Hydrodisplacement of sural nerve for safety and efficacy of endovenous thermal ablation for small saphenous vein incompetence

Abstract

Background Endovenous radio frequency ablation for small saphenous vein incompetence by and large appears to be superior and safer than conventional open surgery. Small saphenous vein ablation from approximately mid-calf to the point proximally where the small saphenous vein dives into the popliteal fossa is considered to be safe, as the sural nerve is in most cases separated from this segment of the small saphenous vein by the deep fascia. The outcome of the distal incompetent small saphenous vein remains unclear. Efficacy of the endovenous radio frequency ablation can be enhanced by increasing the length of the ablatable small saphenous vein segment. Methodology To optimise endovenous radio frequency ablation outcome, the distal small saphenous vein may be made amenable to ablation if safety of the sural nerve can be assured. The sural nerve was successfully located using duplex ultrasound in 100% of our cohort in this study. The standard entry point for venous access was just above the lateral malleolus. After introduction of the introducer sheath, the radio frequency catheter was advanced proximally; the sural nerve was displaced from the small saphenous vein by approximately 1 cm with the administration of tumescent anaesthesia ( hydrodisplacement). A total of 118 patients underwent extended endovenous radio frequency ablation of 124 incompetent small saphenous vein trunks using the method described. Results Successful extended ablation of the small saphenous vein was achieved in 100% of cases and it was confirmed by duplex scanning at one and six weeks. Two neurological events were recorded during the study: 1. One patient with temporary foot drop lasting for less than 6 h with complete recovery. 2. A second patient with a sural nerve sensory deficit reported by the patient at day 2-3, which remains current at six weeks. Conclusions Extended endovenous radio frequency ablation of the small saphenous vein to optimise length of the ablatable vein segment is feasible with careful identification and hydrodisplacement of the sural nerve. This method is shown to be associated with fewer neurological complications than other methods reported in the literature.