VNUS and EVLT Closure Procedure Information: Two Revolutionary Vein Treatment Modalities

Two minimally invasive varicose vein treatment modalities; More specifically, the VNUS closure procedure, also known as VENEFIT, and EVLT (venous delayed treatment), both introduced around the early years of this decade, gained such a strong foothold in the armamentarium of physicians treating varicose veins. As the role of the scalpel became insignificant, varicose vein treatment moved from the hospital to the office, and a diverse group of physicians, from cardiologists to radiologists, entered the field of varicose vein treatment. As a consequence of this revolution in the management of vein diseases, the American College of Phlebology was established, with the objective of providing the necessary knowledge and skills for the use of new vein treatment technologies. In the year 2005, the American Medical Association, AMA, recognized phlebology as a separate self-designated specialty, just like dermatology, vascular surgery, or any other recognized specialty. Currently, Dr. John Mauriello, an anesthesiologist by primary training, is the president-elect of the American College of Phlebology.

The differences between the VNUS and EVLT closure procedure are subtle. Both are intravenous in nature; that is, varicose veins are accessed and treated from within the veins. While the former uses a disposable catheter equipped with a radiofrequency (RF) generating electrode, the latter uses a reusable laser-generating fiber. RF closure was first introduced in Europe in 1998 and was approved by the US Food and Drug Administration (FDA) in March 1999. Endovenous laser vein treatment was first described in 1999 and FDA approved in the year 2002. It should be noted that EVLT is a trademarked term and several other acronyms such as EVLA and CTEV are trademarked with claims that their laser fibers and wavelength produce less pain than others. Although many different radiofrequency ablation catheters are available for a variety of medical applications, the ClosureFAST catheter and ClosureRFS stylet, manufactured by VNUS Medical Technologies, are currently the only FDA-cleared, commercially available systems designed for vein ablation.

Despite the occasional use of the VNUS and EVLT closure procedure for cosmetic purposes, its primary use is for the treatment of varicose veins, or the underlying cause, venous reflux (pooling of blood in the veins of the lower extremities due to faulty venous valves). ) and relief of symptoms associated with enlargement of the nonfunctional saphenous and perforator veins. The saphenous veins are the largest and longest superficial veins; while perforator veins are short connecting veins located along the entire length of the legs. When diseased, these veins allow reverse flow and channel blood directly from the deep veins to the superficial ones. Leg symptoms, which are often not related to the size or abundance of the veins, can include: severe pain, swelling, skin irritation or sores (ulcers), discoloration, and inflammation (phlebitis).

Varicose vein treatment, either with EVLT or VNUS closure, takes less than an hour. A treatment session begins with ultrasound imaging to identify diseased sections of the veins. This is followed by injection of tumescent anesthesia along the diseased vein and insertion of a small catheter into a vein, usually near the knee. Using ultrasound imaging, a laser fiber or radiofrequency electrode is inserted through an intravenous access port (similar to an IV catheter but larger) and guided up the thigh and precisely positioned at the very source of the reverse flow. In the case of EVLT, the laser fiber generates a laser beam that heats and boils the blood in the vessel, causing it to close. In the VNUS closure procedure, the radiofrequency generated by the electrode selectively heats and contracts the collagen in the vein wall, resulting in a fibrotic seal. A session ends with the application of bandages to the treated leg, followed by compression stockings. Compression is vitally important after any venous procedure because its use prevents pooling of blood in the treated leg, prevents bleeding from puncture sites, promotes faster healing of treated veins, and reduces bruising, tenderness and postoperative clot formation. The injection of local anesthetic around the abnormal vein is the most uncomfortable part of the procedure because it usually requires multiple injections throughout the vein. The actual closure of the vein with laser or radiofrequency is usually completely painless. Of course, a follow-up ultrasound examination is essential to evaluate the treated vein and verify adverse outcomes. Although not common, a small number of EVLT patients require narcotic medications for a few days after treatment. Some of the newer LASER wavelengths, energy settings, and newer laser fibers are expected to improve the technology and reduce the pain caused by the procedure.

Regarding the limitations of intravenous procedures, despite some scattered reports of skin burns, the procedures can be considered quite safe. In fact, both procedures can be performed on very thin legs or on very superficial veins without damaging neighboring tissues or skin. Large volumes (500 cc) of diluted lidocaine (0.1%) tumescent anesthetic, injected throughout the entire saphenous compartment prior to radiofrequency application, have the dual function of compressing the vessel against the catheter (for better result) and provide heat. sink that absorbs the heat generated by the device. According to a renowned Los Angeles phlebologist, Dr. R. Dishakjian, the liberal use of tumescent anesthesia pushes the saphenous vein at least 1 cm away from the skin and eliminates any potential injury and burns to surrounding soft tissue structures, including nerves, other veins and arteries. and Skin It should perhaps be mentioned that the application of tumescent anesthesia for intravenous vein treatment was first patented in the United States by VNUS Medical Technologies, which has filed several patent infringement laws against companies that sell vein ablation systems. with endovenous laser. Not all disputes are resolved yet.

For situations where the saphenous veins are very large, the Los Angeles phlebologist says, “Although intravenous catheters are thin, veins as small as 16mm can be treated because epinephrine added to tumescent anesthesia provides better constriction of the vein around the heat-generating tip of the catheter, while prolonging the analgesic effect of lidocaine for up to 6 to 8 hours after the procedure.” The doctor adds that “even significantly tortuous (curved) veins can be treated with the endovenous technique. In cases where the catheter tip cannot be advanced along the entire length of the vein, a second entry point can be used.” of the catheter to avoid a curved vein”. part. Blood clots in the veins are the only absolute contraindication to both EVLT and VNUS closure and require surgical intervention.”

Unfortunately, endovenous techniques do not usually solve the problem of branch varicose veins and spider veins. When left untreated, only 10-20% of patients will experience regression of these branch varices to the point where no further intervention is necessary. Residual varicose veins after the procedure can be treated with a variety of techniques. Treatment options may include phlebectomy simultaneously with vein ablation or delayed treatment after observation of spontaneous regression. If delayed treatment is selected and necessary, a choice may be made between phlebectomy, sclerotherapy, or foam sclerotherapy, depending on physician preference. Phlebectomy involves the surgical excision of a vein or part of a vein; while sclerotherapy and foam sclerotherapy use a needle to inject medication in liquid or foam form directly into diseased vessels.

As with other varicose vein treatment techniques, continuous occlusion of the saphenous vein with the VNUS or EVLT closure procedure does not eliminate the possibility of developing recurrent varicose veins. Recurrent varicose veins from untreated vein segments or new reflux can and will occur in some patients. This, however, does not represent a failure of endovenous ablation. The treatment of varicose veins with endovenous ablation techniques has proven to be as effective as conventional surgical treatment and has increased patient satisfaction.