Podiatric Vein Care
Complications and Pitfalls in Vein Therapy
Complications and Pitfalls in Vein Therapy
Performing any procedure comes with its own risks and complications. When performing endovenous ablation techniques by any of the FDA-approved modalities it is important that you have an understanding of the potential complications that can arise. It is also imperative that you have the patient sign a consent form after you’ve answered all questions and apprise them of the appropriate risks and complications. Patients must understand their optimal outcome and expectations must be kept in check as venous insufficiency and vein diseases are an ongoing circulatory problem that require maintenance throughout the course of their life. They must understand the goal of successful therapy is improvement of quality-of-life as the primary goal and cosmoses as a secondary objective.
The four standard and approved methods for endovenous care include laser ablation, radiofrequency ablation, Varithena® using Polidocanol Foam, and VenaSeal™ using Cyanoacrylate Adhesive. The goal of these endovenous techniques is to close a portion of the refluxing vein and re-route the flow of blood cephalad. A standard consent should include all risks and complications including but not limited to infection, swelling, mild scarring, skin ulceration, burn, nerve injury, matting, skin staining, deep vein thrombosis, skin discoloration, phlebitis, and the need for additional procedures.
The risk of infection is extremely small and is usually seen at the site of entry. A local cellulitis may easily be treated with an oral antibiotic and usually resolves without any incidents. Appropriate sterile technique and cleansing of the skin prior to injection is recommended. Swelling can be seen post treatment and is often limited to the ankle and the lower leg. The use of compression therapy can assist to reduce the swelling and oftentimes the swelling is resolved within a few weeks. Complaints of scarring are infrequent, however a 2 mm scar is present at the entry point. Typically this is not seen with polidocanol as the administration is due to injection therapy. Normally scarring is noted at the site where a larger sheath is placed into the vein. A skin ulceration is noted mostly with thermal ablation or the use of chemicals and is often seen through a tributary branching off of the refluxing vein that goes directly towards the skin surface. It can also be seen with polidocanol where extravasation has occurred. This normally creates a necrosis and does leave a scar on the skin surface. A burn from thermal ablation can scar as steam bubbles generated from the heat of the laser travel towards the surface vessels and create a burn. These burns can either be grade 2 or grade 3 and require local wound care. Nerve injury is typically identified when radiofrequency or thermal ablation is performed on veins below the knee. In this region, the greater saphenous vein runs in close proximity to the saphenous vein and patients can develop nerve-like symptoms of burning and tingling. Typically these are self-limiting and do improve over the course of six months. Normally it is not severe enough to require oral medication or neurologic treatments and is tolerable by patients. Matting is a skin condition where new vessels form in a plush-like appearance in the surface of the skin. This can occur with any modality and is treated with transcutaneous laser treatments. It is very difficult to identify and predict who will develop mottling but it is very commonly seen with Fitzpatrick skin types one and two. Skin staining can occur from coagulant left in the vessel that breaks down and forms staining on the surface. This does go away over the course of the year, however they can be unsightly. Topical hydroquinones or skin lightening creams can assist in breaking up the staining. Again it is very difficult to predict who will stain and staining is seen on all skin types. Deep pain thrombosis is another complication that can arise. Although these treatments are performed in the superficial system, there are communicators called perforators that connect the deep and superficial system. If a coagulant does exist it can travel from the superficial to the deep system. Moreover techniques that are performed close to the saphenopopliteal and saphenofemoral junction run the risk of deep vein thrombosis if you are not adequate distance from the junction itself. It is recommended to perform an ultrasound and scan the patient four days after procedure as well as immediately after so that you can make sure no deep vein thrombus will occur. If the patient does develop a DVT it is imperative the appropriate protocol is taken. Phlebitis or superficial vein inflammation may also develop at ablation site or along the course of another vein site. Swelling erythema and warmth are present and is best treated with the use of compression therapy and regular strength aspirin three times a day. Finally the need for additional procedures must be understood by the patient. Circulation issues, especially in the venous system, require ongoing maintenance and care as the patient ages. The best way to minimize the need for treatment is to continually wear compressive therapy.