Advances in Venous Disease Ablation

In this video, Julianne Stoughton, MD, medical director of the Venous Disease Program in the Fireman Vascular Center at Massachusetts General Hospital, discusses the recent advances the program has made in the treatment of venous disease. Their team is conducting a prospective randomized trial to explore a new, less invasive ablation method, where cyanoacrylate glue adhesive seals the vein.

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Transcript

There are at least 40 million Americans that have venous disease and we all have them in our practice. We have had some tremendous advances in the last two decades in our treatments, so really for a long time we've had just thermal ablation, which was really a very good treatment and it's very successful in closing the veins. But it does create this perivenous injury if you don't have tumescent local anesthesia, which is uncomfortable, so it has sort of driven our non-thermal ablation methods. We have been doing these ablation methods as I said, but we really don't know which is best, and we don't know which patient should have which treatment.

So we're going to be doing a prospective randomized trial looking at cyanoacrylate glue adhesive, which is basically sealing the vein with cyanoacrylate glue which is a fairly new treatment. But we have seen it being very effective in the short-term outcomes of closure anyway. And then we also are comparing it to our more standard of care ablation radiofrequency or laser ablation or endothermal ablation.

So we are going to be taking patients that have venous disease anywhere from stage I, which is just spider veins—but usually, we don't treat those with ablation, but if they have significant symptoms and signs of reflux in their truncal veins—all the way up to if they have a significant leg ulceration and skin changes. Those patients will be randomized into two groups; one will be the patients that have cyanoacrylate glue adhesive. One important exclusion, though, is that they cannot be allergic to adhesives. But patients that are really amenable to either type of ablation, we are going to be randomizing those patients and following them very closely trying to really elucidate which ones do better in the short and the long term with which treatment.

All around the body in the surgical realm, we are getting less and less invasive. With cyanoacrylate glue, again as long as they're not allergic, this has been a fairly inert substance in some of the orthopedic procedures but really there has not been any significant application within the vessels. Certainly, patients that have arteriovenous malformations or now significant venous insufficiency or varicose veins or leg ulcers, this glue actually has been very successful in closing the veins which is much less painful. We will be looking to get that kind of glue that will maybe go through more tortuous veins and tributaries and that would be a wonderful thing because it does seem to close the veins in one treatment rather than sclerotherapy which takes a lot of different treatments to be able to close veins.

I think this is advancing the care of all patients with venous disease, again because we are comparing these very close kinds of ablation but they are very technically different. The experiences are different. We have to look at patient-reported outcomes, we have to look at closure rates and we have to look at recurrence rates. But I think it's really changing the field in the sense that we are not just kind of looking for another tool, we're actually trying to figure out which is the best tool for the different patient populations.

I would say that venous disease is something that has really been underestimated and ignored for many years. And I think the fact that there are so many Americans and patients of ours that have some element of venous disease, and I think it's important that we in the past used to leave until it was really ready to ulcerate or until the patient has had a blood clot. But I think at this point our minimally invasive methods and our, really, attention to the science of it, really is going to help us to know who should be intervened upon and at what point. And I think the answer is going to be an earlier intervention almost like tending a garden, rather than waiting until it's all overgrown.

This is age, gravity, heredity, things we can't change about venous disease yet, we are also participating in some research about genetics and about the etiology and pathophysiology of venous disease. But I think all of these things are yet to be answered and, in the meantime, trying to help to keep patients healthy and feeling good and trying to prevent the progression of this disease is really the most important. And that's what I'm the most proud of with our group.

Learn more about the Venous Disease Program

Refer a patient to the Fireman Vascular Center