Radiofrequency Ablation

Radiofrequency Ablation for Varicose Veins

If you have heard about it and think that you might need it, then you have come to the right place to learn more about the procedure. 

Radiofrequency ablation is a safe, minimally invasive treatment for varicose veins. In a study done by Proebstle, et al., they reported a success rate of 92.6% at 36 months with radiofrequency ablation. (1)

The history of radiofrequency ablation started in the late 19th century and it has been used not just for veins but in multiple surgeries as well.

What is Radiofrequency Ablation?

RFA has been used for neurosurgical procedures such as treatment to trigeminal nerve neuralgia and further expanded to usage for surgeries involving the liver, kidneys, breast, lymph nodes, spleen, and even in the lungs.

It is also used by ophthalmologists (eye surgeons) and dermatologists in different eye and skin conditions but what it is well known for is its use in varicose veins when it was introduced in Europe and in the United States in the early 20th century. 

Since that time, RFA has evolved and the procedure has become well studied and the techniques have improved overtime. 

Radiofrequency Ablation or (RFA) uses a radio wave that produces an electrical current that heats up the insides of the vein walls.  A catheter electrode is being used and it delivers a high radiofrequency that results in venous spasm (a form of contraction), shrinking of deposited collagen and even physical contraction of the vein itself. (2) 

Radiofrequency ablation has replaced vein stripping and ligation as the procedure of choice for varicose veins because it is easier with less down time for the patient. It is also less painful and can be done in the outpatient setting. 

RFA uses a local anesthetic instead of general anesthesia and is more preferable since patients can go home and resume their usual activities after the procedure. This is one reason why it has replaced the conventional treatment for varicose veins— it is more effective and more convenient for patients.   

RFA is the treatment of choice for patients who have looked for a way that has been medically proven to get rid of varicose veins. A lot of patients coming in are satisfied with the outcome from RFA, and these patients are usually those who have tried home remedies, varicose veins creams or even medications that claim to treat varicose veins and were never satisfied with their treatment.

Who needs Radiofrequency Ablation? 

Radiofrequency Ablation

Are you a candidate for RFA?  Patients who have varicose veins that are symptomatic and have a diameter greater than 3 mm may need RFA. Another indication is having perforator veins that are more than 3.5 mm in diameter, with greater than 500 milliseconds of reflux and if the perforator vein runs beneath a healed or active venous ulcer. These are all very technical but don’t worry, our doctor will help identify if radiofrequency ablation is the perfect treatment for you. 

The diameter and the rate of reflux will be determined by the doppler ultrasound that will be done prior to the procedure. This ultrasound will also determine how many of your veins may need radiofrequency ablation. 

The symptoms that you will feel that may indicate that you need RFA may be any of the following:

  1. Pain in the extremity where the varicose vein is noted
  2. Bleeding of the varicose veins
  3. Ulcers or non-healing wounds in the lower extremity (which may also be a sign of chronic venous insufficiency)
  4. Swelling of the extremity
  5. Skin discoloration

How is Radiofrequency Ablation done? 

Prior to the procedure, your veins will be mapped out using the doppler ultrasound. This is used to guide our doctor who will do the procedure. This is painless and no other special preparation is needed. 

Radiofrequency Ablation

Your leg will be draped and cleansed thoroughly to avoid contamination. A local anesthetic will be applied in the area to ensure that no pain will be felt. A small puncture will be done and the vein will be cannulated. The radiofrequency generator is then turned on and the catheter heats up. It is then gently pulled from the vein. 

Radiofrequency Ablation

The catheter is able to treat 7 cm sections of the vein at a given time for 20 seconds. The bigger the section of varicosity, the longer the procedure will take. The doctor will partially remove the catheter after the section is done until the whole vein is treated. (5)

Once completely treated and removed, pressure is applied to the entry point achieving hemostasis and that’s it! The procedure is easy to do and can be done in less than an hour depending on the number of veins that needs the treatment.  

What are the Contraindications of Radiofrequency Ablation?

