By Jill Buterbaugh, RN, MSN, CRNP, FNP-BC
Advancements in technology have made it possible to do things in an office setting that in the past, always had to be done in an operating room. This, coupled with advancements in the procedures themselves, have made it much more likely that many patients can resume their normal lives after the procedure without missing work.
Treating venous insufficiency is done by three different types of procedures. Catheter based ablation procedures that can be either laser or radiofrequency, sclerotherapy, or microphlebectomy. The old horror stories about stripping and ligation were mostly true. It was much more invasive and traumatic than the techniques used today and people had significant pain and bruising post procedure that often was a deterrent from having the procedures done.
Catheter based ablations are done with local anesthetic, requiring several injections along the course of the vein as well as tumescent anesthesia and use heat to seal the veins closed. The local anesthetic is used to numb the insertion site which requires a simple puncture that is generally less than a quarter of an inch. Along the course of the vein, several other areas are numbed for injections of the tumescent anesthesia. The tumescent anesthesia is a mixture of normal saline solution and lidocaine, the local anesthetic, and is injected up the course of the vein.
Tumescent anesthesia serves several purposes. First it compresses the vein against the laser fiber or radiofrequency catheter so there is good contact for treatment. It also forces the blood out of the vein into the deep venous system so there is very little blood loss when having these treatments. Its final purpose is to protect surrounding structures and skin from damage when the heat supply is turned on.
Veins do not have sensory nerves so once the catheter is placed in the vein, treating is causes no discomfort to it specifically. The pain involved in these procedures is from the effects on the surrounding tissues and the skin. The combination of local and tumescent anesthetics is very effective in controlling this pain. The only discomfort that is expected is from several injections of local anesthetic placed in the skin along the course of the vein and that discomfort is brief. Most patients can tolerate this discomfort without issue but a topical anesthetic cream is applied to the area to help decrease pain from the injections. On rare occasion, people who are very bothered by injections require a mild sedation but no general anesthesia.
Following the procedure, there is occasionally bruising and mild discomfort at the insertion site. More bruising can be expected if the patient is on a blood thinner but we do not discontinue blood thinners before this procedure. The bruising may be tender for a few days as any bruise would be. The tumescent anesthesia forces the blood out of the veins so the only blood loss is bleeding at the insertion and injection sites and is controlled easily with direct pressure. Rarely a single suture may be placed if the bleeding is not easily controlled.
Sclerotherapy is done by injecting a chemical into the diseased veins that damages the lining of the veins resulting in the walls swelling then adhering together. This relies on the body’s own immune system to turn the vein into a scar to be broken down for reabsorption. Local anesthetic is not used for this procedure but is generally well tolerated. This type of treatment involves injections approximately every two inches along the vein. The needles are very small and discomfort is minimal. Some mild stinging is described by some patients but usually resolves within a few minutes. There is occasionally some bruising from the injections and some inflammatory redness with tenderness over the vein treated that may last one to two weeks.
Microphlebectomy has replaced the old ligation and stripping. This is where several small punctures are made and small sections of vein are removed. The incisions are generally less than a quarter of an inch and do not require any sutures. The anesthetics used are the same as with the catheter based ablation procedures and involve injections of local anesthetic and instillation of the tumescent anesthesia. Patients may feel a pulling or tugging sensation but no severe pain while the procedure is being done. As expected, this procedure causes more bruising than the others but again is well tolerated.
For more information about treatment of venous insufficiency, please contact us here at Advanced Vein Care. We will be happy to answer your questions and address your concerns.