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By Sue Jerdak, PhD
Painful surgical stripping of veins has become an obsolete procedure for varicose vein treatment, except in rare cases. This is especially true in the West and developed countries, where modern, high-tech, minimally invasive procedures have almost replaced the traditional scalpel for varicose vein treatment. Nowadays, the smaller veins are usually removed either by injections or topical lasers, and the largest of the veins, such as leg saphenous veins, are removed by thermal ablation, a method that relies on heat energy.
Endovenous laser treatment (EVLT) and the VNUS closure procedures have arguably become the gold standard of treatment for the long saphenous or short saphenous veins, which only a decade earlier were removed almost exclusively by surgical stripping and ligation. The closure of these veins is important for the treatment of venous reflux, the underlying cause of varicose veins. Both procedures, EVLT and VNUS closure, are associated with good cosmetic outcome with no surgical scarring in the groin, and patients walk out of the office wearing compression stockings and resume near normal activities soon after.
Most phlebologists and vein surgeons have either the VNUS closure device or EVLT machine in their clinics, and claim their equipment is the best for varicose vein treatment. Very rarely they have both, since the equipments are expensive and they accomplish the same goal. So, which treatment should you choose? Are there clinical studies supporting one treatment over the other?
VNUS and EVLT procedures are almost identical; both treat venous reflux disease using only local anesthesia and elective conscious sedation and are almost equally effective in treating diseased saphenous veins and venous reflux. Also, both are FDA-approved, give equally durable result, and are endovenous in their approach, meaning that they work from inside the varicose vein.
During a typical EVLT or VNUS treatment session, a tiny catheter is inserted inside the affected leg vein near the knee. The catheter is then guided up the thigh and positioned using duplex ultrasound imaging, and energy is generated. The energy, in the form of heat, causes the diseased vein to scar and shrink, sealing it from the inside and effectively closing it down. This will restore the normal circulation pattern in the legs immediately, and prevent the rerouting of blood from the deep veins to the superficial veins. Treatment takes less than one hour. According to publications of the Society of Interventional Radiology, the success rate for vein ablation using both systems ranges from 93-95 percent with minimal side-effects or complications. This success rate is much higher than the 85 percent for the older surgical ligation or stripping method.
So what is the difference in the two modalities? Comparing literature provided by the manufacturers, the only main difference between the two technologies seems to be the way in which heat is generated and delivered to the vein wall. In the case of EVLT, heat comes in the form of a laser beam. In the VNUS closure procedure, on the other hand, the radiofrequency generated by the catheter selectively heats the proteins in the vein wall. It should be mentioned that radiofrequency waves are longer and less energetic than the electromagnetic waves used in the EVLT.
What about patient satisfaction and complications associated with the two procedures? A renowned Los Angeles vein specialist, Dr. R. Dishakjian, says that he uses the VNUS closure procedure in his Los Angeles vein clinic, because it is gentler than the alternative Endovenous laser ablation treatment (EVLT). This claim is supported by a recent study published in the prestigious monthly publication of the Society of Interventional Radiology. The study was designed to address the hypothesis that the VNUS closure is associated with improved recovery and quality-of-life. According to results derived from the study, the VNUS system for radiofrequency (RF) is statistically significantly superior to endovenous laser treatment (EVLT) in providing fast and comfortable recovery and for treating venous reflux. In addition, according to clinical studies published by VNUS Medical Technologies and Mayo clinic, which are also positively endorsed from European national health authorities, minor complications are significantly less prevalent in patients who undergo the VNUS closure compared to those who choose the endovenous laser approach. It should perhaps be mentioned that less than a year ago, the National Innovation Center of the UK National Health Service (NHS) identified the VNUS closure procedure as a select innovative technology that is bringing benefits to National Health Service hospitals and patients.
It should also be pointed out that currently the VNUS radiofrequency system is the only FDA approved technology to treat the shorter perforator veins of the legs. These 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 into the superficial ones. The abnormal blood flow results in the formation of bulging superficial varicosities. Until recently, an invasive endoscopic procedure was the main method of eliminating the abnormal flow in these veins.
So why do many vein clinics use EVLT instead of VNUS closure? It seems that the main reasons are the cost of the equipment and its operation. The reputable Los Angeles vein specialist, Dr. R. Dishakjian, says that the improvement in comfort and quality of life that the VNUS procedure offers comes at an additional cost, but considers them well worth it in terms of safety, comfort and patient acceptance. The Los Angeles vein specialist, who has performed hundreds of VNUS closure procedure to date, says that he continues to be impressed with its efficacy and patient comfort during the procedure.
Like any medical treatment, both EVLT and VNUS closure have certain risks and limitations, which your physician will explain to you as they apply to your individual case. For patients with very thin legs or very superficial veins, a surgeon may suggest surgical stripping because the heat generated from minimally invasive endovenous techniques may cause skin damage or burns. Surgical stripping may also be recommended to patients having either very large or tortuous veins. The latter may prove difficult to negotiate with the laser fiber or the RF catheter. The existence of blood clots in the veins is the only absolute contraindication to both EVLT and the VNUS Closure. The Los Angeles vein specialist says that an expert phlebologist rarely needs to resort to therapies other than the VNUS closure for saphenous or perforator vein closure and that during his long experience with venous reflux therapy in his Los Angeles vein clinic, he encountered only a couple of cases needing an alternative treatment. If your legs are affected by bulging varicose veins and you are intending to get rid of them, make sure to consider the merits of VNUS closure, and accordingly choose your doctor or varicose vein treatment clinic.
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