Challenges and possibilities of treating varicose veins of the lower limbs in a patient with a stented common iliac artery: a case report 

Introduction

Chronic venous disease is a long-lasting morphological or functional abnormality of the venous system leading to the occurrence of subjective and/or objective symptoms that require diagnosis and appropriate management. Forms of chronic venous disease (CVD): primary (most common); secondary (e.g., post-thrombotic syndrome); congenital (rare, e.g., in the course of Klippel-Trénaunay syndrome and distichiasis-lymphedema syndrome) [1].
Risk factors for primary varicose veins include: age, female gender, hereditary factors, pregnancy, sitting or standing work, sedentary lifestyle, obesity, hormonal contraception, flat feet, and habitual constipation [1].
Treatment methods for chronic venous disease include:  
• conservative treatment, which includes compression therapy and pharmacotherapy;  
• surgical treatment, which includes classic Babcock’s surgery, endovenous thermal ablation, methods of mechanical-chemical vein ablation, and chemical ablation using obliterating drugs such as sclerotherapy and glue [1].
There is increased risk of exacerbation of chronic lower limb ischemia during compression therapy. Contraindications to compression treatment are severe lower extremity atherosclerotic disease with ABI < 0.6 and/or ankle pressure < 60 mm Hg [2].
In the case of lower-extremity peripheral arterial disease, patients take antiplatelet drugs, which we do not discontinue during phlebological procedures. Performing minimally invasive procedures in these patients is a better treatment.
There is also no risk of stent damage, which could occur during classical surgery and groin exploration.

Aim

The aim of this case report is to describe a patient who underwent laser thermoablation of the right great saphenous vein (GSV) with miniphlebectomy of tributary varicose veins in the medial malleolar area. Sclerotherapy of tributary varicose veins on the thigh and calf was postponed. The patient suffers from chronic limb ischemia. A year prior, she had a stent implanted in the common iliac artery, which required additional caution during her preparation for the procedure and during the procedures performed.

Case report

A 75-year-old patient presented to the JBS Clinic in Gdańsk in September 2024 due to varicose veins in the right lower limb for diagnosis and treatment (Fig. 1). The patient reported subjective symptoms such as pain, swelling, a feeling of heaviness in the limb, itching of the skin over the varicose veins, as well as a feeling of coldness and tingling in the limb.  
On the first visit, to assess the severity of the clinical condition and the effectiveness of the treatment, the following were used: 
1) revised Venous Clinical Severity Score scale (r-VCSS) [1]:
• before treatment: pain – 2 (moderate), varicose veins – 3 (severe), edema – 1 (mild), pigmentation – 1 (mild), compression – 1 (mild), total – 8 points,
• after treatment: pain – 0, varicose veins – 0, edema – 0, pigmentation – 1 (mild), compression – 1 (mild), total – 2 points;
2) CEAP classification system – C4cEpAs2Pr [3].
A Doppler ultrasound scan of the right lower limb veins was performed on the patient. The patient was diagnosed with an incompetent right great saphenous vein on the thigh and around the knee and tributary varicose veins on the thigh and calf.  
The patient underwent angioplasty of the right common iliac artery with implantation of a stent in June 2023 due to critical ischemia of the right lower limb.  
During the physical examination, the pulse in the right lower limb was checked. In the Doppler ultrasound examination, a point assessment of blood flow in the arteries was performed: femoral, popliteal, anterior tibial, posterior tibial and peroneal. An ankle-brachial index (ABI) measurement was also performed, giving a value of 0.8. 

Treatment applied

The patient was presented with treatment options during the first visit. Due to the patient’s burden of chronic lower limb ischemia, conservative treatment included an attempt to tolerate compression therapy at 23-32 mm Hg. The compression stocking used resulted in a reduction of reported symptoms. 
The proposed treatment plan involved 2 stages. 
In the first stage, laser thermoablation of the right GSV was performed using a 1940 nm wavelength laser, along with Varady’s miniphlebectomy of the veins in the medial ankle area. After the procedure, a compression stocking was applied. Antithrombotic prophylaxis was used for 4 days following the procedure. 
In the second stage, sclerotherapy of the veins on the thigh and calf was performed using polidocanol (POL) 1% foam in a 4ml dose. For telangiectasia in the medial ankle area (corona phlebectatica), POL 0.5% foam in a 2 ml dose and POL 0.5% liquid in a 4 ml dose were administered. 

