This presentation will be very helpful for interventional radiologist, vascualr sergeons and sonographers. We will discuss the basic concept of varicosities and then step by step their thermal ablation under US guiadance.

1. Radiofrequency Ablation of
Varicose Veins
Dr. Muhammad Bin Zulfiqar
PGR IV FCPS Services Institute of Medical
Sciences / Hospital
radiombz@gmail.com

2. Definitions
• Chronic Venous Disease (CVD)
– Venous hypertension of the lower extremities causing
signs and symptoms (CEAP classes 0 to 6)
• Chronic Venous Insufficiency (CVI)
– Venous hypertension of the lower extremities causing signs and
symptoms (CEAP classes 3 to 6)
Eklof B, et al. Revision of the CEAP classification for chronic venous disorders: Consensus
statement. J Vasc Surg. 2004;40:1248-52.

3. Definition
 Telangiectasias - are a confluence of dilated intradermal
venules less than one millimeter in diameter.
 Reticular veins - are dilated bluish subdermal veins, one to
three millimeters in diameter. Usually tortuous.
 Varicose veins - are subcutaneous dilated veins three
millimeters or greater in size. They may involve the saphenous
veins, saphenous tributaries, or nonsaphenous superficial leg
veins.

4. Abnormal Veins
Telangiectasias
Reticular veins
Varicose vein

5. C in CEAP: Clinical, Etiologic, Anatomic, Pathophysiologic
C0
No visible or palpable signs of venous disease
C1 Telangiectasias or reticular veins
C2 Varicose veins
C3 Edema
C4a Pigmentation or eczema
C4b Lipodermatosclerosis or atrophie blanche
C5 Healed venous ulcer
C6 Active venous ulcer
klöf B, Rutherford RB, Bergan JJ, Carpentier PH, Gloviczki P, Kistner RL, Meissner MH, Moneta GL, Myers K, Padberg FT, Perrin M, Ruckley CV,
Smith PC, Wakefield TW; American Venous Forum International Ad Hoc Committee for Revision of the CEAP Classification. Revision of the
CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg. 2004 Dec;40(6):1248-52. Review.

6. Superficial veins
Great saphenous – formed by the union of the dorsal
digital vein of the great toe and the dorsal venous
arch.
 Ascends anterior to the medial malleolus, posterior
to the medial condyle of the femur. It freely
communicates with the small saphenous vein.
 Proximally it traverses the saphenous opening in the
fascia to enter the femoral vein.
Arunachalam et al. Radiofrequency ablation of varicose veins using bipolar device: A step by step approach. C-
1152, ECR 2013
Kasi V, Kalyanpur TM, Narsinghpura K, Chakravarthy D, Mehta P, Cherian M. Bipolar radiofrequency-induced
thermotherapy of great saphenous vein: Our initial experience. Indian J Radiol Imaging 2012;22:86-8.

7. Great Saphenous Vein Anatomy

8. Small saphenous vein
Formed by the union of the dorsal digital vein
of the 5th digit and distal venous arch.
Runs posterior to the lateral malleolus, lateral
to the calcaneal tendon.
 Runs superiorly medial to the fibula and
penetrates the deep fascia of the popliteal
fossa, ascends between the heads of the
gastrocnemius muscle to join the popliteal
vein.

9. Possible Risk Factors Venous
Insufficiency
• Gender
• Age
• Heredity
• Pregnancy
• Standing occupation
• Obesity
• Prior injury or surgery
• Obstruction
Arunachalam et al. Radiofrequency ablation of varicose veins using bipolar device: A step by
step approach. C-1152, ECR 2013

10. Symptoms of Venous Insufficiency
• Leg pain, aching, or cramping
• Burning or itching of the skin
• Leg or ankle swelling
• “Heavy” feeling in legs
• Skin discoloration or texture changes
• Open wounds or sores
• Restless legs
• Varicose Veins
•
Arunachalam et al. Radiofrequency ablation of varicose veins using bipolar device: A step
by step approach. C-1152, ECR 2013

11. Signs of Venous Insufficiency
Image sources: 1 Paul McNeill, MD
2 Rajabrata Sarkar, MD
3missinglink.ucsf.edu/.../stasis_dermatitis.html
4 Amor Khachemoune, CatharineLisa Kauffman: Management Of Leg Ulcers. The Internet Journal of
Dermatology. 2002. Volume 1 Number 2

12. Pathophysiology of Venous Insufficiency

13. Venous Anatomical Landmarks

14. Venous return to right side of heart
accomplished thru the actions of the calf muscle
pump and venous valves.

15. Normal and Abnormal Valve

16. Perforator Veins
Pathologic =
• 3.5mm in size
• Outward flow
>500 ms (0.5 second)
duration, and
• Located beneath
chronic venous stasis
skin changes / ulcer
Gloviczki P, et al. The care of patients with varicose veins and associated chronic venous diseases: Clinical practice
guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011;53:2S-48S..

