Which procedure is the most effective with least side effects?

Question

Im 6ft 1 159 pounds. I was told i need evlt and phelebectomy. Im wondering with the different procedures out there which one is most effective long term. Least side effects. I hear laser is most painful. Rfa can not be effective if you have lg gsv to seal it all the way. Opens up again. Then venaseal... Not sure about that. I have extreme anxiety about these the constant ultrasounds an then constant procedures. Vascular surgeon said sometimes 25 treatments are necessary. Evlt is just beginning.

Thomas Wright, MD · Answer

EVLT and foam sclerotherapy should not be painful.  They are very effective if done by the right hands.  We can often treat saphenous veins and varicose veins comprehensively and completely in 4 treatment for each leg, or just 4 treatment if one leg needs treatment.

Raymond Shaheen, MD, FACS · Answer

Most commonly patients get recommendations for thermal ablation with either RF or laser (EVLT). I find laser may require a little more NSAIDS after the procedure but if the physician modifies the intensity of the laser to match your vein size And pullback speed that will minimize the difference between the two in terms of pain. Laser needs priocedural glasses and the sound can be more alarming for apprehensive patients. Ear buds and music can help. Laser is better for a really large saphenous vein but both of these are older technologies. Heat has a larger zone of injury than the inflammation from non-thermal ablation (1. Venaseal/glue, 2.MOCA/mechanical obliteration and chemical ablation, or 3. Varithena/microfoam).Every technique has slightly different advantages (Glue- less dependent upon perfect compression and closes veins definitively, MOCA- least inflammatory provoking of the catheter options, Varithena- does not use a catheter and is the most versatile particularly in large, tortuous, or very superficial veins) or disadvantages (Glue - avoid if you have multiple allergies particularly to adhesives & uses a larger sheath and stiff catheter, MOCA - may have a fewer insurance coverage & possibly slightly higher partial closure rates due to it being so gentle and well tolerated, Varithena - harder to seal the vein exactly on a dime as you can with catheter-bases techniques and not approved for the small saphenous vein ablation.
If you have severe disease (may need to rule out iliac vein obstruction) and there is a higher-risk of ablation partial failure or anticipated multiple procedures, then Venaseal in my experience is what I use particularly for the thigh GSV/AASV(anterior accessory saphenous vein) or SSV because it has the most definitive closure out there. Also it is best if the pt has very large thighs or has challenges with compression in the thighs. Varithena is so versatile it is great for tortuous AASV, large bulky varicose veins, and can be used for GSV. Also, if you are apprehensive about needles or procedures, Varithena does not require insertion of a catheter and therefore no cut in the skin (just uses numbing skin injection followed by foam injection. If the patient wants the least amount of chemical exposure and doesn’t want all the extra needle sticks from heat-based procedures, MOCA will generally very well via only a micro puncture access even below the knee. MOCA is safe if there are connection veins that drain directly into the deep system (“perforator veins”) and you possibly want to avoid glue or foam in those areas. 
Hope all these details help you determine with your doctor which approach is best for your vein anatomy and overall situation. At 6’1” and 159 Lbs being careful to minimize heat and inflammation to the skin will be major determining factor in the decision making process.

Brian Heeringa, MD, FACS · Answer

EVLT and RFA are pretty much equivalent. I myself prefer RF but honestly they both do a good job. Phlebectomy is also great for treating large superficial tributary varicosities but in the right hand and right setting ultrasound guided sclero can have great results too. I use both techniques in my practice and tailor the treatment to the patients anatomy and preferences. The long term success rate for an ablation should be over 95%. Having said that, 25 procedures seems very excessive. I do feel that venous insufficiency is a chronic disease and you very well may need more treatments later in life. I always encourage people to get second opinions if they are not comfortable with recommended procedures. A vascular surgeon should know how to properly treat veins but ask what percent of their practice is spent on treating veins vs arteries. Some vascular surgeons spend the vast majority of their practice treating arteries and only dabble in vein care and thus may not be as up to date as someone who only treats veins.

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