|Year : 2021 | Volume
| Issue : 2 | Page : 235-239
Ultrasound-guided femoral nerve block for pain management in endovenous laser ablation for varicose vein
Namrata Singh1, Pankaj Banode2, Amit Kumar Singh3
1 Department of Radiodiagnosis, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed University), Wardha, Maharashtra, India
2 Department of Interventional Radiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed University), Wardha, Maharashtra, India
3 Department of Surgery, Heritage Institute of Medical Sciences, Varanasi, Uttar Pradesh, India
|Date of Submission||07-Dec-2020|
|Date of Decision||20-Jan-2021|
|Date of Acceptance||15-Feb-2021|
|Date of Web Publication||18-Oct-2021|
Dr. Namrata Singh
Departments of Radiodiagnosis and Interventional Radiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed University), Wardha, 442105,Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Chronic venous insufficiency and its associated complications are a common condition affecting 15%–20% of the general population. Endovenous laser ablation (EVLA) is an effective day care treatment procedure. Tumescent anesthesia is given during EVLA to for pain relief and to prevent thermal damage to surrounding soft tissue by the laser energy. Regional nerve blocks can be given to reduce the pain of tumescent anesthesia and EVLA procedure. This study was aimed to evaluate pain score in varicose vein patients undergoing laser ablation with or without femoral nerve block. Materials and Methods: A total of 60 patients having only great saphenous vein disease were enrolled and divided into two Groups A and B using random number table. Group A was given tumescent anesthesia before laser EVLA procedure. Group B patients were given ultrasound guided femoral nerve block before tumescent anesthesia and laser ablation. Pain score was recorded intraoperatively, immediate and delated postoperative period (0, 1, and 3 h) on the Visual Analog Score. Data were analyzed using the standard statistical analysis tools. Results: Intraoperative and postoperative pain was significantly lower in Group B patients as compared to Group A (P < 0.0001).Volume of tumescent anesthesia used in Group B was significantly lower as compared to Group A. Conclusion: Femoral nerve block under ultrasound guidance is a safe, easy, and effective technique to reduce intra-operative and postoperative pain in patients undergoing EVLA without significant complications.
Keywords: Endovenous laser ablation, femoral nerve block, great saphenous vein, pain score (Visual Analog Scale), varicose vein
|How to cite this article:|
Singh N, Banode P, Singh AK. Ultrasound-guided femoral nerve block for pain management in endovenous laser ablation for varicose vein. J Datta Meghe Inst Med Sci Univ 2021;16:235-9
| Introduction|| |
Chronic venous insufficiency is a common disorder of the lower extremity venous system, leading to persistent ambulatory venous hypertension manifesting clinically as limb pain, pedal edema, trophic skin changes, and ulcerations., It is a common medical condition affecting approximately 25% women and 15% men. Most common cause for the development for varicose veins is sapheno-femoral reflux., Various risk factors for the development of chronic venous insufficiency include female gender, obesity, advanced age, pregnancy, positive family history, and occupation demanding long-standing hours.,
The traditional method of management of varicose vein has been surgical ligation of sapheno-femoral junction and its tributaries in groin and subsequent stripping of great saphenous vein (GSV) from the level of groin to knee. Endovenous laser ablation (EVLA) being minimally invasive is a better alternative to conventional surgery as it has lesser morbidity, fast recovery, and better cosmetic outcome. EVLA is done using tumescent anesthesia along the GSV which requires multiple skin punctures which is painful to variable degree in different patients. Ultrasound-guided femoral nerve block is a technically easy alternative to relieve intra-operative pain in patients undergoing EVLA. This study was carried out to evaluate and compare intraoperative and postoperative pain in patients undergoing EVLA using local tumescent anesthesia alone versus similar treatment with ultrasound-guided femoral nerve block. As very limited studies which have been carried out on this comparison, our study would help in carrying forward research on this novel and effective therapeutic interventional procedure and increased adoption of this effective procedure.
| Materials and Methods|| |
Patient identification and inclusion criteria
Sixty primary symptomatic varicose vein patients (proven saphenofemoral reflux and GSV reflux on duplex ultrasound) with C2–C4 Clinical, etiological, anatomical and pathological classification (CEAP) class disease who were willing to undergoing EVLA for treatment of varicose veins were included in the study.
- Patients requiring general or spinal anesthesia (patient request/patient requirement)
- Patients with recurrent disease
- Patients having reflux in the deep venous system
- Patients with chronic venous insufficiency with CEAP class other than C2–C4
- Patients with deep venous thrombosis
- Patients hypersensitive to lignocaine
- Patients not willing for participation in study.