17. Treatment Options
• Compression Hosiery (Class I –III)
• Conventional Surgery
– Saphenofemoral(popliteal) ligation, Stripping of
long saphenous vein
• Minimally invasive treatments
– •RFA (VNUS Closure)
– •EVLT
– •Foam Sclerotherapy
Arunachalam et al. Radiofrequency ablation of varicose veins using bipolar device: A
step by step approach. C-1152, ECR 2013

18. Radiofrequency Ablation Device
Bipolar RFA Device
• Bipolar RFA probe; both the electrodes are in
the same probe with an insulator between the
electrodes.
• Radio frequency generator unit.
Arunachalam et al. Radiofrequency ablation of varicose veins using bipolar device: A
step by step approach. C-1152, ECR 2013

19. Generator RFA Probe

20. Mechanism
• Using a bipolar RFA catheter-based approach,
generator delivers radiofrequency (RF) energy to
the vein walls.
• RF energy creates conductive heating that
contracts the vein wall collagen, thereby
occluding the vein
• Controlled heating of the vein wall causes
shortening and thickening of collagen fibrils and
vein lumen diameter shrinkage and fibrotic
sealing of the vein.
Arunachalam et al. Radiofrequency ablation of varicose veins using bipolar device: A
step by step approach. C-1152, ECR 2013

21. Mechanism
• Heating element treats
7 cm of vein at once
• Segmental ablation
technology
• Average treatment
time: 3-5 min For
saphenous and SFJ
tributary treatment
Arunachalam et al. Radiofrequency ablation of varicose veins using bipolar device: A
step by step approach. C-1152, ECR 2013

22. Indication and Contraindications
• Indication
– The RFA is intended for endovascular coagulation
of blood vessels in patients with superficial
venous reflux
• Contraindication
– Patients with thrombus in the vein segment to be
treated
Arunachalam et al. Radiofrequency ablation of varicose veins using bipolar device: A
step by step approach. C-1152, ECR 2013

23. Preoperative ultrasound evaluation
• Reflux > 0.5 seconds in superficial venous system
• Assess GSV, noting:
• Vein depth and maximum diameter
• Presence of tortuous or aneurysmal segments
• Other significant anatomy
– Duplicate systems
– Large side branches
– Incompetent perforators or tributaries
– Assess SSV
• Choosing the Closure Candidate
• Assessment of SSV
Arunachalam et al. Radiofrequency ablation of varicose veins using bipolar device: A step
by step approach. C-1152, ECR 2013

24. Intra-operative Ultrasound
• Vein access
• Catheter navigation
• Tumescent fluid infiltration
• Final tip positioning
• Confirmation of procedure success
Arunachalam et al. Radiofrequency ablation of varicose veins using bipolar device: A step by
step approach. C-1152, ECR 2013

25. Steps in RFA of VV
1.System and Patient Preparation
2.Treatment
3.Post-op Duplex Scan
Arunachalam et al. Radiofrequency ablation of varicose veins using bipolar device: A step by step approach. C-1152, ECR
2013
4. Kasi V, Kalyanpur TM, Narsinghpura K, Chakravarthy D, Mehta P, Cherian M. Bipolar radiofrequency-induced
thermotherapy of great saphenous vein: Our initial experience. Indian J Radiol Imaging 2012;22:86-8.

26. Pre-Op Duplex Mapping
• Exam best performed with patient in 15-
30reverse Trendelenburg or in standing position.
• Leg externally rotated & bent at knee
• Identify and mark:
– Saphenofemoral junction
– Aneurysmal and tortuous segments
– Large branches and perforators
– Vein depths <10 mm from skin surface
– Potential access sites
Arunachalam et al. Radiofrequency ablation of varicose veins using bipolar device: A step by step approach. C-1152, ECR 2013
Kasi V, Kalyanpur TM, Narsinghpura K, Chakravarthy D, Mehta P, Cherian M. Bipolar radiofrequency-induced thermotherapy of great saphenous
vein: Our initial experience. Indian J Radiol Imaging 2012;22:86-8.

27. How to Elicit Reflux
• Grey Scale
– Increase in size >7 mm
– Incompetent valve
– Blood seen flowing on valsalva maneouver
• Color Doppler
– Change of color from blue to red.
• Spectral Analysis
– Duration of reflux is > 0.5 sec.

28. Sterile Leg Preparation
• Prep patient’s leg
circumferentially in a
sterile fashion
• From toes to groin,
or
• From ankle to groin
and wrap foot with
sterile towel
• Circumferential leg
prep with foot
wrapped
Arunachalam et al. Radiofrequency ablation of varicose veins using bipolar device: A step by step approach. C-1152, ECR
2013
4. Kasi V, Kalyanpur TM, Narsinghpura K, Chakravarthy D, Mehta P, Cherian M. Bipolar radiofrequency-induced
thermotherapy of great saphenous vein: Our initial experience. Indian J Radiol Imaging 2012;22:86-8.

