What next after thermal ablation for varicose veins: non-thermal ablation?

BACKGROUND: Endothermal treatment of the great saphenous vein has become the first line of treatment for superficial venous reflux. Newer treatments, especially non-thermal ablation have potential benefits both for patient acceptability and decreased risk of nerve injury.

APPROACH: We describe the current non-thermal options available including advantages and disadvantages. Ultrasound guided foam sclerotherapy avoids the risk of nerve injury, however it is not as effective as endothermal ablation. Mechanochemical endovenous ablation combines mechanical endothelial damage using a rotating wire, with the infusion of a liquid sclerosant (the Clarivein™ system). Reports suggest that this system is safe and effective, eliminating the need for tumescent anaesthesia with no reported case of nerve injury. Finally the VenaSeal™ Sapheon Closure System comprises the endovenous delivery of cyanoacrylate tissue adhesive to the vein causing fibrosis. Peri-operative discomfort seems to be minimal but the complication of thrombophlebitis has been reported in up to 15% of patients.

CONCLUSIONS: Non-thermal options promise comparable treatment efficacy without the added morbidity associated with high thermal energies. The potential of treating venous reflux without the risk of nerve damage may change how surgeons approach venous disease.