

The treatment of venous insufficiency has advanced dramatically over the last few

years with the advent of both endovenous laser and radiofrequency ablation techniques. Patients with venous insufficiency of the legs now have the advantage of procedures performed under local anesthesia in an office setting with immediate recovery.

There have been numerous patient based studies documenting the success and safety of these minimally invasive techniques when treating the great saphenous vein. This vein is the most common cause of lower leg varicose veins and symptoms related to venous reflux.

The small saphenous vein is another commonly affected lower leg vein that develops reflux due to vein valve insufficiency. 6-8% of patients studies for venous disease have reflux in the small saphenous vein. Use of endovenous ablation has not been well studied in this clinical population. There are a few case series studying the use of laser to treat the small saphenous, but none detailing the use of the VNUS Closure catheter. Ablation of the small saphenous vein has been used with good anecdotal reports of success and safety, however.

I recently began a prospective study looking at all patients in my practice at Capitol Vein & Laser who underwent endovenous ablation of the small saphenous vein using the VNUS Closure catheter. This study was presented in poster form at the 2009 annual meeting of the American College of Phlebology, November 4-8.

Beginning January 2009, 51 patients were enrolled in a prospective clinical study determining the safety, ease and efficacy of VNUS Closure of the small saphenous vein. Concerns to date have centered on risk of sural nerve injury (due to proximity to the small saphenous vein) and risk of deep vein clot.

The poster displayed at the meeting showed that initially, all veins treated were closed at one week follow up. As this is an early phase study, longer term data will determine the durability of the ablation. There were no cases of neuralgia or numbness as no sural nerve injuries were reported by the patients. There was no deep vein thrombosis seen at one week follow up, but one superficial phlebitis was seen in mid calf varicosities.

Keys to safe and successful treatment of the small saphenous vein using VNUS Closure include site of access, adequate tumescent anesthesia and keeping the tip of the catheter safely away from the sapheno-popliteal junction.

The sural nerve descends the lower leg from the thigh away from the small saphenous vein in the proximal calf. Approximately halfway down the calf, the nerve then is in close proximity to the vein, at risk for thermal injury. Therefore, I commonly treat this vein only in the proximal calf, to the level of the base of the gastrocnemius muscle. When treatment is kept to this level, nerve damage is minimized. Associated with catheter placement is the need for adequate tumescent to hydrostatically separate the nerve from the heated vein.

Finally, one must be attentive to the sapheno-popliteal junction and sit the catheter tip at least 2cm from the deep vein. This will help minimize the risk of DVT.

In summary, as the poster at the ACP meeting detailed, VNUS Closure of the small saphenous vein is safe and effective in ablating reflux.

by: Garth Rosenberg

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