Perforation or Pain? Early in the history of endovenous laser ablation, phlebologists were taught that endovenous ablation using certain wave lengths of lasers resulted in increased vein wall perforation rates post endovenous laser ablation. These venous wall perforations were felt to result in increased ecchymosis and increased pain experienced by patients post laser ablation.
We have used multiple wave lengths for endovenous laser ablation in our practice: 810nm, 970nm and 1470nm. Since 2002, we have noted a few patients with presentation of acute pain and superficial, segmental erythema of the skin associated with thrombophlebitis. These acute presentations are usually 2-6 weeks post endovenous laser ablation.
We have also reviewed patients with similar findings due to spontaneous thrombophlebitis. Not all patients with superficial thrombosis have acute unrelenting pain. So what is the difference in presentation? I believe that the acute pain is due to thrombosis with pressure expansion of the vein wall termed Acute Closed Loop Thrombophlebitis (ACLT).
Acute Closed Loop Thrombophlebitis presentations can occur spontaneously or in association with heat induced thrombus post endovenous laser ablation. The signs and symptoms appear to be the same, yet the etiology is varied.
ACLT has remained constant in our populations for each of the lasers used in the EVA. Ecchymosis and tenderness have been noted to be decreased as expected with different target chromophores for the different laser wave lengths. Yet patients with ACLT present with specific localized pain associated with localized inflammation and ultrasound evidence of peri-venous inflammation.
Despite treatment of the entire vein by the same wave length laser with same energy in joules and same pull back exposure; localized segments of the treated vein may progress to have an acute inflammatory reaction resulting in significant localized pain. This similar pattern is noted in some patients who present with spontaneous superficial thrombophlebitis and ACLT. No perforations are associated with spontaneous superficial thrombophlebitis. Not all patients with superficial thrombophlebitis will have acute localized pain. Not all patients post endovenous laser ablation will have acute localized pain.
As a general surgeon, I have treated many patients presenting with debilitating pain from acute thrombosis of hemorrhoidal veins. Enucleation with decompression of entrapped thrombus resulted in immediate relief of pain for these patients. The pain reduction was immediate; these patients feel that I am the “best surgeon” and I often get Christmas cards in appreciation.
Presenting with similar symptoms, patients with acute thrombophlebitis due to closed loop syndrome have acute pain. I believe that the factors are similar in ACLT and acute thrombosed hemorrhoids. Thrombosis occurs, heat induced or spontaneous. If the thrombosis is mechanically trapped, increased pressure causes stretch of venous wall and signals from pain receptors within the venous walls leading to significant pain associated with phlebitis.
We have all seen patients with acute pain associated with superficial thrombophlebitis. The standard of care for these patients with acute pain due to superficial thrombophlebitis includes conservative observation, compression stocking support, NSAID medications and local heat. Sequential ultrasound evaluations are recommended to monitor SVT for progression and propagation to formal deep vein thrombosis.
Despite conservative measures; many patients would complain bitterly about increasing pain with progression over a few days. Then the acute pain would slowly resolve over time, similar to the course of an acutely thrombosed external hemorrhoid.
Taking the concept that ACLT and acute external hemorrhoid vein thrombosis are similar animals, we have been treating the ACLT presentations with a similar approach to acute thrombosed hemorrhoids. These patients are treated with ultrasoundguided venous enucleation with peri-venous infiltration of steroids. The ultrasound guided enucleation allows for immediate decompression of venous distention, reduction of intraluminal pressures, and local anesthetic effect with reduction of inflammation by steroid action.
The area of thrombosis and acute phlebitis noted on ultrasound review is again identified and the skin surface marked [Photograph 3]. The skin is prepped with Hibiclens. Approach is delineated for needle aspiration. The skin is infiltrated with 1 percent Xylocaine with epinephrine wheal for anesthetic effect with a 30 gauge needle. The soft tissues around the thrombosed vein are then infiltrated with 1 percent Xylocaine with epinephrine using ultrasound guidance.
A 15-gauge 1.5-inch needle is utilized on a 3cc syringe on suction to puncture the vein wall with ultrasound guidance . Thrombus is aspirated and the vein wall punctured in multiple places along the acute closed loop allowing for complete decompression and evacuation of thrombus.
This must be completed with a large bore needle. Note, multiple punctures must be made in the segment of vein wall, through and through. This must be completed with a larger bore 15-gauge needle to allow for complete decompression.
The site is massaged using the ultrasound gel to allow deep massage without significant skin friction. Often times, residual thrombus will extrude from the skin needle tracts left by the 15-gauge needle.
The vein segment and soft tissues around the vein are then infiltrated with a solution 1cc Kenalog 10mg mixed with 2cc of Xylocaine 1 percent with epinephrine for short segments and a solution of 1cc Kenalog 40mg mixed with 9cc of Xylocaine 1 percent with epinephrine for long segments.
Then 20-30 mmHg compression stockings are placed with simple Kerlex dressings at the skin puncture site. The patient is dismissed to home with similar conservative measure for thrombophlebitis: compression stocking support, NSAID medications and local heat. Patients are warned that drainage may occur at the skin puncture sites for a few days, especially with ambulation.
Our practice has treated multiple patients with Acute Closed Loop Thrombophlitis, both post EVA and spontaneous, with this management approach over the last five years. One hundred percent of treated patients reported immediate relief of acute pain, even when the local anesthetic effects wore off post enucleation and infiltration procedures. To date our practice has had no patients with recurrent symptoms, no vein recannulization post EVA and no infections post enucleation and steroid infiltration.
Try this approach with Acute Closed Loop Thrombophlitis, and you may get some extra Christmas Cards this year!