Minimally Invasive Varicose Vein Surgery - VNUS Venous Closure, Trivex and SEPS

Minimally Invasive Vein Surgery (Trivex and VNUS Closure)

Traditional surgery for varicose veins requires the classic Vein Stripping. This involves incisions in the groin and ankle. A long plastic or metal wire is then introduced into the Greater Saphenous Vein in the ankle and advanced up to the groin. The Greater Saphenous Vein is then divided at its junction with the deep veins, the wire is passed out of the proximal end and attached to a stripping head. The wire is then pulled from the ankle through the entire length of the leg tearing the Greater Saphenous Vein from its attachments and out of the leg. Multiple small incisions along the leg are then required to pluck the tributary veins from beneath the skin. The results are good but the procedure generally requires spinal or general anesthesia, is long and tedious to perform and results in often many incisions on the leg.

Two new procedures have been recently introduced which offer a minimally invasive solution to this common malady, which result in much fewer scars, much shorter operating time and avoids the need for spinal or general anesthesia. Before I proceed in explaining these procedures it is first necessary to briefly refresh the normal anatomy of the venous system and the points at which malfunction occurs.

Microscopic capillaries in the tissues of the leg coalesce into small venules and then tributary veins. Abnormalities in these capillaries in the skin lead to spider angiomata which are treated with sclerotherapy, described elsewhere in this web site. The tributary veins then drain onto the Greater or Lesser Saphenous Veins or, deeper in the leg directly into the deep system. Perforator Veins connect the Greater and Lesser Saphenous veins to the deep system. The Lesser Saphenous Vein Drains into the deep system at the knee while the Greater Saphenous Vein drains into the deep system in the groin. There are valves in the tributaries, the perforators, the Greater and Lesser Saphenous veins and in the deep veins which are supposed to permit only one way flow in the direction from the peripheral tissues ultimately to the deep veins and toward the heart. It is malfunction of the valves in any of these areas that ultimately leads to varicose veins and other venous disease. Specifically which valves are malfunctioning determines the spectrum of symptoms encountered, be it varicose veins, venous stasis or general leg swelling. For the remainder of this discussion, we are concerned with malfunction of the valve between the Greater Saphenous Vein and the deep system, or the valves present in the tributaries. Malfunction of the valves in the perforator vessels between the deep and superficial systems leads to venous stasis ulceration. This condition and its treatment are discussed in the articles "Varicose Veins" and "SEPS" respectively elsewhere on this web site under

All patients evaluated in my practice for varicose veins undergo a venous mapping. This is an ultrasound examination of all of the veins of the leg to determine all areas of venous malfunction and their specific location. This is essential in determining which procedure is most appropriate for treatment.

Venous (VNUS) Closure

Venous Closure is specifically designated for correcting varicose veins due to incompetence of the Greater Saphenous Vein. This procedure uses radiofrequency energy to permanently close the incompetent greater saphenous vein.

After the usual sterile prep and drape of the affected leg a needle is inserted into the greater saphenous vein at about the level of the knee using ultrasound guidance. A guide wire is then inserted through the needle. A larger introducer sheath is then inserted over the guide wire. The VNUS catheter may then be introduced through this sheath and directed up the greater saphenous vein just below its junction with the deep system. A large volume of dilute local anesthesia is then injected with a small needle around the vein along the entire length to be treated. This is called tumescent anesthesia and it provides excellent pain control as well as serving to compress the vein on the catheter. The catheter is then connected to the radiofrequency generator. The leg is compressed with a special tight bandage again to provide pressure and remove the blood from within the vein. With the radiofrequency generator activated the catheter is then slowly withdrawn and the vein is sealed closed. The sheath is withdrawn, the single puncture is closed with a butterfly stitch. The leg is wrapped with a double layer of ACE bandage. The patient may then be sent home ambulatory. No general or spinal anesthesia is required, only mild sedation with the tumescent anesthesia. The ACE bandage is removed after 48 - 72 hours. The whole procedure takes about 20 - 30 minutes.

Risks of the procedure are unusual but include, deep venous thrombosis, skin burn, numbness and tingling in the leg. It is standard procedure to have the patient return in 72 hours for a venous doppler to rule out deep venous thrombosis.

Trivex (Transilluminated Vein Excision)

For patients whose varicose veins are due only to incompetence of the valves of the tributary veins but whose Greater Saphenous Vein is competent (or already treated), Trivex provides a minimally invasive alternative to standard vein excision. The more traditional procedure involves creating many stab wounds along the varicose veins and using a special hook to pluck them from beneath the skin. Utilizing Trivex, only two punctures are necessary for an entire field of varicose veins.

With the patient standing up, the veins are marked with a magic marker. The patient is then placed on the operating table, given some light sedation and the leg is prepped in the usual manner.

Two tiny incisions are then placed on opposite sides of the field of veins to be excised. Through one incision is inserted the transilluminator, which also serves to inject tumescent anesthesia as described in the section on VNUS Closure. The transilluminator shines light from beneath the varicose veins so that they can clearly be seen through the skin. Through the other incision is inserted the resector which is then guided to the veins under direct visualization. The resector then chops up and sucks out the veins. It is carefully designed so that it will not injure the skin or other structures. After resection, more tumescent anesthesia is injected, blood is evacuated, and the leg is wrapped with ACE bandage. The patient is discharged ambulatory and instructed to remove the ACE wrap after 72 hours. It is normal for there to be some bruising and discoloration of the skin which resolves over the next few weeks. Sometimes, special creams or ointments are employed to expedite this process. The end result is far superior to the standard vein excision procedure.

I hope you have found this article both educational and entertaining. As always, I invite any questions that you may have.

Steven P. Shikiar, MD, FACS email