29. Vein Access
• Vein access may be
achieved
percutaneously under
ultrasound guidance
or with a small cut-
down
Arunachalam et al. Radiofrequency ablation of varicose veins using bipolar device: A step by step approach. C-1152, ECR
2013
4. Kasi V, Kalyanpur TM, Narsinghpura K, Chakravarthy D, Mehta P, Cherian M. Bipolar radiofrequency-induced
thermotherapy of great saphenous vein: Our initial experience. Indian J Radiol Imaging 2012;22:86-8.

30. Catheter Advancement and Positioning
• Obtain longitudinal
view of SFJ; advance
catheter until tip
enters image.
• Position catheter tip
2.0 cm distal to SFJ
– Note: Catheter position
may shift during
tumescent infiltration
image
Arunachalam et al. Radiofrequency ablation of varicose veins using bipolar device:
A step by step approach. C-1152, ECR 2013
4. Kasi V, Kalyanpur TM, Narsinghpura K, Chakravarthy D, Mehta P, Cherian M.
Bipolar radiofrequency-induced thermotherapy of great saphenous vein: Our initial
experience. Indian J Radiol Imaging 2012;22:86-8.
Catheter Tip

31. Perivenous Tumescent
Infiltration
• Infiltrate tumescent
fluid into saphenous
compartment under
ultrasound guidance
• Approximately 10 cc
per cm of vein to be
treated
• Create vein depth 1
cm below skin
surface
4. Kasi V, Kalyanpur TM, Narsinghpura K, Chakravarthy D,
Mehta P, Cherian M. Bipolar radiofrequency-induced
thermotherapy of great saphenous vein: Our initial
experience. Indian J Radiol Imaging 2012;22:86-8.

32. Purposes of Tumescent Infiltration
• Compresses vein around heating element
• Exsanguinates treatment vein
• Creates depth between skin surface and
anterior vein wall
• Produces heat sink to protect perivenous
tissue from thermal injury
Arunachalam et al. Radiofrequency ablation of varicose veins using bipolar device: A step by step approach. C-
1152, ECR 2013
4. Kasi V, Kalyanpur TM, Narsinghpura K, Chakravarthy D, Mehta P, Cherian M. Bipolar radiofrequency-induced
thermotherapy of great saphenous vein: Our initial experience. Indian J Radiol Imaging 2012;22:86-8.

33. Final Tip Position
Verification
• Recommendation is 2.0
cm distal to SFJ
• Confirm tip position with
ultrasound:
– First in transverse to
identify true catheter tip
– Then in longitudinal for
caliper measurement to
verify distance to SFJ
• Important step to avoid
mis-aligning catheter
relative to deep venous
system.
Arunachalam et al. Radiofrequency ablation of varicose veins using bipolar device: A step by step approach. C-1152, ECR 2013
4. Kasi V, Kalyanpur TM, Narsinghpura K, Chakravarthy D, Mehta P, Cherian M. Bipolar radiofrequency-induced thermotherapy of great saphenous
vein: Our initial experience. Indian J Radiol Imaging 2012;22:86-8.

34. RFA Start
• Press catheter handle button or START RF button on
generator to initiate treatment
• 120C should be achieved in 3-5 seconds
• Energy delivery will automatically terminate at end of
20 second cycle
Arunachalam et al. Radiofrequency ablation of varicose veins using bipolar device: A step by step approach. C-1152, ECR 2013
4. Kasi V, Kalyanpur TM, Narsinghpura K, Chakravarthy D, Mehta P, Cherian M. Bipolar radiofrequency-induced thermotherapy of great saphenous vein: Our initial
experience. Indian J Radiol Imaging 2012;22:86-8.

35. Treatment on way
Apply external compression; deliver two 20-
second RF cycles to segment closest to SFJ
Quickly index catheter, apply compression
deliver energy*
Repeat withdrawal, compression and
treatments until desired length treated. Last
segment should be ablated carefully, so as to
prevent burning.
*Aneurysmal segments and areas with large tributaries or
perforators may benefit from two treatment cycles
Arunachalam et al. Radiofrequency ablation of varicose veins using bipolar device: A step by step approach.
C-1152, ECR 2013
4. Kasi V, Kalyanpur TM, Narsinghpura K, Chakravarthy D, Mehta P, Cherian M. Bipolar radiofrequency-induced
thermotherapy of great saphenous vein: Our initial experience. Indian J Radiol Imaging 2012;22:86-8.

