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Endovenous Radiofrequency Ablation Treatment is required to eliminate defective superficial veins (Varicose Veins) forcing blood to return to the heart through the normal deep venous system.
What Are Varicose Veins?
Veins and arteries, while both part of the circulatory system, function quite differently from each other. “Poor circulation” is a nonspecific term, which often refers to arterial blockages. Arteries bring oxygen-rich blood from the heart to the extremities and can be thought of like a tube or hose. Veins, unlike arteries, have one-way valves and channel oxygen-depleted blood back toward the heart. If the valves of the veins don’t function well, blood doesn’t flow efficiently. When the valves fail or leak, blood flows back through the vein causing the blood to pool, a condition termed reflux or venous insufficiency.
Normal Vein
Abnormal Vein (Incompetent Valves)
Valve failure in the major leg vein (the great saphenous vein) is the most common cause of vein reflux and varicose veins in other parts of the leg. And typically, veins visible in the lower thigh, knee and calf are often due to vein reflux in higher areas of this major vein. Venous insufficiency dilates the vein and puts additional pressure on the healthy valves. The result is varicose veins that appear as twisted, enlarged veins that lie close to the surface of the skin. It is very important to understand that the varicose veins you see on the surface of the skin are, in fact, branches of the incompetent major superficial leg veins (i.e. Great or Small Saphenous Vein).
Small or Short Saphenous Vein
Great or Long Saphenous Vein
Examples of Varicose Veins:
What Are the Symptoms of Varicose Veins?
  • Aching or burning in the legs
  • Pain in the legs
  • Swelling of the legs or ankles
  • Leg cramps or sores
  • Itching of the skin around a vein
  • Eczema of the skin typically in the calf region
  • Open wounds such as skin ulcers around the ankle
Symptoms secondary to varicose veins are often made worse by prolonged standing, include feelings of fatigue, heaviness, aching, burning, throbbing, itching, cramping, and restlessness of the legs.
What is the Incidence and Cause of Varicose Veins?
Nearly 70% of all women and 30% of men will develop some type of venous disorder due to insufficient blood circulation. Although the exact cause is unknown, there are many that contribute to the weakening of the vein walls, including:
  • Heredity
  • Pregnancy
  • Hormonal factors
  • Being overweight
  • Standing or sitting for long periods of time
  • Advancing age
  • Injury
Heredity is the number one contributing factor causing varicose and spider veins. Women are more likely to suffer from abnormal leg veins. Hormonal factors, including puberty, pregnancy, menopause, the use of birth control pills, estrogen, and progesterone affect the disease. It is very common for pregnant women to develop varicose veins during the first trimester. Pregnancy causes increases in hormone levels and blood volume which, in turn, cause veins to enlarge. In addition, the enlarged uterus causes increased pressure on the veins. Varicose veins due to pregnancy often improve within 3 months after delivery. However, with successive pregnancies, abnormal veins are more likely to remain. Other predisposing factors, include aging, standing occupations, obesity, and leg injury.
How Do We Diagnose Varicose Veins and Venous Insufficiency?
At The Vein Institute of Toronto™, we have developed our own method of evaluating patients through our extensive research and experience in treating patients with a wide variety of varicose and spider veins. The Vein Institute of Toronto™ patient evaluation process is as follows:
  • Upon coming to our office, you will begin by filling out our own confidential patient venous questionnaire.
  • You will then undergo a personal consultation with our Medical Director, Dr. Sanjoy Kundu.
  • He will review your venous questionnaire to focus on the most important findings and symptoms to you.
  • You will then undergo a focussed venous physical examination to map out all your varicose and spider veins.
  • Dr. Kundu will then personally perform a venous ultrasound to examine your superficial and deep venous system.
  • A personalized treatment plan will then be presented to you with the different treatment options
Our patient evaluation process has been taught by Dr. Kundu to numerous physicians in North America and Europe.
What Is EVRF?
At The Vein Institute of Toronto™, EVRF is a quick, minimally invasive, outpatient, laser procedure performed utilizing imaging guidance. After applying tumescent anesthesia to the vein, the interventional radiologist inserts a thin catheter, about the size of a strand of spaghetti, into the vein under ultrasound guidance and guides it up the greater saphenous vein in the thigh or the lesser saphenous vein in the calf. The radiofrequency energy is then delivered inside the vein. This heats the vein and seals it closed. There is no post-operative scarring, as only a tiny radiofrequency catheter and a slim plastic sheath enter the vein via a tiny skin nick.