  1. Veins that are too small or tortuous for access of the catheter.
  2. Veins that are too large to be ablated.
  3. Patients who are pregnant.
  4. Patients who have difficulty in ambulation (stroke patients who are paralyzed on the lower extremities). 
  5. Venous reflux which is aneurysmal in origin.
  6. Patients with poor general health. (3)

It is important that prior to deciding in RFA, patients divulge important clinical histories like prior surgeries or other diseases especially those that involve the veins or the hematologic system. Bleeding problems, medications that increase the risk for bleeding like clopidogrel, enoxaparin or rivaroxaban and conditions that may pose a risk to the procedure should be disclosed to your physician.

You may be asked to temporarily stop medications that may increase your risk for bleeding prior to the procedure. Remember that prior to coming in the clinic, keeping a list of your medications and other comorbidities can be helpful to you and our doctor. 

What are the Complications of RFA?

Pain

Pain is a common side effect of radiofrequency ablation but compared to other surgical procedures it is less in severity. A mean score of 1.21 over 10 was reported by Rasmussend et al., (4) in the pain score of patients on the first 10 days after RFA. 

Patients usually tolerate the pain when taking low dose analgesics like ibuprofen or acetaminophen and can return back to their normal daily activities after the procedure. 

Phlebitis

Phlebitis is inflammation on the site treated with RFA and this may be associated with other symptoms such as redness, swelling and tenderness. Phlebitis can occur at a rate of 8% of patients undergoing radiofrequency ablation and can be manageable with anti-inflammatory medications, rest and cold compress. 

Endovenous Heat Induced Thrombosis (EHIT)

This happens when a thrombus protrudes on the common femoral vein because of a phenomenon called endovenous heat induced thrombosis (EHIT). This incidence is very uncommon and can be avoided by using the catheter ablation tip 2 cm from the saphenofemoral junction. Don’t worry, doctors who are adept in RFA know what to do to avoid this complication

Wound or Skin Burns

Following RFA, there might be small areas with wounds from the incision site and skin burns but since the introduction of tumescent anesthesia, these burns have decreased in incidence from 1.8% to 0.5%. (5) 

Skin Discoloration

Skin discoloration or hyperpigmentation may occur after RFA. Residual blood trapped in the veins may cause this hyperpigmentation but resolves over a few weeks. 

This phenomenon is reduced by the application of tumescence. A tumescent fluid is a mixture of lidocaine (an anesthetic), a sterile saline solution, and sodium bicarbonate. This is injected into the vein and the surrounding tissue during the procedure while guided by the colored Doppler ultrasound. 

It acts as a buffer between the vein and the tissues to protect the tissue from damage. The tumescent fluid helps prevent damage and allows the doctor to only treat the vein. 

Deep Vein Thrombosis

Deep Vein Thrombosis (DVT) can develop in the deep calf and can go around the superficial veins. Its occurrence is extremely rare about 1 in 1000 and with the proper preoperative and postoperative care, the chances of getting it significantly lowers down.

Risks of deep vein thrombosis are decreased by wearing compression stocking post-procedure, using local anesthetic and sufficient ambulation of the patient. Some healthcare providers may prescribe you with medications depending on your case and your other co- morbidities.

Patients who are high risk for DVT should let their doctors know so that additional work up and precaution may be taken. Patients who use oral contraceptives or on hormonal replacement therapy, those with previous history of deep vein thrombosis, patients over 60 years old and those with malignancies are some of the high-risk patients for DVT. 

During the doppler ultrasound prior to the procedure, the presence of thrombus in the deep veins are recognizable and our doctors can treat and give the appropriate medication (usually an anticoagulant) to help with the problem. 

Paresthesia or Numbness

Numbness over the site where RFA is done is a common complication but improves over a few weeks. The incident is also decreased by the use of tumescent local anesthesia. 

Recurrence

Recurrence of the varicose vein may occur because of recanalization of a vein due to a reflux from a tributary (a connected branch of the vein) or an incompetent perforator vein (a vein that connects the deep and superficial).   

