|Year : 2019 | Volume
| Issue : 1 | Page : 44-46
Mechanochemical endovenous ablation: Latest varicose vein treatment
Ravul Jindal, Deepali Verma, Taranvir Kaur, Shabjot Dhillon, Navjot Kaur, Piyush Chaudhary
Department of Vascular Surgery, Fortis Hospital, Mohali, Punjab, India
|Date of Web Publication||8-Mar-2019|
Dr. Piyush Chaudhary
Department of Vascular Surgery, Fortis Hospital, Mohali, Punjab
Source of Support: None, Conflict of Interest: None
Superficial dilated veins known as varicose veins develop due to damaged valves. Treatment of varicose veins is very important to undertake because of its acute (bleeding and clot formation) and chronic complications (lipodermatosclerosis and venous ulcers). Various techniques have been used for their treatment in the form of endovenous laser treatment, radiofrequency ablation, steam ablation and others. Now mechanochemical endovenous ablation (MOCA) has emerged as the latest nonthermal technique for the varicose vein treatment. It can be done by two methods as follows: Clarivein (Vascular Insights, US) and Flebogrif (Balton, Poland). We have presented in this case report, efficiency of MOCA technique in a 40-year-old, very pain sensitive male with CEAP classification C3EpAsPrand no deep vein insufficiency. MOCA was done as a day care procedure under local anesthesia. Standard protocol for technique was followed. Postprocedure patient was discharged after 20 min of observation. Follow ups were done at 6 weeks, 3 months and 6 months. Skin changes settled at 6 weeks without complications. In this technique, complications which are usually seen in thermal techniques are comparatively rare. Overall MOCA technique is highly effective modality for the treatment of varicose veins with success rates reaching up to 94%.
Keywords: ClariVein, flebogrif, mechanochemical endovenous ablation, varicose veins
|How to cite this article:|
Jindal R, Verma D, Kaur T, Dhillon S, Kaur N, Chaudhary P. Mechanochemical endovenous ablation: Latest varicose vein treatment. Indian J Vasc Endovasc Surg 2019;6:44-6
|How to cite this URL:|
Jindal R, Verma D, Kaur T, Dhillon S, Kaur N, Chaudhary P. Mechanochemical endovenous ablation: Latest varicose vein treatment. Indian J Vasc Endovasc Surg [serial online] 2019 [cited 2019 Jul 15];6:44-6. Available from: http://www.indjvascsurg.org/text.asp?2019/6/1/44/253737
| Introduction|| |
The World Health Organization defines varicose veins of the lower limbs, as superficial dilated veins that present as enlargements that are baggy or cylindrical due to a damaged vein valves. In 70% of cases, saphenous veins are affected. It is reported in 40%–60% of men and 25%–30% of women. In some western series, but exact incidence and prevalence in India are still unknown.
The treatment of varicose veins has undergone a sea change in the past few years. With the introduction of noninvasive radiofrequency ablation (RFA) and endovenous laser treatment (EVLT) (both of which are thermal techniques), the treatment for varicose veins has totally changed. However, these techniques are still associated with the requirement of tumescent anesthesia and rare injury to the nerves. Now, newer nonthermal techniques such as mechanochemical endovenous ablation (MOCA) and glue closure are coming in a big way, and we are waiting for the long-term results of these techniques. Our 2 years follow-up of the MOCA application showed that the method was significantly less traumatic compared to thermal methods with its efficacy reaching up to 96%. We described this relatively new technique to make physicians aware of the latest development in the management of varicose veins.
| Case Report|| |
The patient was 40-year-old male who had the right leg varicose veins and skin changes at ankle. Clinically, his CEAP classification was C3EPASPR[Figure 1]. He had no other major clinically significant medical history. His duplex scan showed normal deep veins, incompetent saphenofemoral (SF) junction Grade III filling up the varicosities and incompetent calf perforator.
Newer nonthermal technique with minimum needle pricks was used, as the patient was very pain sensitive. Needle pricks are more in thermal techniques due to tumescent anesthesia requirement. After informed consent, the intervention was performed under local anesthesia as a daycare procedure in the operating room.