The Closure procedure provides the following benefits for patients and physicians:
  • Minimally Invasive Outpatient Procedure. Closure catheters are inserted into the vein via a tiny incision in the lower leg, eliminating the need for groin surgery and general anesthesia. The Closure procedure can be performed using local anesthesia in a physician’s office, as well as in an outpatient hospital setting or surgicenter.
  • Clinically Proven Less Post-Operative Pain. The Closure procedure does not involve pulling the diseased vein from the thigh as with vein stripping surgery, or using 700°C laser energy, which boils blood to occlude a vein as with endovenous laser (EVL). In the RECOVERY Trial, a multi-center head-to-head comparative randomized trial comparing the Closure procedure with EVL, the Closure procedure was found to have less patient pain and less patient bruising than EVL for the best patient recovery experience available from a minimally invasive vein treatment. Additionally, other randomized comparative studies have shown that patients receiving the Closure procedure return to normal activity and work significantly faster than those receiving vein stripping.
  • Excellent Clinical Outcomes. The ClosureFast™ catheter, which represents the latest advancement in the Closure procedure, has been shown in a multi-center study to have a 97.4 efficacy rate at one year. This shows that the treatment is highly effective and, as proven in the RECOVERY trial, is gentle on the patient.
  • Cosmetically Appealing. Because treatment with Closure is minimally invasive and is catheter-based, it results in little to no scarring. As with any medical procedure, you are encouraged to review all safety information associated with the procedure by consulting your physician.
At The Vein Institute of Toronto™, we have developed our own method for performing EVRF through our research, patient feedback and extensive procedure experience. We perform one of the largest volumes of EVRF in Canada and North America and are a training and luminary site for the EVRF procedure for other physicians.
The Vein Institute of Toronto™ Method:
  1. Each patient undergoes a personal physician consultation as outlined above.
  2. On the day of the procedure, the patient undergoes an application of local anesthetic spray and cream to the area to be treated to minimize discomfort.
  3. The patient undergoes a mapping ultrasound by Dr. Kundu before the procedure to confirm the patient’s anatomy and area to be treated in order to decrease procedure time and note any changes from the time of the patient’s consultation.
  4. Utilizing Dr. Kundu’s unique micropuncture technique, we access the vein to be treated and insert a plastic tube enclosing the radiofrequency catheter.
  5. Dr. Kundu ensures the correct positioning of the radiofrequency catheter using the ultrasound as a guide to ensure complete and accurate treatment.
  6. We then apply tumescent anesthesia around the vein to ensure effective action of the radiofrequency energy and minimize patient discomfort.
  7. After the procedure is completed, one of our knowledgeable staff will help the patient apply the medical compression stockings. Dr. Kundu will then personally review the post-procedure instructions with the patient.
  8. The patient is then entered into our post-procedure protocol (see below) to ensure the vein treated by the radiofrequency ClosureFast™ has been effectively closed and that the branch varicose veins are appropriately treated by either foam sclerotherapy or microphlebectomy.
  9. Each patient is able to walk out after the procedure and return to work within two days depending on the type of occupation.
If you would like to have a consultation please contact the Vein Institute, Toronto’s premier clinic for leading edge, state of the art treatments for leg varicose, spider and facial veins.
A. VNUS® ClosureFast™ Endodovenous Radiofrequency Ablation System:
At The Vein Institute of Toronto™, we utilize the latest generation RFG Advanced Radiofrequency Generator with the ClosureFast™ catheter, enabling controlled vein lumen contraction for a fast and effective treatment. Temperature and power are continuously monitored for optimal performance.
B. Use of Micropuncture Technique for Vein Access with No Surgical Cutdowns:
At The Vein Institute of Toronto™, we utilize a unique micropuncture technique to insert the radiofrequency catheter, which minimizes patient discomfort and has led to a 98% technical success rate in performing the procedure.
C. Use of a Mechanical Pump to Apply Tumescent Anesthesia
Closure of the saphenous vein is accomplished in our office using only tumescent anesthesia. Tumescent anesthesia is one of the major advances in vein surgery. It was developed by Klein. It has been used most commonly by dermatologists and plastic surgeons for liposuction. Recently it has been applied to other procedures, including, particularly, vein surgery. Tumescent means swelling or distention. When we administer tumescent anesthesia, the tissues are flooded with dilute liquid anesthetic and become distended giving an appearance resembling the outside of an orange. The French term for this is “peau d'orange”. The unique feature of tumescent anesthesia is that it involves the use of a very low concentration of local anesthetic. The large volume of fluid causes vessels to be compressed, resulting in minimal bleeding. The anesthesia achieved by this technique is excellent and has a prolonged duration, allowing the patient to get home long before the anesthesia wears off. Additionally, the post-operative discomfort seems remarkably diminished. There are no incisions in the groin. We utilize a Klein pump during administration of the tumescent anesthesia to minimize patient discomfort.
