Endovenous Thermal Ablation
The first procedure typically performed is the venous ablation. This is where the vein is burned with either laser or radio frequency catheters. During this procedure, the patient is sedated with valium, nitrous oxide, or both. The patient can choose the level of sedation they prefer.
During this procedure, the sonographer will map the vein to be ablated and mark a location that appears to be a good access point. What we look for is whether the vein is straight and has a large diameter, which makes accessing the vein easy. Veins will sometimes spasm or be a smaller diameter early in the morning when the patient hasn’t been standing or active all day, or when the leg is cold. In these cases, we use gravity, a Nitroglycerin patch, and a blanket to help warm up the leg and increase the diameter of the vein.
Once a location is marked, we prep the leg with a cleansing/sterilizing solution and set up the procedure using sterile technique. We ask that the patient not touch the sterile field, so to prevent infection. When the physician enters the room, he will also dress in a sterile gown and will don sterile gloves. We take every precaution to keep the patient safe and infection free.
At this point, the physician will access the vein and start the procedure. Once the vein is accessed, a “guide” wire is inserted and the sonographer will follow the wire up the vein to make sure we are in the vein and not in the surrounding tissue. After that, the catheter, with the heating element, is inserted and once again the sonographer follows the catheter with ultrasound to make sure it is in the vein to be treated.
Once the catheter is an acceptable distance from the deep venous system, we need to numb around the vein. This is two-fold: The first reason is to numb and protect the tissue surrounding the treated vein from being burned. The second is to compress the vein around the catheter so the walls of the vein will be treated.
Once this all complete, the catheter is slowly removed and the vein will be ablated. We close the access point with steri strips and the procedure is finished. The patient is then required to wear a compression stocking for one week.
Sclerotherapy uses ultrasound guidance to inject a medication into veins, causing the vein to scar and close permanently. This procedure is routinely used at IVC and patients want to know how this procedure compares to endovenous thermal ablation (EVTA) as far as pain caused during the procedure and recovery time after the procedure.
The sclerotherapy procedure often involves multiple injections along the course of the the problematic veins. These injections utilize a very small needle so most patients tolerate the procedure very well. Patients often ask if a local numbing agent could be used to anesthetize the area before the injection of the sclerosing agent. This technique is not used as this would require two needle sticks, one needle stick to inject a numbing agent and another needle stick to inject the sclerosing agent. In general most patients tolerate the sclerotherapy procedure well and do not need any anesthetic agent. Though most patients find both EVTA and sclerotherapy very tolerable, patients often find sclerotherapy the easiest of the procedures we perform.
Post-procedure pain is usually localized to the area where the vein was injected. This pain is not nearly as intense as the pain following the EVTA but will be noticeable for longer. In fact it may take several weeks for the veins to be resolved by the body. During this time you may experience tenderness from these areas. A mild pain reliever like ibuprofen helps but really the biggest factor is giving the body time to resolve the treated veins.
One of the most frequent questions asked is will the procedures hurt. This is often a difficult question to answer, because everyone experiences pain differently. Some patients report no pain after the procedure and for others the pain can be significant. For the purposes of this discussion we will discuss the average of what most of our patients experience.
The EVTA (endovenous thermal ablation) procedure utilizes radio frequency or laser energy to close long, large diameter veins. This procedure uses heat to close the vein permanently, however, the heat also can also cause temporary surrounding tissue damage which is what causes most of the post-procedure pain. Typically, the most painful part of the procedure is the injection of local anesthetic. Most patients tolerate these injections well. We offer patients a relaxing medication like valium or nitrous oxide that can help make these injections more tolerable. Patients often report two weeks of a mostly dull achy pain after the procedure. This can be constant for the first week and by the second week the pain reduces daily until it’s gone. An anti-inflammatory medication like ibuprofen is typically the best medication to treat the post-procedure pain. Alternatively patients may take Tylenol.
People often describe a cord like sensation that resembles a pulled muscle. This sensation results from the treated vein shrinking in length and causing a tightness. This can last for one to two months as the vein is resolving. Patient often become concerned that something will tear or break, but that does not happen and some mild to medium stretching of the leg can help this resolve faster.
One of the side effects of EVTA can be paresthesia or numbness, this usually occurs on the inside of the calf sometimes from the knee down to the ankle. This results from a sensory nerve that is close to the treated vein becoming ablated. The numbness is temporary for most patients but can take several months to resolve. Often while the nerve is repairing itself patients can experience a tingling or burning sensation. There is a small percentage of patients that this numbness never completely resolves in, and they describe a funny sensation while shaving their legs or putting on socks. This does not effect function of the leg at all.