Study design, setting and methodology
This was a prospective, case controlled interventional study, carried out from September 2019 to March 2020 in the interventional radiology department of a tertiary care hospital. Participants were randomized using random number table and were divided into two groups: A and B. Sixty patients of varicose veins with CEAP class C2–C4 having unilateral symptomatic GSV reflux were included in the study. The detailed ultrasound evaluation of deep and superficial venous system of affected limb was done by certified radiologist. All patients were explained about EVLA procedure and femoral nerve block at the time of enrolment for the study. The study participants were divided into two groups (Group A and B) using randomization table. Preoperative coagulation profile, complete blood count, and lignocaine sensitivity testing were done in all patients. All procedures were done on day care basis after obtaining prior informed written consent.
Procedure for Group A (endovenous laser ablation with tumescent anesthesia)
Patients were kept supine with table in reverse Trendelenburg position to distend the GSV. Cleaning and draping of affected limb were done under all aseptic precautions. After injecting small amount of intradermal local anesthetic agent (1% lidocaine), incompetent GSV was punctured using 18G needle under ultrasound guidance. After puncturing the vein, J tip of 0.035-inch Terumo guidewire was advanced and introducer sheath was inserted after removal of puncture needle. Tip of laser fiber was introduced through the sheath and was positioned 3 cm distal to saphenofemoral junction. After that tumescent anesthesia (lidocaine 400 mg/L [0.04%], epinephrine 1 mg/L [1: 1,000,000], and sodium bicarbonate 10 mEq/L) diluted in normal saline solution was injected using 10 ml syringe under ultrasound guidance. After perivenular tumescent anesthesia, when GSV was completely collapsed, laser energy (Biolitec laser machine with 980 nm radial fibre) of 50–120 J/cm was delivered by depending on the diameter of vein. Additional tumescent anesthesia was given if patient complained of pain.
Procedure for Group B (endovenous laser ablation with femoral nerve block and tumescent anesthesia)
Patients in this group were positioned and prepared similar to Group A. The linear ultrasound transducer (Hitachi Aeriatta S65 with high frequency 7.5–10 MHz linear array transducer by Hitachi Corp Japan) was used to visualize the common femoral vessels transversely at the groin with transducer placed over the inguinal crease. Immediately, lateral to the common femoral artery and deep to the fascia iliaca, femoral nerve was identified as hyperechoic oval structure [Figure 1]. Using in-plane technique, a single skin puncture was made at 45° angle with a 22 G, 1.5-inch-long needle to inject 10 ml of local anesthetic solution (2% lignocaine) around the nerve, avoiding nerve puncture. After 2–3 min of femoral nerve block, anesthesia was assessed for sensory loss. Thereafter, tumescent anesthesia was administered and EVLA was performed with the same technique as described for Group A. Intraoperative and postoperative pain was recorded in patient record sheet depicting Visual Analog Score from 0 to 10. Postoperative pain assessment was done at 0, 1, and 3 h.
After the completion of procedure, all patients were examined for postprocedural motor nerve block and findings were recorded. To check motor block, patients were asked to flex the hip and keep the knee in full extension, after that strength of quadriceps femoris muscles was evaluated. Femoral motor block was defined as severe (3-unable to extend the knee, adduct the thigh), moderate (2–unable to keep the knee extended and thigh adducted against gravity), mild (1 – unable to keep the knee extended and thigh adducted against manual resistance), no motor block (0 – no restriction of active movement range) of motion. Postprocedure duration of hospital stay was recorded in the patient record sheet.
Assessment of pain
Intraoperative, immediate, and delayed postoperative pain was assessed by the Visual Analog Scale (VAS). which consists of a straight line having two endpoints defining extreme limits such as “no pain at all” at one end and “pain as bad as it could be” on the opposite end. This line can be further divided into 10 points. The patients were given the Visual Pain Analog score and were asked to mark the pain level on the line between the two endpoints.
Interpretation of Visual Analog Scale
The following cutoff points on the pain VAS have been recommended:
- 0 = No pain
- 1–3 = Mild pain
- 3–6 = Moderate pain
- 7–10 = Severe pain.
