venous disorders are among the most frequent disease patterns in the western world . in germany
up to 40% of females and 20% of males suffer from symptoms that range from tiredness , a sensation of heaviness , pains and swellings in the legs to open , non - healing sores .
occasionally , varicose veins may result in vein inflammations and vein thromboses [ figures 15 ] .
incompetent gvs ( duplex ultrasound ) yet even at the start of the 21 century there was no alternative therapy available to treat varicosis .
it was generally accepted that surgery was the only option [ figure 6 ] . within less than five years
endoluminal therapy techniques had been authorized in germany , dividing the community of vein surgeons into enthusiastic advocated and bitter opponents .
these treatments triggered a new debate about treatment strategies ( in general ) and their successes , which still rages today .
highly conservative surgeons and phlebotomists till view these methods with scepticism because there is no crossectomy or ligation of the sapheno - popliteal junction .
this flies in the face of traditional wisdom , which calls for the complete crossectomy and ligation at the level of the deep vein of the gsv and the resection of the ssv segment near the sapheno - femoral junction .
this has been proven to be vital by many studies , including the 2007 german groin recurrence study conducted by mumme .
at least it is incontestable that the new methods spawned an enhanced scientific investigation of varicosis .
every year more than 300,000 operations on veins are performed in germany . unlike in the us
where more than 80% of all operations were conducted endoluminally even in 2008 , about 90% of all operations in germany are still performed using traditional techniques .
the main reason for this is that new methods have not yet been approved by the federal joint committee for outpatient care for statutorily insured patients .
the latest mrg report published in 2011 actually puts the percentage of endoluminal treatments at about 95% of all venous operations in the usa .
initial problems and side effects of the endoluminal techniques included the long duration of treatment in the case of the closureplus technique and the excessive energy emission sometimes encountered in the case of the endoluminal laser treatment that led to painful phlebitides and extensive ecchymoses . yet
even initial studies and meta - analyses showed the results of these treatments to be at least equivalent to traditional stripping operations with crossectomy , while the new treatments proved to have fewer side effects and less risk of complication.[412 ] all studies report fewer side effects and a high level of patient acceptance .
the primary closure rates and the early and mid - term results could compete with the results of the traditional surgical stripping operation with crossectomy [ figure 7 ] .
interestingly enough , crossectomy performed in conjunction with endoluminal treatment had no significant influence on the result of the treatment . whereas the radio wave treatment was performed according to a standard treatment protocol from the beginning
, the endoluminal laser treatment has been subject to considerable changes since the first publications by bone in 1999 and navarro in 2001 .
the objective was to achieve a further reduction in side effects while ensuring a secure primary closure of the treated veins and permanent success of the treatment .
a period of low energy output to the vessel was followed by a phase of high energy application . after the introduction of new laser wavelengths with higher absorption by water and new laser fibers with radial or spherical emission , the side effects were substantially reduced in recent years .
sroka demonstrated the reduction of isolated heat buildups and perforations in the vein wall by means of the new radial emitting laser fiber on the cow foot model .
the recovery study demonstrated that treatment with a closurefast catheter was significantly superior to the 980-nm laser .
3 cm below the junction 3 days after closurefast treatment over the course of time further endovenous techniques have come onto the market , but they have not yet found such a wide application as the closurefast treatment and the laser treatment .
they include a second radiofrequency technique ( rfitt ) , a hot steam technique ( svo ) and , since summer 2010 , a novel sclerosing catheter technique ( clarivein ) .
the efficiency of endovenous techniques has been demonstrated in many studies and meta - analyses .
the special advantages offered by endoluminal techniques include dispensing with the need for general anaesthetic , the quick return to everyday activities , an improved quality of life and shorter periods of disability [ figures 8 and 9 ] . 1 week after elves radial laser - treatment 1 week after elves radial laser - treatment
the indications and contraindications for the endoluminal techniques correspond to those for classical vein surgery .
in fact , the therapeutical spectrum has actually been widened , as it is possible for instance to operate several truncal veins in a single op session , and to operate patients who are undergoing anticoagulant treatment and patients with an increased anaesthetic risk .
