Recent Progress of Varicose Vein Treatment Especially about Endovascular Heat Ablation, SEPS and Foam Sclerotherapy

Abstract

There were three epoch making events in therapy of varicose veins. The first one is that the endovascular heat ablation (EVHA) using diode laser was authorized by the Ministry of Health Labor and Welfare in January 2011. The second one is that Subfascial Endoscopic Perforator Surgery (SEPS) was also authorized in April 2014. All of the therapies which were covered by the national insurance system had been the procedures for superficial veins but the SEPS is procedure for the perforating veins. The third one is that the foam usage of Polidocasklerol was listed formally at the medical package insert in September 2016. Moreover stub avulsion was introduced as figure-related improvement method with a smaller operation wound instead of conventional varicectomy and the other existing therapies are progressing every day. Therefore, by this education seminar, I lecture mainly on the EVHA, SEPS and foam sclerotherapy in varicose vein treatment. Finally I show one case which you should remember. (This is a translation of Jpn J Vasc Surg 2017; 26: 225-230.).

Keywords: SEPS; laser ablation; sclerotherapy; varicose vein.

Fig. 1 Bare tip fiber and radial ring fiber. Bare tip fiber: A laser is irradiated only forward. The direct contact between the unevenly placed heated tip and the vessel wall results in heterogeneous heating of the vein and perforation. Radial (2) ring fiber: A laser is irradiated in entire circumference via prism, and uniform irradiation prevent the perforation of vein wall. The bottom figure is called radial 2 ring fiber with structure to irradiate from two places, but there is 1 ring fiber to irradiate from one place. About the direction of the irradiation light, there are right angle for fiber and slant ahead too.

Fig. 2 Endovenous heat-induced thrombosis (EHIT) classification. Class 1: Venous thrombosis to superficial deep junction (SFJ of SPJ), but not extending into deep system. Class 2: Non-occlusive venous thrombosis, with an extension into deep system of a cross sectional area less than 50%. Class 3: Non-occlusive venous thrombosis, with an extension into deep system of a cross sectional area greater than 50%. Class 4: Occlusive deep vein thrombosis of common femoral/popliteal vein.

Fig. 3 Schema of TPS-SEPS (two port system subfascial endoscopic perforator surgery). One port is for an endoscope, the other is for dissecting forceps and the ultrasonic coagulation and cutting device. All two ports are inserted at the normal skin without stasis dermatitis. We do SEPS without air tourniquet nor dissecting balloon catheter. The all devices we use are originally designed for laparoscopic surgery. UCCD: Ultrasonic Coagulation & Cutting Device; IPV: incompetent perforating vein

Fig. 4 Both leg findings at initial investigation. He had multiple former operation skin scars and ulcers with stasis dermatitis on his both legs. Pseudomonas aeruginosa and MSSA were detected at the ulcers by the bacterial culture.

Fig. 5 MR Venography findings & CT Angiogram findings. MR Venography (right side) showed the extensive occlude lesions of IVC, both iliac veins, femoral veins, popliteal veins, anterior & posterior tibial veins and fibular veins. CT Angiogram (left side) showed normal arterial flow to both legs.