The patient was placed in a supine position and draped. 6F sheath was inserted into the great saphenous vein at knee level under ultrasound guidance. Then, Flebogrif™ (Balton) catheter was prepared after flushing the lumen with normal salineGlide guidewire was passed into the sheath up to the SF junction. Flebogrif™ catheter, a special catheter which has retractable metallic barbs, was passed over the guidewire and placed proximal to SF junction. The blades of the catheter were opened after its tip had been placed 2 cm below the SF junction [Figure 2]. Guidewire was removed from the catheter. Tumescent anesthesia was not required during the procedure. Initially, 1.5 ml of sclerosant foam-Sodium tetradecyl sulfate (STD, fibrovein 3%) (STD pharmaceutical Ltd., UK) was injected with compression of the SF junction with ultrasonography (USG) probe. The system was withdrawn by 4 cm each time and 0.5 ml of foam was injected up to the point of entry. Compression of the vein was performed with hand while withdrawing the catheter. Foam was prepared with STD (1 ml of sclerosant mixed with 4 ml of air). Multiple injections were given to treat the below knee varicosities with foam sclerotherapy. After the procedure was over, compression bandaging was done and the patient was observed for 15–20 min in the postoperative period after which he was discharged. The patient was allowed to walk immediately and encouraged to carry on his routine life. Only anti-inflammatories were given to control pain. The patient was advised to change dressing and to wear stockings after 24 h for 4–6 weeks.
Patient was followed up at 2 weeks, 6 weeks, 3 months, 6 months and 1 year with clinical examination and USG. He was observed for bruise, pain score and quality of life scores. His postoperative recovery was wonderful. Skin changes settled in 6 weeks. There was minimal bruise and no cord-like feeling with patient returning to work next day.
Our own experience in the past 2½ years where we have performed MOCA in sixty patients and have their follow-up for 2 years is included. There was no difference in male and female ratio and median age was 45 years. Fifty-eight patients underwent unilateral MOCA and in two patients bilateral intervention was performed. Patient did well postoperatively and in terms of complications one patient has infection, three patients have bruise and no patient had skin necrosis or deep venous thrombosis. On an average, around 5 ml foam was used for one leg. Most of the patient has intraoperative VAS pain score as 3–4 and in postoperative it was 0–2 in 1st week. The procedure was successful in 100% patients. On follow-up, three patients had there long saphenous vein opened up on USG though they were not symptomatic (92% occlusion rate). All these three patients underwent laser ablation of the long saphenous vein on follow-up. We want to follow-up these patients for 5 years and compare the results with laser and RFA.
| Discussion|| |
Surgical methods for treating varicose veins were replaced in the late 1990s by percutaneous ablation methods, namely, RFA and EVLT, which were not only minimally invasive but also effective. Currently, EVLT is the most commonly used technique to treat varicose veins. One of the biggest drawbacks to do thermal ablation is that we have to give tumescent anesthesia to these patients which require 3–4 needle pricks.
The side effects commonly seen with thermal methods are pain, paresthesias, hematomas and transient skin discoloration, which are seen in a relatively small number of patients. Serious complications include injury to deep veins; iatrogenic arteriovenous fistula and pulmonary embolism are uncommon.,, The main drawbacks were pain during tumescent anesthesia, cost of inventory as buying laser or RF machine.
There was always a need to develop methods where we could avoid tumescent anesthesia. Newer nonthermal methods which are developed in the past few years are MOCA, glue (cyanoacrylates) closure, and foam sclerotherapy. All these newer methods are less traumatic, with fewer local complications, are free of thermal effects; require no investment on inventory and are thus a valid alternative to thermal methods. MOCA is done mainly by two methods-ClariVein and Flebogrif™. ClariVein uses a special infusion catheter with a rotating wire tip designed for the controlled 360° dispersion of specific agents to the targeted treatment area of the vein while Flebogrif use catheter with metallic barbs to injure media of the venous wall followed by the chemical ablation of the vein. In India, we have only Flebogrif device available, but most of the published results with MOCA device are with Clarivien. Hence, this study is very important as very limited data are available with Flebogrif device.
MOCA procedures, especially ClariVein [Figure 3] requires no investment on inventory is the better-known method of the two with its effectiveness reaching 96% in a 2-year follow-up. This is the first hybrid technique that works by mechanical injury of the venous wall with simultaneous sclerotherapy. Its advantages are that it allows the patient to return to normal activity the very next day. In addition, it does not require tumescent anesthesia since it is a nonthermal technique. For this same reason, there is no risk of skin burns, nerve or muscle damage and postoperative pain. Furthermore, the risk of thrombotic complications is lower.