The use of RFA causes less recurrence compared to surgery and frequently, recurrence of varicose veins are less likely to be symptomatic when RFA was previously done. (6)

All these complications are avoidable and our doctors are experts in performing radiofrequency ablation and you are assured of the best with the least complications possible. 

Aftercare of Radiofrequency Ablation

After the procedure, you can go straight home since radiofrequency ablation is an outpatient procedure. You may be asked to take some time to rest and you will be prescribed with medications to help ease the pain. 

You are encouraged to walk and be active after the procedure. This will help decrease the risk of deep vein thrombosis. Strenuous activities are typically avoided in the first few days after the procedure. 

You will be wearing a compression stocking with about 20-30mmHg for at least 14 days. This will help prevent the formation of blood clots (along with walking), decrease phlebitis and pain. You may remove your stocking when taking a bath or when you are in bed. 

Your stockings may feel uncomfortable and tight but it has to be for you to get the benefits of its compression. Aside from wearing your stockings, walking around and being active is very important as it is the number one way to avoid serious complications like deep vein thrombosis. 

Follow up may vary but our doctor may ask you to come to the clinic after 1 to 3 weeks to check on your veins and to see if there are any complications from the procedures. 

If you experience the following after the procedure, seek help immediately:

  1. Sudden onset of difficulty of breathing which worsens when you move 
  2. Sudden onset cough where you cough up blood
  3. Sudden onset chest pain
  4. Pain in the calf
  5. Continuous bleeding in the area where the procedure is done

Conclusion

Varicose veins are very common and have been a problem for a long time especially when symptoms are bothersome. There are a lot of available treatments that claim to help varicose veins like creams, medications and even home remedies but most of these fail because they do not treat the underlying cause of varicose veins. 

With the advancement in medical procedures, radiofrequency ablation has become the treatment of choice for patients with varicose veins and have helped decrease the down time of patients, caused lesser pain compared to other conventional procedures, with lesser cost, and better outcomes. 

To recap, we have discussed the following in this article: 

Table of Contents

If you think you or someone you know can benefit from radiofrequency ablation or if you want to be screened, you can contact us here for a free consultation!

References

  1. Proebstle, T. M., Alm, J., Göckeritz, O., Wenzel, C., Noppeney, T., Lebard, C., Pichot, O., Sessa, C., Creton, D., & European Closure Fast Clinical Study Group (2011). Three-year European follow-up of endovenous radiofrequency-powered segmental thermal ablation of the great saphenous vein with or without treatment of calf varicosities. Journal of vascular surgery54(1), 146–152. https://doi.org/10.1016/j.jvs.2010.12.051
  2. Kayssi, A., Pope, M., Vucemilo, I., & Werneck, C. (2015). Endovenous radiofrequency ablation for the treatment of varicose veins. Canadian journal of surgery. Journal canadien de chirurgie58(2), 85–86. https://doi.org/10.1503/cjs.014914
  3. Medical Advisory Secretariat (2011). Endovascular radiofrequency ablation for varicose veins: an evidence-based analysis. Ontario health technology assessment series11(1), 1–93.
  4. Rasmussen LH, Lawaetz M, Bjoern L, Vennits B, Blemings A, Eklo¨f B. Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose veins. Br J Surg 2011;98:1079–87
  5. Merchant RF, Pichot O, Group CS. Long-term outcomes of endovenous radiofrequency obliteration of saphenous reflux as a treatment for superficial venous insufficiency. J Vasc Surg 2005;42:502–9; discussion 509
  6. Hinchliffe RJ, Ubhi J, Beech A, Ellison J, Braithwaite BD. A prospective randomized controlled trial of VNUS closure versus surgery for the treatment of recurrent long saphenous varicose veins. Eur J Vasc Endovasc Surg 2006;31:212–8
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Dr. Nima Azarbehi

Dr. Nima Azarbehi, our leading physician, has years of experience including chronic complicated conditions, urgent and emergency care, hospital medicine, dermatology, gastroenterology with endoscopy, rheumatology, pediatrics, newborn and obstetrics, aesthetics, office procedures, allergy management and treatment, cardiopulmonary management and intensive care management in hospital setting.

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