Ultrasound Guidance in Radiofrequency Ablation of Multiple Incompetent Vessels Using Single-Site Access

Abstract

Varicose veins are common in the adult population, occurring in approximately one third of men and women. Several endovenous treatment options are now available, including radiofrequency, laser thermal, and foam ablation. These minimally invasive procedures rely on the use of ultrasound for safe and efficacious treatment. Ultrasound has become standard for diagnosis of venous pathology, and its increasing use has lead to a more thorough description of the variability in lower-extremity venous anatomy. The presented patient case exemplified variations in venous anatomy that may be encountered during endovenous ablative procedures and how these variables can be managed under ultrasound guidance. The patient was a 58-year-old woman who was experiencing leg pain from her calf varicose veins despite conservative therapy. Her superficial reflux was greater than 0.5 seconds, and radiofrequency ablation was recommended. At time of the procedure a large, incompetent anterior accessory saphenous vein (AASV) with a corresponding segment of hypoplastic great saphenous vein (GSV) at the proximal thigh was noted. Her AASV was transmitting venous reflux to the lower, more medial, true GSV through a large collateral. With the use of ultrasound, the GSV was accessed distally at the upper calf and a guidewire passed through the collateral vein to the AASV. This allowed the radiofrequency catheter to pass from the lower GSV to the saphenofemoral junction and treat both segments of incompetent vein from a single access site. To the authors' knowledge, this selective cannulation of the AASV from the true GSV during radiofrequency ablation has not been previously reported in the literature. Alternative treatment would have required separate sheath access of each vein, leading to greater patient discomfort, extended procedure time, and a less-effective therapy. This case highlights the integral role of skilled ultrasonography during radiofrequency venous ablation in a certified laboratory, especially when dealing with variations in venous anatomy of the lower extremity.