the insufficient lateral branches are treated in the same session by means of mini - phlebectomy or foam sclerotherapy , since they do not degenerate completely after a treatment of the truncal varicosity alone and may cause pour - in effects and rechannelizations [ figures 10 and 11 ] .
foam sclerotherapy with veinlite in case of insufficient accessory veins the proximal , subfascially running part of the vein can also be treated by endoluminal techniques . here
the laser is advantageous due to the immediate energy emission on the laser tip , since it can also treat short vein segments .
the hot steam therapy is the only technique that can be used on the lateral branches completely , but it still has to prove its purported advantages here .
most users recommend the use of a compression stocking for one week post - operatively .
a thrombosis prophylaxis is offered for a period stretching from 5 - 7 days to not at all in the us . in germany
the prophylaxis is usually carried out , for forensic reasons , in compliance with guidelines with low - molecular heparin .
it was known that complications occur less often than with traditional vein surgery procedures , and this was backed up by pertinent studies .
deep leg vein thromboses occur extremely rarely.[2023 ] nevertheless , the danger of an appositional thrombus growth into the deep vein system at the sapheno - femoral junctions was pointed out . however , these thrombi degenerated without negative consequences .
frequent side effects of endoluminal treatments are ecchymoses and periphlebitic problems which occurred mainly in case of treatments by means of a laser with a low wavelength and a high energy emission to the vein [ figures 12 and 13 ] .
ecchymosis after laser - treatment hyperpigmentation after closurefast but these side effects could be reduced considerably by new laser wavelengths , novel radial or spherical emitting laser fibers and by optimizing the energy density .
so in the us , for forensic reasons , endoluminal treatment is rarely performed below the knee joint .
it can degenerate within a year , but cases of permanent hyperpigmentations are also described .
post - operative bleeding and wound infection are extremely rare complications . in the radiofrequency obliteration , energy is delivered to the vein wall by means of a bipolar current in the rf range . the occlusion results from creating a fibrosis of the vein wall .
two catheters were available for this technique , which differed in the number of electrodes on the catheter tip and in the catheter diameter : 
 vnus closureplus 6-french cathetervnus closureplus 8-french catheter [ figure 14 ] 
  vnus closureplus 6-french catheter vnus closureplus 8-french catheter [ figure 14 ] the access to the vein is achieved by ultrasound - guided puncturing at the lower insufficiency point of the vein and insertion of an introducer sheath .
the catheter tip should be placed by maintaining a distance of 2 cm to the deep vein and be located distal to the orifice of the epigastric vein .
after the placement of the catheter the cooled tumescent anaesthetic is circuminjected around the vein to be treated under ultrasound guidance by means of a pump . then the catheter is withdrawn manually in anti - trendelenburg - position . here
the withdrawal rate is 1 cm / min for the first 4 cm , then 3 cm/ min .
the treatment temperature of 120 is reached after 6 seconds and is applied for 14 seconds per term to the vein wall , with the respective segment near the sapheno - femoral junction being treated twice .
the treatment is carried through again in anti - trendelenburg - position of the surgical table and with cooled tumescent anaesthetic that is injected under ultrasound guidance .
tumescent anaesthesia protects the surrounding tissue from heat damages und produces a vasospasm of the vein to be treated , which facilitates a close contact to the heating element of the catheter .
a big advantage of this treatment is the standardized treatment technique with reproducible parameters that are monitored acoustically and optically by the generator . in the treatment the vein is punctured under ultrasound guidance at the distal insufficiency point by means of a 16 g needle , either with the patient standing or lying down .
subsequently , an introducer sheath is inserted via a guide - wire . with its help the radiofrequency catheter
can then be advanced , under ultrasound guidance , up to the region of the sapheno - femoral junction .
