Bonding - an alternative in the treatment of diseased veins?

Vein fusion procedures in Poland already have a history of more than five years. The first procedures using the innovative VenaSeal system were carried out by doctors Tomasz Grzela and Cezary Szary in Warsaw, in early 2013.

The first procedures we performed concerned inefficient venous trunks, i.e. the saphenous and saphenous veins. As we gained experience in using this method, it became apparent that bonding is a very versatile technique, but one that also has some limitations - Doctors Cezary Szary and Tomasz Grzela comment.

There are currently several registered systems on the market using endovascular glue for the treatment of venous insufficiency of the lower limbs, a condition that affects one in five men and up to one in two women.

What caused a new product and a new technological solution to appear on the phlebology market? Experts from the Phlebology Clinic in Warsaw, doctors Justyna Wilczko, Cezary Szary and Tomasz Grzela, will try to explain.

Glue - an idea for a new method in the treatment of venous insufficiency.

The beginning of the new millennium saw an incredible development in phlebology, the field of medicine dealing with the prevention, diagnosis and treatment of venous diseases. The introduction of endovascular techniques - thermal closure of veins with radiofrequency electromagnetic wave energy and laser light energy - has improved the effectiveness of treatment. At the same time, there has been a reduction in the rate of intra- and post-operative complications, which was mainly related to the low invasiveness and constant intra-operative control of intravenous procedures using ultrasound.

Despite the clear progress compared to traditional surgical treatment, the use of thermal methods is associated with the need for local anaesthesia and the wearing of compression stockings in the postoperative period. There is therefore still a need to make the treatment of venous insufficiency even less invasive and less burdensome for the patient than the thermal methods used today, while maintaining a high level of efficacy comparable to these methods. An endovascular adhesive introduced to the market a few years ago seems to meet all these expectations.

Firstly painless, secondly equally effective....

The original idea of treating insufficient veins with cyanoacrylate glue was to perform these procedures completely without anaesthesia, to be faster and to have at least as much effect as the method considered the gold standard at the time, i.e. intravenous thermal ablation at the
using an intravenous laser - Cezary Szary from the Department of Phlebology comments.

Treatments carried out using cyanoacrylate adhesives are classified as non-thermal techniques. This means that no heat energy is given off when the adhesive is applied to the lumen of the vessel to be sealed, as is the case with intravenous laser treatments, for example. In the case of vein sealing, the procedure is painless; however, some patients may experience vasospasm during the sealing process. This usually lasts from a few to several seconds and subsides spontaneously.

From the patient's point of view, bonding means, above all, that a good aesthetic effect is quickly achieved, that there is no need for long-term convalescence, and that the patient can quickly return to daily activities, which is no small matter in today's world. - adds Dr Justyna Wilczko.

Vein bonding procedures are performed in a treatment room setting. They do not require any cutting or pulling out of inefficient veins. They are carried out from a skin puncture access, always under ultrasound guidance.

Our experience of several years with various systems shows that, although the procedure itself is apparently quite easy to perform, an essential condition for high efficacy and low risk of complications is the correct qualification of the patient and the experience of the doctor performing such a procedure. A real guarantee of success is an experienced phlebologist with the ability to qualify the patient for treatment on the basis of the Doppler ultrasound examination of the veins of the lower limbs performed by him or her, doing these procedures on a daily basis - emphasises Dr Tomasz Grzela from the team at the Department of Phlebology.

Although bonding procedures can be performed without the need for compression stockings, according to the assessment of our experts, the use of compression therapy in the post-operative period, also for bonding procedures, accelerates the shrinking of the closed vein, reduces the risk of inflammation of the vein, and improves post-operative patient comfort resulting from the 'pull' of the fibrotic venous vessels.

Following adhesive treatments performed both with catheter-based systems and those in which the adhesive is delivered to the vessel by ultrasound-guided injection, wearing compression devices has been shown to improve treatment outcomes. This approach also allows treatment using several methods simultaneously - Dr Wilczko adds.

Post-treatment effects - better, worse or similar?

The use of intravenous adhesives allows doctors to treat quickly (the average bonding procedure takes about 10-20 minutes) and virtually painlessly. But is it really more effective?

A patient presenting to the doctor with a venous problem usually complains of a deteriorating appearance of the legs and an annoying feeling of heaviness, which is worse in the evening, especially after prolonged immobilisation (e.g. sitting). Post-operative efficacy is often viewed through the prism of these two inconveniences.

When the procedure is performed, we expect that there will be both a reduction in discomfort and an improvement in appearance. Usually both conditions are met. However, treating venous disease is not the same as treating varicose veins or spider veins. It is often a much more complex problem than we thought just a few years ago. As our daily practice shows, venous insufficiency in the same patient can have several causes. If we manage to remove one and ignore the others, the treatment effect will be incomplete and unsustainable. The treatment of venous insufficiency is definitely more complex than just closing the saphenous vein with a laser or glue. - comments Dr Cezary Szary.

Vein taping - not just for varicose veins?

Initially, adhesive treatment of dilated lower limb veins was limited to the use of catheter systems, which were inserted into the insufficient saphenous veins, and less frequently into the saphenous veins.

In our experience, the classical approach to vein treatment advocated at the beginning of the introduction of this method allowed us to treat less than 30-40% patients presenting to the Phlebology Clinic.
The diagnostic and therapeutic algorithm currently used at our institution allows us to significantly expand this group. Importantly, it enables us to provide causal treatment for venous insufficiency - adds Dr Justyna Wilczko.

The solution turned out to be the so-called hybrid approach, i.e. the use of several different methods (e.g. sclerotherapy or mini-surgery) during the same procedure. This has also become possible thanks to the appearance of new adhesive preparations on the market. Such solutions allow phlebologists to treat an even wider spectrum of venous problems, including the more complicated ones, which undoubtedly include recurrent varicose veins.

According to experts from the Department of Phlebology, the problem of recurrent varicose veins is usually the result of an inadequately diagnosed problem, inappropriate choice of treatment method and lack of prophylaxis after the procedure performed. This problem is particularly evident in patients operated on years ago, i.e. at a time when the availability of new diagnostic methods, and even more so of minimally invasive treatment methods, was very limited, and knowledge of vein pathophysiology and treatment was much less than it is today.

Progress in modern phlebology is largely due to advances in diagnostic imaging, especially examinations performed using new diagnostic techniques such as high-resolution Doppler ultrasonography, intravascular ultrasound, magnetic resonance venography and digital phlebography. These methods have enabled us to better understand the mechanisms leading to damage to the venous system, as well as to better control the treatment process,
with a thorough assessment of its impact.

It turns out that what seemed obvious to us a few years ago does not quite work today. In view of the results obtained using modern diagnostic methods, we have had to revise some of our previous views - concludes Dr Grzela.

However, vein taping is a method that fits in well with the new diagnostic and treatment trends. Its undoubted, yet another advantage, is its high versatility.

Nowadays, after appropriate diagnostic tests and patient qualification, we perform procedures using adhesive techniques for the treatment of both large, straight venous trunks (e.g. the saphenous vein, or saphenous vein) and their tortuous subcutaneous branches. The use of endovascular adhesives expands our treatment options for atypical varicose veins, inefficient perforating veins (so-called perforators), as well as various types of venous malformations, both their simple and complex forms.

Authors: Dr Cezary Szary, Tomasz Grzela, MD, PhD, Dr Justyna Wilczko

The article appeared in the capital edition of Gazeta Wyborcza on 22.06.18.