Results

The patient was followed up after a week, one month, and three months after the first stage of the procedure. 
After one week, physical examination revealed bruising on the thigh and in the area of the inner ankle bone. This is a normal occurrence after this type of procedure. Ultrasound examination did not show signs of a blood clot in the deep veins of the right lower leg. The right GSV is closed from the knee area to the junction with the femoral vein. The area where the varicose veins were removed near the inner ankle bone is healing properly. A decrease in the diameter of the varicose veins was observed. 
At the one-month follow-up, the right GSV was found to be scarred. The tributary veins on the thigh and calf decreased in size. Sclerotherapy was performed during the visit. Compression therapy was applied after the procedure. 
After three months, physical examination revealed discoloration and thickening along the closed varicose veins. A procedure to remove the blood clot (thrombectomy) was performed to relieve symptoms and shorten healing time. The patient was satisfied with the resolution of the symptoms she had reported before treatment and with the cosmetic effect of the procedures performed (Fig. 2). 

Discussion 

In the present case, according to the current ESVS 2022 recommendations [1], the patient was offered treatment for incompetent right GSV using a thermal method with a laser. This procedure is classified as a Class I recommendation with the highest level of evidence (A) in the guideline. 
The initial result of the GSV closure using a laser with a longer wavelength – 1940 nm – is satisfactory. Seven days after the procedure, the patient reported no pain. Scientific studies confirm [1] that using a 1940 nm wavelength laser for treating incompetent veins in the lower limbs is associated with minimizing post-operative inflammatory pain and bruising, and also endothermal heat induced thrombosis (EHIT). This is due to the fact that, in higher wavelength lasers, the absorption coefficient of water in the vessel wall is higher than it is with lower wavelengths, targeting hemoglobin. Park published satisfactory initial outcomes with less pain and fewer complications, in the laser treatment of incompetent saphenous veins [4].
Similarly, Keo et al. found that pain experienced after treating incompetent GSV was lower when using a 1940 nm wavelength laser compared to 1470 nm. This treatment allowed the patient to return to full fitness faster [5]. 
After laser thermal ablation with miniphlebectomy and sclerotherapy, the patient was fitted with a graduated compression stocking of 23-32 mm Hg. The patient tolerated the compression well. She did not report any discomfort after the procedures. In the COMETA study published in 2021, these results indicate that wearing compression stockings after endothermal ablation is advantageous in the first few days after treatment and is especially beneficial for those having concurrent phlebectomies [6].
Tan et al., in their review of compression therapy after sclerotherapy, highlighted the fact that compression has a positive impact on healing and reduces postoperative discomfort such as pain, swelling, and bruising [7].
In the CONFETTI study published in 2023, it was concluded that wearing compression stockings after sclerotherapy provides a significant benefit in terms of pain reduction in the short term after the procedure compared to patients who did not use compression [8]. The ankle-brachial index is a non-invasive tool for the assessment of vascular status. It is a key factor considered during compression selection for patients with chronic lower limb ischemia. The ESVS 2022 expert panel highlights the significance of this measurement and stresses the need to reduce compression pressure in cases of impaired arterial status or severe neuropathy. 

Summary 

Combining endovascular laser treatment, miniphlebectomy, and sclerotherapy for incompetent great saphenous vein and tributary can be an effective treatment method for patients with a stent in the iliac artery. It is crucial to emphasize the need for personalized treatment plans and close monitoring of these patients. 

Disclosures

1. Institutional review board statement: Not applicable.
2. Financial support and sponsorship: None.
3. Conflicts of interest: None.

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