. then the vein can be circuminjected by a cooled tumescent solution under ultrasound guidance .
the region of the sapheno - femoral junction is treated in two cycles , at least .
likewise it is possible to carry through up to three cycles at outgoing lateral branches or incoming high - volume perforator veins .
the catheter is withdrawn in 6.5 cm steps , with the vein being heated to 120 per cycle [ figures 1524 ] .
closurefast generator ( vnus medical ) closurefast treatment ( animation ) closurefast treatment ( animation ) closurefast treatment ( animation ) closurefast treatment ( impressions ) closurefast treatment ( impressions ) closurefast treatment ( impressions ) closurefast treatment ( impressions ) closurefast treatment ( impressions ) in general , all truncal veins can be treated by the catheter without any problems .
likewise , truncal vein recurrences can be treated ; where necessary with an additional foam sclerotherapy via the guide - wire channel of the catheter . with a combination of this sort
it is recommended that the polidocanol foam be applied first and the catheter then purged with nacl solution , since otherwise an explosive mixture might develop because of the heat of the catheter .
the length of the heating element made it possible to treat the truncal veins quickly , but with this configuration the catheter could be used on the truncal vein only . here
due to the 7.5 cm long heating element a vein segment with a length of at least 10 - 15 cm is required so that the catheter can be securely introduced into the vein .
normally this is too long , in particular when the accessory veins are to be treated in the same session . for this reason covidien introduced a catheter with a short heating element of 3 cm this spring .
the second radiofrequency technique by means of rfitt is far from being as widely spread as the closurefast technique .
the rfitt catheter too is introduced using the seldinger technique into the vein to be treated . in compliance with a consensus conference of august 2011
. a withdrawal rate of between 2.5 and 6 s / cm is recommended , depending on the vein diameter , with the first 10 cm being treated twice .
this , however , has the disadvantage that the catheter has to be carbonized more frequently and , in some cases , has to be pulled out several times for cleaning and then re - introduced .
absorbtion of pure water and a hemoglobin solution whereas the lasers with low wavelengths mainly have a good absorption in hemoglobin , the higher laser wavelengths are particularly well absorbed in water .
initially a smoothly cut laser fiber ( bare fiber ) with a diameter of 600 m was used .
the guiding catheter was placed by means of a j - type guide - wire under ultrasound assistance near the sapheno - femoral junction using the seldinger technique .
when tumescent anaesthesia is used , the temperature around the treated veins does not exceed 32 celsius . the linear endovenous energy density ( leed in j / cm ) is decisive for the efficiency of endoluminal laser therapy .   at first , energy densities as low as 25 j / cm were used . in order to optimize the results ,
the energy doses were temporarily increased to 120 to 150 j / cm , which resulted primarily in an increase in side effects .
most patients were treated with this recommended energy dose . in doing so , it was possible to improve the closure rates while also reducing the level of side effects .
the main side effects reported were pain , paraesthesias and ecchymoses.[3234 ] furthermore , a continuous withdrawal of the catheter replaced the initially pulsed withdrawal of the fiber . the pulsed mode caused perforations of the veins and , as a consequence , larger ecchymoses .
it is pointed out that high power along with a short application time tends to have an evaporating effect , and low power along with a longer application time has a coagulating and shrinking effect . in case of lasers with a lower wavelength and use of a bare fiber steam bubbles
develop in the vein during the continuous withdrawal , which release the generated heat into the vein wall , thereby destroying the same . in a multicenter study the 980-nm laser ( treatment with bare fiber )
was found to be inferior to the radio wave closurefast catheter in the treatment of identical patient populations with respect to quality of life and side effect rate .
the closure rate of the treated veins was 100% in both treatment arms after a month .
in recent years there has been a trend towards the use of lasers with higher wavelengths of 1320 and 1470 nm . due to the higher absorption in water
three years ago the radial emitting catheter with a laser ring ( elves radial ) was introduced in the treatment of truncal veins .
combined with the 1470-nm laser the side effects of the laser treatment were further reduced .
especially the number of ecchymoses , the frequency of periphlebitis and post - operative pain and paraesthesias ( tenderness ) were reduced considerably in comparison with the bare fiber and the lasers with a lower wavelength . at the same time
compared to the bare fiber , which was applied with a laser power of 15 watts , the power could be reduced to 10 watts . here
the recommended energy density is between 60 and 80 j / cm . on the laser tip a temperature of 120
this spring the biolitec company introduced a novel laser fiber with two radial emitting laser rings . in this fiber the power is divided between the two laser rings and is 50% each .
the power of the laser is increased again to 15 watts and is divided by two to achieve 7.5 watts per laser ring .
the area of energy emission is twice of that of the one - ring fiber . as a result it is possible to work still more carefully and faster .
