Endovenous laser ablation of the great saphenous vein has replaced high ligation and stripping of this vein for many centers in patients exhibiting symptoms related to the valvular incompetence of this vein, usually with varicose veins (FIGURE 1). In some centers, radiofrequency ablation is preferred over laser ablation, but the techniques are similar. Before considering ablation, these patients must have a complete peripheral vascular examination to determine whether the varicosities are primary or secondary, to evaluate the status both the superficial and deep venous systems, and to ascertain the adequacy of the arterial system. Venous duplex scanning is used to check for patency and the presence of reflux in both venous systems.
Evidence of obstruction in the deep system may contraindicate ablation of the superficial system because of reliance on it for venous return from the leg. Other contraindications include discontinuity or tortuosity of the greater saphenous vein, pregnancy and active breast-feeding, allergy to local anesthetics, liver dysfunction, and severe coagulation disorders. Patients are required to wear compression stockings in the postoperative period, and an inability to tolerate them is a relative contraindication.
Some patients prefer general anesthesia, but more commonly, tumescent anesthesia is preferred, especially in the ambulatory setting. Tumescent anesthesia consists of the infusion of a dilute local anesthetic solution (usually 0.1% lidocaine) into the subcutaneous space surrounding the veins to be treated. Epinephrine may be added to the solution for its vasoconstrictive effect, and sodium bicarbonate is included for buffering to minimize discomfort on infusion.
Patients are placed supine with a moderate Trendelenburg position to reduce venous hypertension.
The skin is prepped from the umbilicus through the entire lower extremity and foot. The toes are covered with a sterile plastic bag or glove. If phlebectomy, which is the removal of visible varicose veins through tiny stab incisions, is to be performed as well, the veins are marked with indelible ink in the preoperative holding area with the patient upright to ensure adequate filling. Then a time-out is performed.
Using a 7.5-MHz ultrasound probe encased in a sterile sleeve, the greater saphenous vein is identified at or below the level of the knee (FIGURE 2). If general anesthesia is not used, the skin is anesthetized with 1% lidocaine, and a 21-gauge access needle is inserted into the vein. A 0.018-inch micropuncture wire is inserted through the needle into the vein to secure access, and then the needle is removed (FIGURE 3). A small nick is made in the skin where the wire exits and a 4- or 5-French access sheath is inserted over the wire. The wire and sheath dilator are removed, and a ...