Klein Pump for Tumescent Anesthesia
  1. At The Vein Institute of Toronto™, you will undergo a comprehensive venous consultation by a physician. This comprises your venous history and physical examination, followed by a venous duplex ultrasound in order to assess for superficial venous reflux, rule out deep venous thrombosis and map out the anatomy of your superficial venous system. This allows us to develop a personalized treatment plan for you.
  2. If you decide to proceed with the procedure, please follow the pre-procedure instructions (page 6) and medication protocol comprised of Arnica™ and Bromelain to minimize post-procedure discomfort, bruising and pigmentation, thus optimizing results. An EVA kit, including Arnica™ tablets/gel, Bromelain tablets and gel pack, may be obtained from The Vein Institute of Toronto™.
  3. The EVA procedure is performed according to our own tested and proven protocol, which was developed by physicians from around the world (page 7). EVA is a minimally invasive, ultrasound-guided procedure involving endovenous ablation of the affected saphenous vein. At The Vein Institute of Toronto™, our EVA protocol using our unique micropuncture technique has produced a 99% technical success rate and 92% clinical success rate in over 2200 procedures to date.
  4. After the procedure, a physician assistant will assist you to put on the required compression stockings. Please wear the Class II (30-40 mm Hg) compression stockings for the first 72 hours and then from first thing in the morning to before bedtime for another 10 days. For optimal results, please follow the post-procedure instructions (page 8).
  5. You will be seen in follow-up at one and twelve weeks after the procedure or as per your personal schedule and individual requirements. At each follow-up, a venous ultrasound will be performed to confirm the treated saphenous vein is closed. Foam sclerotherapy injections (which are included as part of your procedure) will be performed for any residual branch varicose veins (page 9) at your discretion or if clinically necessary. Please bring your stockings for all follow-up appointments. All post-EVA follow-ups are included as part of the procedure.
  6. At your 1 and 12-week follow-up appointments, you will be instructed on our Leg Wellness Program to improve the conditioning of your legs.
EVA Pre-Procedure Instructions
  1. Take 5 pellets of Arnica™, 3 times per day, for 5 days prior to the procedure. Place pellets under the tongue and allow them to dissolve in your mouth. Arnica™ is a homeopathic medicine which has been shown to reduce pain, bruising and swelling after the EVA procedure.
  2. Take one 500 mg Bromelain tablet twice per day, for 5 days prior to the procedure. DO NOT TAKE Bromelain, if you have a sulfa allergy.
  3. Your normal medications may be taken on the morning of your procedure along with a light breakfast. You may eat and drink normally before the procedure. However, please avoid products containing alcohol and/or caffeine.
  4. Please do not take blood thinners for 1 week prior to the procedure. Please check with the physician who prescribed your medication to verify that you may discontinue this medication for this period of time. Please inform the physician performing the EVA procedure of any health problems, allergies experienced and/or medication you are currently taking. Tetracycline or Minocin should be discontinued for 10 days before and after the procedure.
  5. Wear loose, comfortable clothing that can be worn over the stockings after the procedure. Please bring a warm pair of socks with you to keep your feet warm prior to the procedure. Please do not wear sandals to the procedure.
  6. We have a compression stocking service onsite to ensure that you are measured and fitted with the correct type and size of stockings. Accurately fitted stockings are essential to ensure the success of the procedure.
  7. Please read the enclosed post-procedure instructions (page 8) prior to your procedure. Please bring your stockings to your follow-up appointments. Have someone accompany and drive you home after the procedure.
The EVA Procedure
  1. Please arrive AT LEAST 60 MINUTES before your procedure time, to allow for proper preparation before the procedure. On arrival, you will be asked to change into a procedure gown and to remove your trousers or shorts, leaving your undergarments and socks on.
  2. A local anesthetic cream will be applied to the area to be treated. This should be applied at least 60 minutes before your procedure to maximize effectiveness. You will also be given an oral sedative (Ativan) and pain killer (Oxycodone) at your discretion to minimize discomfort during the procedure.
  3. A pre-treatment photograph will be taken to act as a baseline for your chart. A repeat mapping venous ultrasound will be performed. A tourniquet will be applied to your leg, in a standing position.
  4. You will then lie down on the treatment table and a cleaning solution will be applied on the leg(s) to create a sterile field for treatment. Sterile drapes will be placed around the treatment area (All materials used are sterile and disposed of after a single use).