the tissue is irradiated for a longer period with less power . with a longer irradiation time
the advantages of the laser remain unaffected even in the treatment of short vein segments .
a further novel laser fiber is the tulipa fiber. it offers the advantage that the fiber is intraluminally centered because the expanded members on the fiber tip keep the fiber away from the vein wall .
initial results indicate that , in comparison with the bare fiber , the number of ecchymoses and post - operative pains can also be reduced [ figures 2631 ] .
elves generator ( biolitec ) elves radial laser ( animation ) elves laser fiber with one radial emitting laser rings elves laser fiber with two radial emitting laser rings laser treatment ( impression ) in 2009 a technique with hot steam ( steam vein occlusion : svo ) was introduced in the treatment of varicosis .
the generator produces 120 hot steam which is released into the vein via a handpiece and a screwed - on catheter . prior to this
the catheter is placed 3 cm in front of the sapheno - femoral junction using the seldinger technique . while the catheter is pushed back centimeter by centimeter ,
an additional tumescent anaesthesia can be dispensed with , in contrast to the techniques described above .
the postulated advantage of this technique is the possibility of treating the truncal veins and all , even meandering , lateral branches .
the truncal veins are treated by means of the svo catheter , whereas in the treatment of the lateral branches the svo handpiece is placed directly onto the permanent intravenous catheter .
the lateral branches are punctured at intervals of 10 cm by the permanent intravenous catheter . due to the exclusive puncture
in contrast to the techniques described above it is a non - thermal catheter sclerotherapy .
the clarivein catheter is inserted into the vein directly via an 18 g peripheral venous catheter without the help of an introducer sheath .
when the catheter engages in the handle an angled tip on the catheter comes out .
the catheter tip is placed 0.5 cm below the sapheno - femoral junction . by means of a motor in the handpiece the angled tip of the catheter
rotates at 3500 rpm in the vessel , thus causing a vein spasm and damage on the endothelium .
the sclerosing agent ( aethoxysclerol ) which is supplied at the same time continuously below the rotating tip is homogeneously distributed by the rotation and introduced into the vein wall .
in the radiofrequency obliteration , energy is delivered to the vein wall by means of a bipolar current in the rf range .
the occlusion results from creating a fibrosis of the vein wall . over the course of time the vein degenerates completely . at first ,
two catheters were available for this technique , which differed in the number of electrodes on the catheter tip and in the catheter diameter : 
 vnus closureplus 6-french cathetervnus closureplus 8-french catheter [ figure 14 ] 
  vnus closureplus 6-french catheter vnus closureplus 8-french catheter [ figure 14 ] the access to the vein is achieved by ultrasound - guided puncturing at the lower insufficiency point of the vein and insertion of an introducer sheath .
the catheter tip should be placed by maintaining a distance of 2 cm to the deep vein and be located distal to the orifice of the epigastric vein .
after the placement of the catheter the cooled tumescent anaesthetic is circuminjected around the vein to be treated under ultrasound guidance by means of a pump . then the catheter is withdrawn manually in anti - trendelenburg - position . here
the withdrawal rate is 1 cm / min for the first 4 cm , then 3 cm/ min .
the treatment temperature of 120 is reached after 6 seconds and is applied for 14 seconds per term to the vein wall , with the respective segment near the sapheno - femoral junction being treated twice .
the treatment is carried through again in anti - trendelenburg - position of the surgical table and with cooled tumescent anaesthetic that is injected under ultrasound guidance .
tumescent anaesthesia protects the surrounding tissue from heat damages und produces a vasospasm of the vein to be treated , which facilitates a close contact to the heating element of the catheter .
a big advantage of this treatment is the standardized treatment technique with reproducible parameters that are monitored acoustically and optically by the generator . in the treatment the vein is punctured under ultrasound guidance at the distal insufficiency point by means of a 16 g needle , either with the patient standing or lying down .
subsequently , an introducer sheath is inserted via a guide - wire . with its help the radiofrequency catheter
can then be advanced , under ultrasound guidance , up to the region of the sapheno - femoral junction .
