Re: Endovenous Laser Treatment of Saphenous Vein Reflux: Long-term Results: Reply: Drs. Min and Khilnani respond

Abstract

Although ultrasound (US)-guided sclerotherapy is a useful technique for treatment of nonsaphenous sources of reflux and select cases of saphenous vein incompetence, multiple studies of US-guided sclerotherapy of the great saphenous vein (GSV), alone or in combination with high ligation, have failed to demonstrate long-term results equal to those of surgical ligation and stripping of the GSV (1Belcaro G Nicolaides AN Ricci A et al.Endovascular sclerotherapy, surgery, and surgery plus sclerotherapy in superficial venous incompetence: a randomized, 10-year follow-up trial—final results.Angiology. 2000; 51: 529-534Crossref PubMed Scopus (66) Google Scholar, 2Kanter A Thibault P Saphenofemoral incompetence treated by ultrasound-guided sclerotherapy.Dermatol Surg. 1996; 22: 648-652Crossref PubMed Google Scholar, 3Rutgers PH Kitslaar PJ Randomized trial of stripping versus high ligation combined with sclerotherapy in the treatment of the incompetent greater saphenous vein.Am J Surg. 1994; 168: 311-315Abstract Full Text PDF PubMed Scopus (147) Google Scholar). These disappointing results have led to the development of new minimally invasive treatment options for ablating the incompetent saphenous vein, including endovenous laser, radiofrequency, and foam sclerotherapy, which thus far appear to have lower recurrence rates than liquid sclerotherapy treatment of the GSV (4Weiss RA Weiss MA Controlled radiofrequency endovenous occlusion using a unique radiofrequency catheter under duplex guidance to eliminate saphenous varicose vein reflux: a 2-year follow-up.Dermatol Surg. 2002; 28: 38-42Crossref PubMed Scopus (202) Google Scholar, 5Min R Khilnani N Zimmet SE Endovenous laser treatment of saphenous vein reflux: long-term results.J Vasc Interv Radiol. 2003; 14: 991-996Abstract Full Text Full Text PDF PubMed Scopus (535) Google Scholar) The authors believe that the GSV recanalization rate of less than 7% at 2 years reflects the effectiveness of endovenous laser in ablating the GSV (5Min R Khilnani N Zimmet SE Endovenous laser treatment of saphenous vein reflux: long-term results.J Vasc Interv Radiol. 2003; 14: 991-996Abstract Full Text Full Text PDF PubMed Scopus (535) Google Scholar). Theoretically, combined endovenous laser and sclerotherapy of the GSV might yield superior results to either technique used alone; however, the current technique does not allow leaching of sclerosant into the GSV as the author of the letter suggests. As noted in the Materials and Methods section of the article, all subjects underwent duplex US evaluation (including pulsewave and color Doppler) to document complete occlusion of the treated GSV segment. Continued occlusion of the GSV was documented with duplex US throughout the follow-up period, including before the start of sclerotherapy treatment of branch tributaries 1 month after endovenous laser treatment. Sclerotherapy was not performed unless the entire treated segment of GSV was documented as occluded by duplex US. Although it is true that some of these tributaries may have been in communication with the GSV before treatment, complete occlusion of the GSV after endovenous laser treatment would not allow flow of sclerosant into these saphenous vein segments during subsequent injection of the varicosities. The comment was made that “unfortunately, the specific numbers of patients who underwent sclerotherapy for distal varicose tributaries versus small telangiectasias” were not provided. In practice, nearly all patients presenting with significant saphenous vein reflux will have both varicose tributaries and secondary telangiectasia and will want both conditions treated. Although one could argue that the much of the “medical” benefit of treatment is achieved following endovenous laser ablation of the GSV, as evidenced by the symptomatic relief obtained after correction of the saphenous vein reflux, the vast majority of patients will not believe that their treatment is complete until the full aesthetic restorative benefits are achieved. Therefore, in our practice, we routinely treat the remaining varicose veins and secondary telangiectasias with follow-up compression sclerotherapy in patients undergoing endovenous laser treatment. Whether the branch varicosities are treated with ambulatory phlebectomy or compression sclerotherapy is unimportant because, with proper operator training, both techniques will yield equivalent results (6Miyazaki K Nishibe T Sata F et al.Stripping operation with sclerotherapy for primary varicose veins due to greater saphenous vein reflux: three-year results.World J Surg. 2003; 27: 551-553Crossref PubMed Scopus (6) Google Scholar, 7Brethauer SA Murray JD Hatter DG Reeves TR Hemp JR Bergan JJ Treatment of varicose veins: proximal saphenofemoral ligation comparing adjunctive varicose phlebectomy with sclerotherapy at a military medical center.J Vasc Surg. 2001; 35: 51-58Google Scholar). What is important is that we use our clinical skills to narrow the diagnosis, confirm our clinical suspicions with noninvasive evaluation, and listen to our patients. In this way, we can best map out an appropriate course of treatment with use of the vast array of tools now available to optimally deliver proper and complete care to realize the physician's and, more importantly, the patient's goals.