Editing Varicose veins (section)

==== {{anchor|ETA}} Endovenous thermal ablation ====

There are three kinds of endovenous thermal ablation treatment possible: laser, radiofrequency, and steam.<ref>{{cite journal | vauthors = Malskat WS, Stokbroekx MA, van der Geld CW, Nijsten TE, van den Bos RR | title = Temperature profiles of 980- and 1,470-nm endovenous laser ablation, endovenous radiofrequency ablation and endovenous steam ablation | journal = Lasers in Medical Science | volume = 29 | issue = 2 | pages = 423–429 | date = March 2014 | pmid = 24292197 | doi = 10.1007/s10103-013-1449-4 }}</ref>

The Australian Medical Services Advisory Committee (MSAC) in 2008 determined that [[endovenous laser treatment]]/ablation (ELA) for varicose veins "appears to be more effective in the short term, and at least as effective overall, as the comparative procedure of junction ligation and vein stripping for the treatment of varicose veins."<ref>Medical Services Advisory Committee, [http://www.msac.gov.au/internet/msac/publishing.nsf/Content/7CAA933675966F4DCA25801000123B62/$File/1113-Assessment-Report.pdf ELA for varicose veins]. MSAC application 1113, Dept of Health and Ageing, Commonwealth of Australia, 2008.</ref> It also found in its assessment of available literature, that "occurrence rates of more severe complications such as DVT, nerve injury, and paraesthesia, post-operative infections, and haematomas, appears to be greater after ligation and stripping than after EVLT". Complications for ELA include minor skin burns (0.4%)<ref name="Elmore">{{cite journal | vauthors = Elmore FA, Lackey D | title = Effectiveness of endovenous laser treatment in eliminating superficial venous reflux | journal = Phlebology | volume = 23 | issue = 1 | pages = 21–31 | year = 2008 | pmid = 18361266 | doi = 10.1258/phleb.2007.007019 }}</ref> and temporary [[paresthesia]] (2.1%). The longest study of endovenous laser ablation is 39 months.<ref>{{Cite web|last=Publishing|first=BIBA|date=2007-02-13|title=What is the best treatment for varicose veins?|url=https://vascularnews.com/what-is-the-best-treatment-for-varicose-veins/|access-date=2021-08-31|website=Vascular News|language=en-GB}}</ref>

Two prospective randomized trials found speedier recovery and fewer complications after radiofrequency ablation (ERA) compared to open surgery.<ref>{{cite journal | vauthors = Rautio TT, Perälä JM, Wiik HT, Juvonen TS, Haukipuro KA | title = Endovenous obliteration with radiofrequency-resistive heating for greater saphenous vein insufficiency: a feasibility study | journal = Journal of Vascular and Interventional Radiology | volume = 13 | issue = 6 | pages = 569–575 | date = June 2002 | pmid = 12050296 | doi = 10.1016/S1051-0443(07)61649-2 }}</ref><ref>{{cite journal | vauthors = Lurie F, Creton D, Eklof B, Kabnick LS, Kistner RL, Pichot O, Sessa C, Schuller-Petrovic S | display-authors = 6 | title = Prospective randomised study of endovenous radiofrequency obliteration (closure) versus ligation and vein stripping (EVOLVeS): two-year follow-up | journal = European Journal of Vascular and Endovascular Surgery | volume = 29 | issue = 1 | pages = 67–73 | date = January 2005 | pmid = 15570274 | doi = 10.1016/j.ejvs.2004.09.019 | doi-access = free }}</ref> Myers<ref>{{cite journal| vauthors = Myers K |title=An opinion – surgery for small saphenous reflux is obsolete!|journal= Australian and New Zealand Journal of Phlebology|volume=8|issue=1|date=December 2004}}</ref> wrote that open surgery for [[small saphenous vein]] reflux is obsolete. Myers said these veins should be treated with endovenous techniques, citing high recurrence rates after surgical management, and risk of nerve damage up to 15%. By comparison ERA has been shown to control 80% of cases of small saphenous vein reflux at 4 years, said Myers. Complications for ERA include burns, paraesthesia, clinical [[phlebitis]] and slightly higher rates of [[deep vein thrombosis]] (0.57%) and [[pulmonary embolism]] (0.17%). One 3-year study compared ERA, with a recurrence rate of 33%, to open surgery, which had a recurrence rate of 23%.{{citation needed|date=February 2021}}

Steam treatment consists in injection of pulses of steam into the sick vein. This treatment which works with a natural agent (water) has results similar to laser or radiofrequency.<ref>{{cite journal | vauthors = van den Bos RR, Malskat WS, De Maeseneer MG, de Roos KP, Groeneweg DA, Kockaert MA, Neumann HA, Nijsten T | display-authors = 6 | title = Randomized clinical trial of endovenous laser ablation versus steam ablation (LAST trial) for great saphenous varicose veins | journal = The British Journal of Surgery | volume = 101 | issue = 9 | pages = 1077–1083 | date = August 2014 | pmid = 24981585 | doi = 10.1002/bjs.9580 | doi-access = free }}</ref> The steam presents a lot of post-operative advantages for the patient (good aesthetic results, less pain, etc.)<ref>{{cite journal| vauthors = Milleret R |title=Obliteration of varicose veins with superheated steam |journal= Phlebolymphology |date=2011 |volume=19 |issue=4 |pages=174–181}}</ref> Steam is a very promising treatment for both doctors (easy introduction of catheters, efficient on recurrences, ambulatory procedure, easy and economic procedure) and patients (less post-operative pain, a natural agent, fast recovery to daily activities).<ref>{{cite journal | vauthors = Woźniak W, Mlosek RK, Ciostek P | title = Assessment of the efficacy and safety of steam vein sclerosis as compared to classic surgery in lower extremity varicose vein management | language = english | journal = Wideochirurgia I Inne Techniki Maloinwazyjne = Videosurgery and Other Miniinvasive Techniques | volume = 10 | issue = 1 | pages = 15–24 | date = April 2015 | pmid = 25960788 | pmc = 4414100 | doi = 10.5114/wiitm.2015.48573 }}</ref>

ELA and ERA require specialized training for doctors and special equipment. ELA is performed as an outpatient procedure and does not require an operating theatre, nor does the patient need a [[general anaesthetic]]. Doctors use high-frequency ultrasound during the procedure to visualize the anatomical relationships between the saphenous structures.{{citation needed|date=February 2021}}

Some practitioners also perform phlebectomy or ultrasound-guided sclerotherapy at the time of endovenous treatment. This is also known as an [[ambulatory phlebectomy]]. The distal veins are removed following the complete ablation of the proximal vein. This treatment is most commonly used for varicose veins off of the great saphenous vein, small saphenous vein, and pudendal veins.<ref>{{cite book |doi=10.1016/B978-012369515-4/50030-2 |chapter=Principles of Ambulatory Phlebectomy |title=The Vein Book |date=2007 |last1=Almeida |first1=Jose I. |last2=Raines |first2=Jeffrey K. |pages=247–255 |isbn=978-0-12-369515-4 }}</ref> Follow-up treatment to smaller branch varicose veins is often needed in the weeks or months after the initial procedure.