  5. Local anesthetic (“freezing”) will be injected at the vein entry site. A needle is placed through the skin using ultrasound guidance into the vein to be treated. At The Vein Institute of Toronto™, we utilize a unique micropuncture technique to maximize success and minimize your discomfort. A guidewire will be placed through the needle into the vein. You may feel mild discomfort as the wire is being positioned. A vascular sheath (tube) will be placed over the guidewire and positioned at the junction of the superficial and deep venous system using ultrasound guidance. The ablation device will be placed through the sheath to the correct position.
  6. Branch vein sclerotherapy for your enlarged varicose veins will also be performed at the same sitting with a foam Sotadecrol® solution under light or ultrasound guidance. Pigmentation can occur after sclerotherapy in 2 to 4% of patients. The pigmentation usually resolves in 6 to 10 weeks with our post-treatment protocol.
  7. Tumescent anesthetic, using a special mechanical pump, will be applied around the vein to increase the effectiveness of the ablation and minimize your discomfort (only for laser or radiofrequency). The ablation device is then activated and pulled back along the vein. The ablation device is activated for a period of approximately 5 minutes. For the safety of patients and staff, we utilize and fully adhere to ablation safety protocols. After the catheter is removed, a small antibiotic dressing is placed on the skin, in order to prevent infection and promote healing.
  8. Immediately after the treatment, dressings and support stockings will be applied to the treated area on your leg(s). We suggest you walk for five minutes after the procedure, before leaving the clinic to promote deep venous circulation.
EVA Post-Procedure Instructions
  1. Keep support hose and Comprilan® bandage on for the first 72 hours continuously. After the first 72 hours, please wear the stockings from first thing in the morning (after a short 10-minute shower), until bedtime at night for another ten days. If bleeding occurs from the puncture site, apply pressure for five minutes. Remove the gauze dressing/bandages on your leg 72 hours following the procedure.
  2. You can go back to work the following day. You can resume daily activities the same day of the procedure (excluding exercise). You can resume exercising the following day (no lifting weights, sit-ups or push-ups for 2 weeks after the procedure). It is mandatory to walk at least 10 minutes every hour for the first 6 hours after the procedure. We strongly encourage walking at least 30 minutes per day from the day after the procedure for two weeks. You can shower immediately after the procedure (if you wear a leg bag) but no hot baths, hot tub, Jacuzzi, sauna or tanning for 6 weeks after the procedure.
  3. Bruising, localized swelling, some tenderness, tightness and pain are normal along the inner thigh or behind the calf after treatment. Bruising may occur the same or following day. In most cases, it will be gone after 2 weeks but could remain longer. You may develop “lumpy” areas in your groin, which are tender and part of the normal healing process. Apply a gel pack (part of EVA kit) three times daily and Arnica Gel™ twice per day from day 3 to day 5 after the procedure to reduce the bruising. From day 5 to 14 after the procedure, please apply warm compresses to the bruised and lumpy areas. Redness, tenderness and swelling around the point of entry may remain longer than 2 weeks. If you have pain and leg swelling involving the entire leg or calf, please call our office immediately.
  4. To Decrease Pain, Bruising and Persistent Discolouration/Pigmentation
    • Please continue to take 5 pellets of Arnica™, 3 times per day, and one 500 mg Bromelain tablet twice per day for 14 days after the procedure in order to reduce pain, swelling and bruising. Also, drink at least 2 liters of water per day to decrease discolouration/pigmentation at the sites of treatment.
    • Elevate your leg on a couch or chair and please apply a cold gel pack for 10 minutes at a time three times daily to the bruised and painful areas from day 3 to day 5 after the procedure. Then apply a warm gel pack to the bruised/painful or lumpy areas from day 5 to day 14 after the procedure. After each application of the gel pack or warm compress, apply Arnica Gel™ to the bruised areas. Apply Hiruval 35™ cream three times daily to discoloured areas from day 3 after the procedure for at least 6 weeks or until discolouration/brownish pigmentation disappears.
    • Please purchase generic Ibuprofen tablets (not Advil™) and take 600 mg three times daily orally for seven days after the procedure date. Ibuprofen may be purchased at any pharmacy.
    • It is essential to try to avoid sun exposure after the procedure. It is mandatory to apply a strong medical grade sunblock SPF 40 to 50 (available here) at sites of bruising or discolouration if there is any sun exposure.
What Should I Do Before My Follow-Up Appointment?