. then the vein can be circuminjected by a cooled tumescent solution under ultrasound guidance .
the region of the sapheno - femoral junction is treated in two cycles , at least .
likewise it is possible to carry through up to three cycles at outgoing lateral branches or incoming high - volume perforator veins .
the catheter is withdrawn in 6.5 cm steps , with the vein being heated to 120 per cycle [ figures 1524 ] .
closurefast generator ( vnus medical ) closurefast treatment ( animation ) closurefast treatment ( animation ) closurefast treatment ( animation ) closurefast treatment ( impressions ) closurefast treatment ( impressions ) closurefast treatment ( impressions ) closurefast treatment ( impressions ) closurefast treatment ( impressions ) in general , all truncal veins can be treated by the catheter without any problems .
likewise , truncal vein recurrences can be treated ; where necessary with an additional foam sclerotherapy via the guide - wire channel of the catheter . with a combination of this sort
it is recommended that the polidocanol foam be applied first and the catheter then purged with nacl solution , since otherwise an explosive mixture might develop because of the heat of the catheter .
the length of the heating element made it possible to treat the truncal veins quickly , but with this configuration the catheter could be used on the truncal vein only . here
due to the 7.5 cm long heating element a vein segment with a length of at least 10 - 15 cm is required so that the catheter can be securely introduced into the vein .
normally this is too long , in particular when the accessory veins are to be treated in the same session .
for this reason covidien introduced a catheter with a short heating element of 3 cm this spring .
the second radiofrequency technique by means of rfitt is far from being as widely spread as the closurefast technique .
the rfitt catheter too is introduced using the seldinger technique into the vein to be treated . in compliance with a consensus conference of august 2011
. a withdrawal rate of between 2.5 and 6 s / cm is recommended , depending on the vein diameter , with the first 10 cm being treated twice .
this , however , has the disadvantage that the catheter has to be carbonized more frequently and , in some cases , has to be pulled out several times for cleaning and then re - introduced .
the endoluminal laser therapy has gone through many changes since its introduction . initially laser generators with wavelengths of between 810 and 980 nm were used .
absorbtion of pure water and a hemoglobin solution whereas the lasers with low wavelengths mainly have a good absorption in hemoglobin , the higher laser wavelengths are particularly well absorbed in water .
the laser fibers used have also developed significantly . initially a smoothly cut laser fiber ( bare fiber ) with a diameter of 600 m was used .
the guiding catheter was placed by means of a j - type guide - wire under ultrasound assistance near the sapheno - femoral junction using the seldinger technique .
when tumescent anaesthesia is used , the temperature around the treated veins does not exceed 32 celsius . the linear endovenous energy density ( leed in j / cm ) is decisive for the efficiency of endoluminal laser therapy .   at first , energy densities as low as 25 j / cm were used . in order to optimize the results ,
the energy doses were temporarily increased to 120 to 150 j / cm , which resulted primarily in an increase in side effects .
most patients were treated with this recommended energy dose . in doing so , it was possible to improve the closure rates while also reducing the level of side effects .
the main side effects reported were pain , paraesthesias and ecchymoses.[3234 ] furthermore , a continuous withdrawal of the catheter replaced the initially pulsed withdrawal of the fiber .
the pulsed mode caused perforations of the veins and , as a consequence , larger ecchymoses .
it is pointed out that high power along with a short application time tends to have an evaporating effect , and low power along with a longer application time has a coagulating and shrinking effect . in case of lasers with a lower wavelength and use of a bare fiber steam bubbles
develop in the vein during the continuous withdrawal , which release the generated heat into the vein wall , thereby destroying the same . in a multicenter study the 980-nm laser ( treatment with bare fiber ) was found to be inferior to the radio wave closurefast catheter in the treatment of identical patient populations with respect to quality of life and side effect rate .
the closure rate of the treated veins was 100% in both treatment arms after a month . in recent years
there has been a trend towards the use of lasers with higher wavelengths of 1320 and 1470 nm . due to the higher absorption in water
three years ago the radial emitting catheter with a laser ring ( elves radial ) was introduced in the treatment of truncal veins .
combined with the 1470-nm laser the side effects of the laser treatment were further reduced .