Bishawi et al. reported that this procedure has an effectiveness reaching up to 97% in the first 6 weeks after the procedure. Over a 2-year follow-up, its effectiveness is maintained at 96%. According to his report, there were no complications such as skin or nerve damage. A total of 28% of patients presented with small hematomas, 17% had local skin hardening and 18% felt discomfort beyond the 1st week after the procedure. Several other studies have confirmed its effectiveness over follow-up periods between 6 and 24 months. We came across only one publication where Flebogrif catheter is used where preliminary results showed that its results are comparable with the ClariVein system in the 3-month follow-up period. The follow-up is too small and it is due to low number of people using this catheter and short follow-up period.
In terms of comparison between Flebogrif and ClariVein no published literature could be found. ClariVein device is from the US, and it works with an electrical rotation of the single wire along with injection of foam sclerotherapy. Flebogrif is a relatively simple device with no electrical rotation of the wire so it is less expensive than ClariVein. Flebogrif has springs which come out of the catheter and when we withdraw the catheter, it injures the intima of the vein and causes the spasm and more exposure to the wall of the sclerosant. According to discussion with the users of these device, ClariVein is not recommended for the vessels <4 mm and >14 mm veins, but Flebogrif catheter may be used in these conditions, but we could not come across any robust data to support this. information.
| Conclusions|| |
MOCA system is effective with success rates reaching up to 94% in the 2 years follow-up period. The procedure performed with this technique not only has a low complication rate and a good cosmetic effect but also seems to improve patient quality of life in the postoperative period similar to endovenous laser ablation. If long-term results are comparable to the thermal techniques than we feel that the MOCA may be another alternative to thermal techniques in future, particularly in obese patients, a patient who are pain sensitive and also where buying the expensive hardware for the thermal technique is not possible.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Vasić DM, Davidović LB, Maksimović ZV, Crni AR, Marković MD, Pejkić S, et al.
Primary varicose veins: Frequency, clinical significance and surgical treatment. Srp Arh Celok Lek 2004;132:398-403.
van Eekeren RR, Boersma D, Holewijn S, Vahl A, de Vries JP, Zeebregts CJ, et al.
Mechanochemical endovenous ablation versus RADiOfrequeNcy ablation in the treatment of primary great saphenous vein incompetence (MARADONA): Study protocol for a randomized controlled trial. Trials 2014;15:121.
van den Bos RR, de Maeseneer MM. Endovenous thermal ablation for varicose veins: Strengths and weaknesses. Phlebolymphology 2012;19:163-9.
Shepherd AC, Gohel MS, Lim CS, Hamish M, Davies AH. Pain following 980-nm endovenous laser ablation and segmental radiofrequency ablation for varicose veins: A prospective observational study. Vasc Endovascular Surg 2010;44:212-6.
Proebstle TM, Vago B, Alm J, Göckeritz O, Lebard C, Pichot O, et al.
Treatment of the incompetent great saphenous vein by endovenous radiofrequency powered segmental thermal ablation:First clinical experience. J Vasc Surg 2008;47:151-6.
Proebstle TM, Alm J, Göckeritz O, Wenzel C, Noppeney T, Lebard C, et al.
Three-year European follow-up of endovenous radiofrequency-powered segmental thermal ablation of the great saphenous vein with or without treatment of calf varicosities. J Vasc Surg 2011;54:146-52.
van den Bos R, Arends L, Kockaert M, Neumann M, Nijsten T. Endovenous therapies of lower extremity varicosities: A meta-analysis. J Vasc Surg 2009;49:230-9.
Bishawi M, Bernstein R, Boter M, Draughn D, Gould CF, Hamilton C, et al.
Mechanochemical ablation in patients with chronic venous disease: A prospective multicenter report. Phlebology 2014;29:397-400.
Nadzwyczajny HA, Zubilewicz T. On application of Flebogrif (mechanco-chemical ablation) in treatment of lower limbs varicose veins on the basis of 200 procedures performed with the use of above mentioned system. Acta Angiol 2016;22,4:137-42.
[Figure 1], [Figure 2], [Figure 3]