36. External Compression
• Good vein wall contact important to
procedure success
• Apply external compression over entire
heating element using ultrasound probe
Lengthwise over heating element, plus 2
fingertips just distal to probe (avg probe
length = 5 cm)

37. Key Points On Vein Compression
• Inadequate vein compression around heating
element may result in:
• Incomplete treatment, or
• Damage to heating element
• Employ all compression and exsanguination
techniques:
• Perivenous tumescent infiltration
• Trendelenburg position
• External compression along full length of heating
element
Arunachalam et al. Radiofrequency ablation of varicose veins using bipolar device: A step by step approach. C-1152, ECR
2013
4. Kasi V, Kalyanpur TM, Narsinghpura K, Chakravarthy D, Mehta P, Cherian M. Bipolar radiofrequency-induced
thermotherapy of great saphenous vein: Our initial experience. Indian J Radiol Imaging 2012;22:86-8.

38. End Treatment
• Withdraw catheter immediately after each
segment treatment to allow further vein wall
contraction
• Perform duplex ultrasound scan to evaluate
treatment results
• No re-treatment algorithm
• Do not re-advance catheter through acutely
treated vein segment

39. Injection of Sodium Tetradecyl Sulphate
• Our patients were also
having perforators so
Injection Sclerotherapy
of 8 limb were done.
• Perforators identified
and inj. With 1 CC STD
injection mixed with
4CC air.
• Follow up Scan
showed successful
results.

40. Immediate Postprocedural Scan
• Assess GSV for patency
• Compressibility of treated GSV variable
• Note thickened GSV walls

41. Potential Complications
• Vessel perforation
• Haematoma
• Thrombosis
• Pulmonary embolism
• Phlebitis
• Infection
• Paraesthesia
• Skin necrosis
1 Shepherd et. al. Randomized Clinical Trial of VNUS ClosureFAST radiofrequency ablation versus laser for Varicose Veins BJS
2010;97:810-818
2 Lewis BD J Vasc Interv Radiol. 2010 Feb;21(2):302 Radiofrequency endovenous ClosureFAST versus laser ablation for the
treatment of great saphenous reflux--a multicenter, single-blinded, randomized study (RECOVERY study)

42. Randomized Trial
• Number of randomized trials comparing the bipolar RFA vs.
vein stripping
• bipolar RFA found to be superior to vein stripping in every
statistically significant outcome (1)
– less post-operative pain
– less bruising
– quicker recovery
– higher quality of life scores
• 81% o bipolar RFA patients returned to normal activities
within 1 day vs. 47% of vein stripping patients (2)
• bipolar RFA patients returned to work more than 1 week
sooner than vein stripping patients (2)
1 LurieF, et al. EurJ VascEndovascSurg. 2005;29:67-73.
2 Lurie, F, et al. Prospective randomized study of endovenousradiofrequency obliteration (Closure
procedure) versus ligation and stripping in a selected patient population (EVOLVeSStudy), J VascSurg2003;
38(2): 207-14

43. Rasmussen Study - Results
RF Ablation
(n=124*)
Endovenous
Laser Ablation
(n=124*)
Vein Stripping
(n=123*)
Ultrasound-Guided
Foam
Sclerotherapy
(n=123*)
Efficacy at 1 year
(reflux-free rate)
95.2% 94.2% 95.2% 83.7%
(p<0.001)
Post Intervention Pain
Scores* (1 – 10)
1.21
(p<0.001)
2.58 2.25 1.60
(p<0.001)
Time to return to normal
activities (days)
1
(p<0.001)
2 4 1
(p<0.001)
Time to resume work
(days)
2.9
(p<0.001)
3.6 4.3 2.9
(p<0.001)
Indirect cost (€) Lost
work
560 840 1120 560
Total costs (€) 1996 2200 2199 1559
*In the 10-day period post-procedure.
Rasmussen et al. Randomized clnical trial comparing endovenous laser ablation, radiofrequency ablation,
foam sclerotherapy and surgical stripping for great saphenous varicose veins. BJS 2011;98:1079-1087

44. Advantages of RFA
• Quicker Procedure
• Local Anaesthetic
• Cheaper
• Obviates need for admission to hospital
• Less morbidity
• Faster return to normal activities
1 Shepherd et. al. Randomized Clinical Trial of VNUS ClosureFAST radiofrequency ablation versus laser for Varicose Veins BJS
2010;97:810-818
2 Lewis BD J Vasc Interv Radiol. 2010 Feb;21(2):302 Radiofrequency endovenous ClosureFAST versus laser ablation for the
treatment of great saphenous reflux--a multicenter, single-blinded, randomized study (RECOVERY study)

45. Take Home Message
• Endovenous RFA is safe and effective method
and an alternative to surgical procedures in
the treatment of varicose veins.
• it is well tolerated by patients
• Has only insignificant side effects.
• Can be performed on day care basis.
• Our initial experience in 5 patients is
promising.

46. THANK YOU