I've had my GSV ablated, and then my LSV ablated between the mid-calf to knee. But a follow-up ultrasound found much reflux in my LSV between the ankle to mid-calf. My doctor advises to ablate this area as well, but also advised of sural derve damage risk, which scares me. He has only done this procedure a couple of times (but he is a very experienced vascular surgeon), and so I wanted to ask this group what their thoughts were on the risk. Thank you in advance!
This area needs sclerotherapy, not laser ablation.
Published on Jul 11, 2012
Experienced phlebologists/vascular surgeons should have a very low (<3%) rate of temporary sural nerve damage. This is usually because they are not achieving a good protective sleeve of local anesthesia around the LSV, which will displace the nerve, they are bringing their laser below the fascia level, or using way too much power. Exceptions can occur with anomalous nerve location, but the tip off is pain in the foot/ankle during the procedure, which is an immediate indication to abort.
Published on Jul 11, 2012
That's a great question, and that area is a very "slippery slope." We don't use heat (laser) to treat the distal small saphenous vein for that very reason, but we have used chemical foam ablation with great success without injury to the sural nerve. I don't know if anyone can answer your question because most of us don't use lasers there because of the likely probability of sural nerve damage. This is not a chronic numbness issue but rather a chronic pain. Go with CO2 foam.
Published on Jul 11, 2012
If you ablate between the ankle and mid-calf, there is a relatively high risk of injuring your SSV. This is why I never laser that segment. I prefer to treat that segment using ultrasound guided foam sclerotherapy. In so doing, I find that I almost never injure the sural nerve using this method and I have been treating vein issues like these for almost 10 years. If he/she is looking to laser that segment, I would not allow that to happen.
Published on Jul 11, 2012
If using laser or radiofrequency is the best option, I suggest seeking the most experienced vascular physician in your area with expertise in that particular technique. The incidence of sural nerve injury in the hands of someone with limited experience can be significant. You may have weakness and a foot drop as a result.
Published on Jul 11, 2012
The risk of rural nerve damage by ablation in this area is very low, but if it happens to you, then it is significant. Done awake with good tumescent anesthesia works very well and I have treated veins in the area frequently with excellent results. There are alternatives to laser closure in this area including Clarivein and Varithena for simple foam sclerotherapy.
Published on Jul 11, 2012
It is possible to ablate the lower portion of the small saphenous vein below the muscle, but your doctor is correct to warn you about the risks of injury to the sural nerve that is close to the vein in that location. If you are continuing to have symptoms related to reflux in this vein, EVLA in this location can be considered. The rates of sural nerve injury range from 1.3-11% in the literature, with resolution of numbness/parasthesia in half the patients that developed it.
Published on Jul 11, 2012
The sural nerve damage due to EVLT has been reported to be 0-10% in the literature. It can occur from sheath or cather insertion, tumescent administration or from heat induced by EVLT. The rates of aural nerve damage are inversely related to operator experience. Administration of higher volumes of tumescent may be helpful in preventing the nerve damage. The other options will be to consider non-heat inducing ablative therapies such as Clarivein. Hope that helps. Good luck.
Published on Jul 11, 2012
Your doctor is using an approach that is different from what I would normally do. At the end of the day, you need to trust your surgeon.
Published on Jul 11, 2012
What your surgeon recommends is the standard of care. This risk may be overstated, but I don't believe that there is sufficient data to know the success rate, as you define it. I have treated the LSV to the ankle, when indicated, and never encountered a sural nerve injury as a result.
Published on Jul 11, 2012
I would advise waiting at least three months and reevaluate. Often the reflux will resolve with reduced pressure from above and time. I advise against ablation. If this is persistent and causing symptoms, varicose veins or venous hypertensive changes, I would use foam sclerotherapy. There is a risk of sural nerve damage treating the short saphenous ablation but experience is the best option. Sclerotherapy by an a surgeon who has this experience is the safer option.
Published on Jul 11, 2012
I agree that there is a risk for nerve damage with the proposed procedure. I would say our success rate without nerve damage is 90%. How long ago did you have the LSV ablated? Maybe the area in question will close down on its own with more time.
Published on Jul 11, 2012
In my opinion, reflux in lower posterior leg in an abated saphenopopliteal junction is very rare. Reflux has to come from an incompetent valve. I would locate the area and treat that. It usually is from an incompetent perforater, or reflux from a branch of the greater saphenous vein, or a rare bifid lesser saphenous vein.
Published on Jul 11, 2012