Transilluminated powered phlebectomy for varicose veins

# Guidance
Current evidence on the safety and efficacy of transilluminated powered phlebectomy for varicose veins includes small numbers of patients and is of limited quality. It does not appear adequate to support the use of this procedure without special arrangements for consent and for audit or research. Clinicians wishing to undertake transilluminated powered phlebectomy for varicose veins should inform the clinical governance leads in their Trusts. They should ensure that patients offered it understand the uncertainty about the procedure's safety and efficacy and should provide them with clear written information. Use of the Institute's information for the public is recommended. Clinicians should ensure that appropriate arrangements are in place for audit or research. Publication of safety and efficacy outcomes will be useful in reducing the current uncertainty. NICE is not undertaking further investigation at present.# The procedure

# Indications
Transilluminated powered phlebectomy is used to treat varicose veins, which affect 2533% of women and 1015% of men. Varicose veins are a sign of underlying venous insufficiency.
People with venous insufficiency may have symptoms of fatigue, heaviness, aching, burning, throbbing, itching and cramps in the legs. Chronic venous insufficiency can lead to skin discolouration, inflammatory dermatitis, recurrent or chronic cellulitis, cutaneous infarction and ulceration.
Transilluminated powered phlebectomy is intended as an alternative to hook phlebectomy for symptomatic varicose veins in the leg, and is usually done as an adjunct to surgery for long or short saphenous vein incompetence.

# Outline of the procedure
Under anaesthetic, an endoscopic transilluminator is inserted underneath the skin to illuminate the vein clusters to be resected; tumescent anaesthesia is then instilled under pressure via the cannulated illuminated device. A suction device with guarded blades (resector device) is then introduced via another incision at the other end of the varicose vein, and the varicosities are cut and removed by suction. Once removal of the veins is complete, tumescent anaesthesia is again introduced via a cannulated illuminator device to minimise bruising, pain and haematoma formation.
The resector device can also be inserted through the first incision, minimising the number of incisions made during the procedure.

# Efficacy
The main efficacy outcomes identified in the studies were reduced pain and greater cosmetic satisfaction compared to hook phlebectomy. Comparative data suggested that transilluminated powered phlebectomy resulted in similar or less pain, at six weeks, and greater cosmetic satisfaction. The evidence reported in the non-comparative studies supported these findings. The available studies reported short-term results only.
The evidence indicated that fewer incisions were required for transilluminated powered phlebectomy than with hook phlebectomy (mean 6 versus 17 incisions in one study). There was also some evidence to suggest that the number of incisions reduced with surgeon experience. For more details, refer to the 'Sources of evidence' section.
One Specialist Advisor commented that the cosmetic advantages of the procedure can be negligible because of damage to the subcutaneous fat. It was noted by one Advisor that this procedure might be particularly suitable for the treatment of multiple and recurrent varicosities, which can be difficult to treat by hook phlebectomy.

# Safety
The comparative data indicated that transilluminated powered phlebectomy had fewer complications than hook phlebectomy. Common complications reported in the studies included haematomas, bruising and paraesthesia.
One case of deep vein thrombosis, in a study of 114 patients (0.9%), was also reported as a complication of the procedure. For more details, refer to the 'Sources of evidence' section.
The Specialist Advisors listed the main potential complications as haematoma, pain and bruising. Neuropraxia, causing sensory disturbance, was also listed by one Advisor as a potential complication, although it was considered that the incidence of this would be low.

# Other comments
Although the evidence suggested the procedure is effective, the evidence was too limited to be conclusive. A particular weakness is that there are no data on the number of veins treated during the procedure in each patient.
The Institute noted the lack of long-term follow-up data and the Specialist Advisors' anxiety about potential complications.
Andrew DillonChief ExecutiveJanuary 2004# Further information

# Sources of evidence
The evidence considered by the Interventional Procedures Advisory Committee is described in the following document.
'Interventional procedures overview of transilluminated powered phlebectomy for varicose veins', April 2003.

# Information for patients
NICE has produced information on this procedure for patients and carers. It explains the nature of the procedure and the guidance issued by NICE, and has been written with patient consent in mind.# Changes since publication
The guidance was considered for reassessment in October 2009 and it was concluded that NICE will not be updating this guidance at this stage. However, if you believe there is new evidence which should warrant a review of our guidance, please contact us.
January 2012: minor maintenance.# About this guidance
NICE interventional procedure guidance makes recommendations on the safety and efficacy of the procedure. It does not cover whether or not the NHS should fund a procedure. Funding decisions are taken by local NHS bodies after considering the clinical effectiveness of the procedure and whether it represents value for money for the NHS. It is for healthcare professionals and people using the NHS in England, Wales, Scotland and Northern Ireland, and is endorsed by Healthcare Improvement Scotland for implementation by NHSScotland.
This guidance was developed using the NICE interventional procedure guidance process.
We have produced a summary of this guidance for patients and carers. Information about the evidence it is based on is also available.
Your responsibility
This guidance represents the views of NICE and was arrived at after careful consideration of the available evidence. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. This guidance does not, however, override the individual responsibility of healthcare professionals to make appropriate decisions in the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.
Copyright
 National Institute for Health and Clinical Excellence 2004. All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE.
Contact NICE
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