Dr. Shortell is Chief of Vascular Surgery at Duke University Medical Center. She specializes in general vascular surgery, surgery of the aorta, lower extremity bypass, and varicose vein treatment. She received her medical degree from Cornell University in 1984 before completing her residency at the University of Rochester between 1984 and 1989. She is a distinguished member of the Society for Vascular Surgery, and a member of the Association of Women Surgeons and the American College of Phlebology.
Dr. Cynthia Shortell spoke with Body1 about varicose vein treatment, which she discussed recently at the Veith Symposium on vascular surgery. She has particular expertise in radiofrequency ablation and laser therapy, so she offered an in-depth comparison of those two techniques.
Body1: What do you like about this field, and how did you get into it?
Dr. Shortell: After I trained as a vascular surgeon, and from the start of my career, I began to develop a vein practice in addition to my arterial practice. There are so few vascular surgeons who are female, and so many patients with varicose veins are female. I think many vascular surgeons don’t take varicose veins seriously. If you listen to patients and tell them you can treat them and offer them options, rather than just saying they have to live with it, patients respond to that. They tell their friends or they tell their doctor and you get more patients that way. So I think it’s probably a combination of interest in the patients and also being female.
Body1: At this meeting, you’ve been discussing faulty valves in the great saphenous vein and the short saphenous vein. Where are those veins?
Dr. Shortell: The great saphenous runs along the inside of the leg from the ankle bone, up into the top of the thigh and the groin area, and there it enters the deep venous system. The short saphenous begins also at the ankle but on the outside of the leg, and the outside of the achilles tendon and then it usually ends just before the knee joint where it enters the deep system of veins as well.
Body1: How are faulty valves in those veins treated?
Dr. Shortell: There are really four types of treatments for these problems. One is conventional stripping, which involved making an incision on the top and bottom of the saphenous vein, tying it off and ripping it out. And needless to say, that’s been done for many years and while it’s definitely effective, it’s associated with a lot of problems for patients: lots of bruising, scarring, nerve damage. For all those reasons, it takes a long time before patients can get back to work, requires general or spinal anesthesia and is not suitable for more elderly patients. But it’s also not suitable for young active patients because a lot of these patients are young mothers or working women or both and it’s really hard to take six weeks off to have your veins done.
Then there is radiofrequency ablation, which is also called RFA, and endovenous laser therapy, which is abbreviated ELT.
And in both of those cases the idea is the same – there’s a heat source that is applied to the inside of the vein wall and essentially cooks the vein and seals it shut. It’s important to understand that it’s not shutting the vein down with blood in it. It’s eliminating all the blood and sealing it shut.
Body1: How do those two techniques eliminate the blood?
Dr. Shortell:Well, the blood is eliminated a few different ways. First of all, the leg is elevated, tumescent anesthesia is applied, which is a very dilute form of anesthesia that squeezes the vein. There’s a drip of fluid that goes inside the vein to try to dilute the blood as well. Then, as the catheter is withdrawn, it basically seals the vein shut behind it. It’s almost like a zipper – as you pull, it seals the vein.
Body1: Does it push the blood out as it seals it shut?
Dr. Shortell: Well, yes. It’s not a lot of blood but yes, it does.
Body1: One of the treatments boils the blood, is that correct?
Dr. Shortell: That’s the laser. As it boils the blood, it still seals these walls shut. It’s similar to radiofrequency ablation, but it’s using a laser source of energy instead of radiofrequency.
There is actually still significant amount of debate about how laser works, and one of the theories is that the laser boils the blood and then the steam bubbles disperse and they connect with the wall and then coagulate the protein that way. In other words, it basically cooks it. That's what you’re doing when you put something in the oven.
There is another theory which is gaining more preeminence. That theory says the laser fiber itself is what’s heating the wall, not the steam bubbles. There have been several experiments involving physics that strongly support this, and seem to disprove the steam bubble theory.
Body1: What is the last type of treatment?
Dr. Shortell: The last type is chemical sclerosants. And there are a couple of types of chemicals that can be used. Sotredecol, or STS, is a chemical irritant that causes the vein to shut down. And it can be mixed with air to create a foam. This is also an effective treatment for saphenous reflux. It’s more controversial than RFA and laser. A lot of people oppose the use of foam because they feel it’s dangerous, since microemboli are created that briefly circulate in the bloodstream. However, there has never been any adverse clinical event related to this phenomenon.
Body1: Do patients who undergo this therapy have to wear stockings 24 hours a day for weeks? Are they able to shower?
Dr. Shortell: Some patients do wear stockings 24 hours a day, but in some cases people aren’t given any stockings at all, they’re given ace bandages to wear for one week. I’ve never told a patient not to shower.
Patients can resume their normal activities immediately. I’ve had patients who even go to an aerobics class after RFA. They’re encouraged to be active, they need to be active to prevent blood clots. The same is true for laser treatments.
Body1: There is a risk that some of these procedures will leave a scar or discoloration. How big of a risk is it using the different procedures? And does it deter people from pursuing these treatments?
Dr. Shortell: The risk depends on the therapy. It’s higher with laser than with the other modalities. There is some incidence of this with RFA and foam as well. The greatest risk of discoloration is if there is only partial sealing of the vessel at first, and you don’t treat it to seal it completely. Those discolorations and lumpy areas occur because the vein has shut down with blood in it. So, if you’re very diligent about looking for persistent flow and treating it right away, that’s an important way to prevent that. It’s more common in the smaller veins, not the saphenous veins.
Body1: Is the discoloration permanent?
Dr. Shortell: It can be permanent or it can be temporary. It can take as long as a year or two to fade. Usually after a year it has faded in, I would say, all but maybe a handful of patients.
Body1: What is your preferred treatment?
Dr. Shortell: I have used radiofrequency ablation a lot, but we’ve actually switched over to laser recently and have had a lot of success with laser. It has some definite advantages over RF. It is more reliable in the short-term. Radiofrequency, in maybe 20 percent or more cases, requires some sort of additional treatment at the time of the initial procedure.
Body1: What kind of additional treatment?
Dr. Shortell:The doctor might have to make an incision to tie off the vein, or have to use multiple passages of the catheter if the vein just doesn’t shut down the first time. With laser that happens much less often, I would say maybe 1-2% at most. You can also treat larger veins with laser.
Body1: Does RFA have advantages over laser?
Dr. Shortell:Yes actually, RFA tends to have virtually no swelling, bruising, or discomfort following a procedure. Whereas with laser, usually around 6 days after the procedure patients will begin to experience some bruising and swelling for a few days.