COMMENTARY • COMMENTAIRE
©2015 8872147 Canada Inc. Can J Surg, Vol. 58, No. 2, April 2015 85
Endovenous radiofrequency ablation for the
treatment of varicose veins
aricose veins affect approximately 26% of the adult population and are
a frequent cause of discomfort, loss of productivity and deterioration
in health-related quality of life.
Numerous therapies have been
de veloped for the treatment of this condition. Conventional open surgical
interventions include ligation of the great saphenous vein at the saphenofem-
or al junction and stripping. Smaller veins have also been treated with phlebec-
tomies. More recently, less invasive modalities, such as foam sclerotherapy,
endovenous laser therapy (EVLT) and endovenous radiofrequency ablation
(RFA), have also been used. While endovenous approaches are associated with
fewer postoperative complications, such as hematoma, pain or saphenous
nerve injury, there is currently no strong evidence to suggest an overall advan-
tage for any particular treatment approach.
The RFA procedure involves using a catheter electrode to deliver a high-
frequency alternating radiofrequency current that leads to venous spasm, col-
lagen shrinkage and physical contraction.
The patient’s leg is prepped with
antiseptic solution and draped in a sterile fashion. With ultrasound guidance,
the vein is cannulated, and local tumescent anesthetic is then injected around
the target venous segment. The catheter is then introduced through a sheath.
The radiofrequency current is then delivered, resulting in circular homogen-
eous denaturation of the venous collagen matrix and endothelial destruction at
a temperature of 110–120° C. Venous segments 3–7cm in length are treated
in 20-second cycles. Patients are instructed to wear 20–30 mm Hg graduated
elastic compression stockings for at least 14 days.
Compared with conventional open surgery, RFA can be performed in the
outpatient setting without the requirement for hospital admission or general
anesthesia. However, the procedure is not feasible in tortuous or very small or
large veins, and it may be less cost-effective than open surgery because of the
cost of the catheters.
To our knowledge, our institution was the rst in Canada to offer RFA for
the management of varicose veins using the venet procedure with second-
generation ClosureFast catheters (Covidien). Between 2010 and 2013,
173pa tients underwent RFA performed by 3 vascular surgeons. The average
age of the patients was 52 ± 14 years, and 143 (83%) of the patients were
women. Our patients were referred to the clinic either by their family doctors
Ahmed Kayssi, MD, MSc, MPH
Marc Pope MD, MSc
Ivica Vucemilo, MD
Christiane Werneck, MD, MScCH
Accepted for publication
Oct. 15, 2014
Division of Vascular Surgery
University of Toronto
89 Queensway West, Suite 500
Mississauga ON L5B 2V2
Varicose veins are a common condition that can be treated surgically. Available
operative modalities include saphenous venous ligation and stripping, phlebec-
tomy, endovenous laser therapy and radiofrequency ablation. Radiofrequency
ablation is the newest of these technologies, and to our knowledge our group was
the rst to use it in Canada. Our experience suggests that it is a safe and effective
treatment for varicose veins, with high levels of patient satisfaction reported at
short-term follow-up. More studies are needed to assess long-term effectiveness
and compare the various available treatment options for varicose veins.
86 J can chir, Vol. 58, N
2, avril 2015
or another vein clinic, and they underwent preoperative
Doppler ultrasonography to identify reux within the tar-
get vein. The decision to offer a patient RFA was based on
the target vein anatomy and diameter. The maximum vein
diameter considered for the procedure was 1.8cm, and the
minimum was 0.4 cm. Elderly patients also underwent
arterial duplex scans to rule out arterial insufciency.
Most (72%) patients underwent treatment of a single
limb, and 89% of patients underwent treatment of a single
vein. The great saphenous vein was most frequently
treated (81%), followed by the small saphenous (7%) and
the accessory great saphenous (1%).
Postoperatively, the median time that patients took off
work was 2 days. While 80 (69%) patients needed no post-
operative analgesia, 35 (30%) patients used over the coun-
ter oral analgesics, such as acetaminophen or ibuprofen.
Only 1 patient needed an opioid analgesic. Duplex ultra-
sonography performed 2–4 weeks after the procedure
demonstrated successful vein occlusion in 99% of patients.
Only 1 patient showed evidence of partial recanalization
on follow-up. Two (1%) patients reported persistent pain
at 30-day follow-up, and 6 (4%) patients demonstrated
skin discoloration. Eight (5%) patients with residual large
veins returned to our clinic after the follow-up period and
underwent phlebectomy procedures.
Telephone interviews were conducted several weeks after
the procedure to assess patient satisfaction. Of the 111 (65%)
patients contacted, 83% were extremely satised, 12% were
very satised, 3% were somewhat satised, and 2% were not
too satised with their RFA experiences. However, all of
those who responded indicated that they would have this
procedure again and would recommend it to a friend.
Our experience suggests that RFA is a safe and effective
treatment for the management of varicose veins that is
associated with a high success rate and patient satisfaction.
Only 1 patient in our series demonstrated target-vein
recanalization on follow-up. This was a cirrhotic patient
with a history of hepatic failure who was on chronic anti-
coagulation therapy for multiple medical comorbidities.
Her vein was also 1.5 cm in diameter, which was close to
the cutoff of 1.8 cm that we accept in our practice.
To our knowledge, our group is the rst to describe the
successful implementation of RFA in Canada, where public
health insurance guidelines have greatly restricted the criter ia
for reimbursing venous procedures and where many vein
surgeries are performed at private clinics. In the face of this
changing reimbursement landscape, we believe that RFA is a
viable alternative to more conventional open vein surgeries
and EVLT, which are more widely available in Canada.
Our work as well as studies by other groups will hope-
fully continue to enrich the debate on the most suitable
intervention for the management of venous disease. A
2011 review by Ontario’s Medical Advisory Secretariat
found that RFA was superior to open vein surgery when
comparing postoperative pain, duration of recovery, major
adverse effects and patient preference, while open surgery
was less costly than RFA.
However, the same review
found no evidence to suggest major differences in postop-
erative pain between RFA and EVLT when pain was
adjusted for analgesic use, and any differences did not per-
sist after 1-month follow-up. Furthermore, the 2 proced-
ures did not differ when comparing treatment effectiveness
or durability. This was mostly because of a lack of studies
that have assessed long-term recurrence after either treat-
ment. Prospective, long-term studies are thus clearly
needed to compare the clinical and cost-effectiveness of
both treatments and provide health care consumers with
the best standard of care.
Afliations: All authors are from the Division of Vascular Surgery,
Trillium Health Partners, University of Toronto, Mississauga, Ont.
Competing interests: None declared.
Contributors: All authors contributed substantially to writing and/or
revising and to the conception and design of the manuscript and
approved the nal version for publication.
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