EVLT and stab phlebectomy on left leg?

Question

Hello, So I went to a vascular surgeon recently for my varicose veins on my left leg. She suggested I need to get EVLT on top of the leg and some sort of vein removal on bottom half of the leg ( since EVLT can cause nerve damage). I think she mentioned it is called, stab phlebectomy. My question is this... how accurate is her diagnosis? What is the difference between Sclerotheraphy vs stab phlebotomy? Are there any side effects or consequences of stab phlebectomy? Thanks

Raffy Karamanoukian, MD, FACS · Answer

It’s important to distinguish between varicose veins and spider veins when choosing between laser therapy, sclerotherapy, and vein surgery. With two board certified vein specialists, our center uses a combination of visual examination, functional flow measurements, ultrasound, transillumination, and infrared light to map out vein networks prior to therapy. Lasers can be used to treat deep varicose vein insufficiency, vein perforators, and varicose veins. Sclerotherapy is ideal for spider veins and reticular veins. Whereas surgery is reserved for severely incompetent varicose vein segments.

Best,
Dr. Karamanoukian
Realself100 Surgeon

Best,
Dr. Karamanoukian
Realself100 Surgeon

Michael Nguyen, MD · Answer

Ambulatory phlebectomy or microphlebectomy is a minimally invasive procedure to treat superficial varicose veins under the skin. It is used to complement saphenous vein reflux treatments with thermal energy such as EVLT (endovenous laser treatment) or RF (radiofrequency). Ambulatory phlebectomy is effective and also save on the remaining varicose veins after treating reflux. It causes minimal or no scarring. Incisions that are necessary to perform the procedure are very small and only local anesthetic is needed for the comfort of the patient. On the other hand, guided sclerotherapy treats feeder veins that are harder to see, and therefore ultrasound guidance is needed to deliver the medication to the correct area. The medication that is used is Asclera (polidocanol). This medication makes the vein smaller and eventually disappear. Spider veins can be also treated with sclerotherapy without the need of ultrasound guidance. For all of these procedures patients are advise to wear compression stockings after for optimal results. Your physician can help you make informed health care decision on the best treatment or combination of treatments that is best for you according to your specific goals.

Albert Malvehy, MD · Answer

It sounds like you are under the care of someone who knows what they are doing. Microphlebectomy is also called stab phlebectomy or ambulatory phlebectomy; all these terms mean essentially the same thing. The doctor uses a local anesthetic which numbs the area and controls bleeding and then makes a series of small (usually 1-2 mm) incisions in the skin in order to physically remove the vein. In selected parts of the leg, and with certain vein types, this means quick results and rapid healing. Sclerotherapy can also be used for most of these, but typically requires longer healing and may result in discoloration of the skin.

John Landi, MD · Answer

What your doctor told you was correct.  Below the knee the saphenous nerve is close to the vein and can be injured from the heat of the laser.  However this can be avoided by generous use of tumescent anesthesia or by using a different form of closure procedure such as Clarivein or Varithena.  Varicose veins can be treated by either sclerotherapy (injection of a solution to dissolve the vein) or removal through very tiny incisions.  I prefer the phlebectomies.

Hratch Karamanoukian, MD, FACS · Answer

There are EVLT lasers that are safe to ablate the saphenous veins below knee. With adequate administration of tumescent anesthesia, saphenous nerve injury can be avoided. We perform such procedures daily in our practice. Contact me on the link below for more information. H Karamanoukian MD FACS RVT RPVI RPhScertified vein specialist with ABVLM credentials

Hugo Pin, MD · Answer

Very good explanation below from Dr. Manu. 
Stab phlebectomy involves removing the varicosities (bulging veins) through tiny incisions (1-2 mm) with a small hook. There is generally no side effects and no complications. It is a very efficient way to get rid of large superficial veins, with a much quicker recovery than with sclerotherapy only. 
There is no need for GA, laser and phlebectomy are generally done under local anesthesia and you will be standing up straight after the procedure. 
80% of my patients with large veins are treated by EVLT and phlebectomy, the other 20% with laser only, or with sclerotherapy.

Manu B. Aggarwal, MD · Answer

It sounds like you had an ultrasound that showed you have a vein, called the Great Saphenous Vein (GSV), that is not working properly. That means that blood is tending to fall back down the vein -- instead of going up to the heart. This is called venous insufficiency. Reflux for this vein means that blood is going back down the vein for more than 500ms or 0.5seconds.To further clarify, the GSV is a superficial vein that lies closer to the skin, but still underneath the varicose veins (bulging vein). You also have another set of veins that lie deeper in between your muscles, called the deep venous system. This system carries most of the blood back up to the heart. This system can also have reflux. As for what happens when you have reflux, the backup from the superficial vein can cause varicose veins (bulging veins). So EVLT is used to close off the superficial vein (GSV) and ambulatory phlebectomy is used to remove the varicose veins. EVLT should be done to the entire length of the GSV that is refluxing. Yes, performing it below the knee does increase the chance of nerve damage. However, it is more the comfort of the physician. Our practice has been doing EVLT for 14 years and used to only do the upper leg with EVLT. If nerve damage is a serious concern, EVLT can be done to the upper leg and ultrasound guided sclerotherapy can be done to the bottom half of the GSV if it is refluxing. Just make sure the entire length of the refluxing vein is being treated. As for the varicose veins, ambulatory phlebectomy is the preferred method for removal of varicose veins. This has been shown in the medical literature.  Some practices chose to do sclerotherapy to the varicose veins. However, this requires usually multiple visits and wearing compression stockings for weeks after each visit. This works as well, however, it is more visits, more costly and has its own set of risks (skin discoloration being the main one patients hate). I hope this helps!

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