  1. Do not shave your legs or apply cream for one day prior to and on the day of your follow-up appointments. No tanning within two weeks of the treatment date. Do not take Tetracycline or Minocin 10 days before or after sclerotherapy. Eat a snack one hour prior to your treatment. Bring shorts to wear during the procedure and slacks to wear out of the office. Sclerotherapy will only be performed if necessary.
What Should I Do After My Sclerotherapy Treatment?
  1. Keep stockings on continuously for the first 72 hours. Only take off stockings to go to the washroom or for showers. After the first 72 hours, wear your stockings from morning to night for another 7 days (ideally, take a quick 5-minute shower and then put them on before doing the rest of your morning routine). Compression stockings help decrease bruising at the sclerotherapy sites.
  2. To decrease Pain, Bruising and Persistent Discolouration/Pigmentation
    • Please take 5 pellets of Arnica™, 3 times per day and one 500 mg Bromelain tablet twice per day for 11 days after the procedure in order to reduce pain, swelling and bruising. Also, drink at least 2 liters of water per day to promote healing, reduce bruising and prevent discolouration or pigmentation.
    • Elevate your leg on a couch or chair and please apply gel pack for 10 minutes at a time three times daily to the bruised and painful areas from day 3 to day 7 after the procedure. Then apply a warm compress to the bruised/painful or lumpy areas from day 7 to day 14 after the procedure. After each application of the gel pack or warm compress, apply Arnica Gel™ to the bruised areas. Apply Hiruval 35™ cream three times daily to discoloured areas from day 3 after the procedure for at least 6 weeks or until discolouration disappears.
    • Please purchase generic Ibuprofen tablets (not Advil™) and take 600 mg three times daily orally for seven days after the procedure date. Ibuprofen may be purchased at any pharmacy.
    • It is critical to avoid sun exposure after sclerotherapy. It is mandatory to apply a strong sunblock SPF 40 to 50 (available here) at sites of bruising, discolouration or pigmentation if there is any sun exposure.
  3. You can resume normal daily activities, excluding exercise today. You can resume exercising in 2 days. You can shower in the morning but no weight lifting, sit-ups, push-ups, hot baths, hot tub, sauna and Jacuzzi for 6 weeks after sclerotherapy.
  4. Bruising, local swelling, areas of bumpiness, lumps and some tenderness are normal after treatment, but please feel free to call the office if you have any questions or concerns.
  5. You will not notice an immediate improvement. Clearance of varicose veins and discolouration usually occurs over a 4 to 12 week period and, in some instances, may take longer.
Q. How much and where can the bruising occur after the procedure?
  • The bruising can be quite marked (black and blue) for two weeks along the inner thigh for Great Saphenous Vein Treatments and on the posterior calf for the Small Saphenous Vein Treatments. This is normal.
Q. Where does the pain occur and what does it feel like?
  • The initial pain immediately after the procedure will be like an aching pain along the inner thigh for Greater Saphenous Vein Treatments and on the posterior calf and behind the knee for Lesser Saphenous Vein Treatments.
  • After the first week, you will experience a tightening inside the leg along the inner thigh for Greater Saphenous Vein Treatments and on the posterior calf and behind the knee for Lesser Saphenous Vein Treatments. All of the above are normal.
  • You may also experience a transient numbness or loss of sensation in the treated area, which is also normal.
Q. What is used for sclerotherapy?
  • We use a foam solution comprised of Sotadecrol®, which has been used for over 30 years.
Q. What will I experience after sclerotherapy?
  • You will feel tender, hard lumpy areas after sclerotherapy for up to four weeks, which is a sign of normal healing, and will usually produce a good response.
Alternative Treatment Options:
Surgical Treatment – Vein ligation and stripping is performed under general anesthesia, regional or local anesthesia.
During this procedure, the physician will make an incision at the groin to allow the greater saphenous vein to be tied off and cut.
The vein is then pulled out of the leg through an incision at the knee.
Due to the surgical nature of this procedure, downtime can vary from two to three weeks, and it is more painful than other non-invasive alternatives.
In addition, there are high rates of recurrence with the surgical procedures.
One study found a 29% recurrence rate after ligation and stripping of the greater saphenous vein, and a rate of 71% after high ligation.
These recurrence rates are similar to those reported in other studies.
Call 416-929-0834 for a physician consultation (Referral letter required from a physician)
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If you would like to have a consultation please contact the Vein Institute, Toronto’s premier clinic for leading edge, state of the art treatments for leg varicose, spider and facial veins.
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Small or Short Saphenous Vein
Great or Long Saphenous Vein
Varicose Veins
Endodovenous Radiofrequency Ablation System
Klein Pump for Tumescent Anesthesia