especially the number of ecchymoses , the frequency of periphlebitis and post - operative pain and paraesthesias ( tenderness ) were reduced considerably in comparison with the bare fiber and the lasers with a lower wavelength .
compared to the bare fiber , which was applied with a laser power of 15 watts , the power could be reduced to 10 watts . here
the recommended energy density is between 60 and 80 j / cm . on the laser tip a temperature of 120
this spring the biolitec company introduced a novel laser fiber with two radial emitting laser rings . in this fiber the power is divided between the two laser rings and is 50% each .
the power of the laser is increased again to 15 watts and is divided by two to achieve 7.5 watts per laser ring .
the area of energy emission is twice of that of the one - ring fiber . as a result it is possible to work still more carefully and faster .
the tissue is irradiated for a longer period with less power . with a longer irradiation time the tissue ( vein ) can coagulate even more thoroughly .
the advantages of the laser remain unaffected even in the treatment of short vein segments .
a further novel laser fiber is the tulipa fiber. it offers the advantage that the fiber is intraluminally centered because the expanded members on the fiber tip keep the fiber away from the vein wall .
initial results indicate that , in comparison with the bare fiber , the number of ecchymoses and post - operative pains can also be reduced [ figures 2631 ] .
elves generator ( biolitec ) elves radial laser ( animation ) elves laser fiber with one radial emitting laser rings elves laser fiber with two radial emitting laser rings laser treatment ( impression )
in 2009 a technique with hot steam ( steam vein occlusion : svo ) was introduced in the treatment of varicosis .
the generator produces 120 hot steam which is released into the vein via a handpiece and a screwed - on catheter . prior to this
the catheter is placed 3 cm in front of the sapheno - femoral junction using the seldinger technique . while the catheter is pushed back centimeter by centimeter ,
an additional tumescent anaesthesia can be dispensed with , in contrast to the techniques described above .
the postulated advantage of this technique is the possibility of treating the truncal veins and all , even meandering , lateral branches .
the truncal veins are treated by means of the svo catheter , whereas in the treatment of the lateral branches the svo handpiece is placed directly onto the permanent intravenous catheter .
the lateral branches are punctured at intervals of 10 cm by the permanent intravenous catheter . due to the exclusive puncture
in contrast to the techniques described above it is a non - thermal catheter sclerotherapy .
the clarivein catheter is inserted into the vein directly via an 18 g peripheral venous catheter without the help of an introducer sheath .
when the catheter engages in the handle an angled tip on the catheter comes out .
the catheter tip is placed 0.5 cm below the sapheno - femoral junction . by means of a motor in the handpiece the angled tip of the catheter
rotates at 3500 rpm in the vessel , thus causing a vein spasm and damage on the endothelium .
the sclerosing agent ( aethoxysclerol ) which is supplied at the same time continuously below the rotating tip is homogeneously distributed by the rotation and introduced into the vein wall .
taken as a whole , endoluminal treatment techniques today play an essential role in the treatment of varicosis .
the early and mid - term treatment results achieved by endoluminal laser therapy and radio wave therapy with closurefast are at least as good as those of the traditional stripping operations , not to mention the considerably lower complication rates and a greater patient comfort .
although these two treatment techniques are used in a standardized manner , they , too , are subject to further developments .
the objective is to further enhance patient comfort and to achieve permanently optimal closure rates of the treated veins .
the rfitt treatment has not yet been studied sufficiently ; in particular there is still a lack of randomized studies looking at longer - term treatment results .
the hot - steam and clarivein treatments are still too new on the market to allow us to pass any judgement at this stage .
 venous disorders are among the most frequent disease patterns in the western world . 
 still at the turn to the 21st century there was no alternative available to the surgical treatment of varicosis . 
 meanwhile the endoluminal treatment methods have established and have demonstrated their efficiency while having lower side effects in comparison to the traditional treatment , even though conservatively oriented surgeons are still skeptically eyeing these methods . in the us , according to the latest mrg report of 2011 , about 95% of all venous surgeries are already done endoluminally . 
 this paper offers an overview of prevailing treatment standards of the most important endoluminal therapy techniques and shows current trends . 
INTRODUCTION
Endoluminal radio frequency obliteration
Endoluminal laser therapy
Further endoluminal techniques
SUMMARY