All the patient data were recorded in the Excel sheet and statistical analysis was done by descriptive and inferential statistics using the Chi-square test, Student's unpaired t-test, and Mann–Whitney U-test. The software used in the analysis was SPSS (version 24, IBM Corp, Armonk, New York, USA), GraphPad Prism 7 (GraphPad Software Inc. San Diego, California, USA ), and P < 0.05 was considered level of significance.
| Results|| |
Both Groups A and B had 30 study participants each. The mean age of patients in Group A was 44.1 years and in Group B was 49.6 years. In Group A, 53.3% patients were female and 46.7% male, whereas in Group B, 60% patients were female and remaining 40% were males [Table 1].
|Table 1: Patients characteristics, intra-operative and postoperative data|
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In both the Groups A and B, pain score was recorded intraoperatively during the administration of tumescent anesthesia and EVLA procedure. Pain score was again recorded at 0 h, 1 h, and 3 h postoperatively. Patients in Group B experienced less pain intraoperatively as well as postoperatively as compared to Group A as depicted in [Graph 1] showing mean VAS pain score of both the groups.
None of the patients in Group A experienced postprocedural motor block, whereas the patients in Group B experienced variable degree of motor block which was recorded after half an hour of EVLA procedure. Eleven (36.6%) patients experienced mild restriction of active movement, 17 (56.6%) patients had moderate restriction while 2 (6.6%) patients had severe restriction of movement. All patients underwent motor block reassessment 3 h after the procedure and none of them had residual motor block. Both study group patients were administered tumescent anesthesia before EVLA. Group B received tumescent anesthesia after femoral block. Total volume of tumescent anesthesia used in Group B was significantly less as compared to Group A. Average volume of tumescent anesthesia used in Group A was 301.3 ml while in Group B was 185.6 ml and the difference was statistically significant (P = 0.001). The average duration of procedure in Group A was 29.06 min and in Group B was 30.5 min. The difference in the duration of procedure was statistically insignificant (P = 0.64). The mean length of GSV ablated in Groups A and B was 34.5 and 35.9 cm, respectively, which was also statistically insignificant (P = 0.13). The average duration of postoperative hospital stay in Group A was shorter (3.1 h) as compared to Group B (4 h).
| Discussion|| |
Chronic venous insufficiency is a debilitating condition causing lower limb edema, pain, skin pigmentation, and venous ulcer secondary to long-standing venous hypertension., Sapheno-femoral junction incompetence is the most common cause of lower extremity varicosity most commonly affecting the great saphenous venous system., EVLA of GSV is a safe, minimally invasive day care procedure for treatment of incompetent veins with good cosmetic results, lesser morbidity, and faster postoperative recovery. The postoperative complications such as surgical site infection, hematoma formation, and nerve damage are significantly lower with EVLA as compared to surgical ligation and stripping of GSV (Trendelenburg operation).,
In EVLA technique, obliteration of saphenous vein is obtained by inducing thermal damage to vascular endothelium. As laser ablation causes luminal occlusion and reduces neo-vascularization, the chances of recurrence of disease are also greatly reduced., Most of the interventional radiologists and the endovascular surgeons use perivenular tumescent anesthesia for EVLA. Tumescent anesthesia given in perivenous space around GSV causes collapse of the vein and prevents surrounding tissue damage from excess heat produced by laser. The tumescent anesthesia relieves pain of laser ablation but administration of tumescent anesthesia itself is a painful process as it requires multiple injections in perivenous space.
Analgesia can be obtained by various modes such as general anesthesia, intravenous sedation, spinal block, epidural block, and regional nerve blocks. Intravenous sedation can lead to respiratory depression and can interfere with postprocedure mobility. Unilateral spinal anesthesia, epidural anesthesia, and general anesthesia completely relieve the procedure-related pain; however, patients are predisposed to anesthesia-related complications such as high spinal anesthesia, basal lung atelectasis, and aspirational pneumonia. As spinal and general anesthesia increases duration of postoperative immobilization, the chances of deep-venous thrombosis are increased. Furthermore, these anesthesia procedures increase the procedural cost, hospital stay, and overall treatment cost. Regional block for analgesia is a good alternative to spinal and general anesthesia, without significant effect on treatment cost, procedure duration, and hospital stay. Ultrasound gives clear depiction of anatomy of femoral triangle and the femoral nerve is distinctly seen as an oval hyperechoic structure just lateral to common femoral artery. Femoral nerve supplies skin and muscles in the medial aspect of thigh and proximal anterior aspect of the knee, making the interventions possible on great saphenous and small saphenous veins. Ultrasound-guided visualization of the femoral nerve makes femoral block a relatively fast and safe procedure, increasing success rate of block with minimal complications.,
In this study, pain experienced by patients during injection of tumescent anesthesia and subsequent laser ablation was significantly lower in patients who underwent ultrasound guided femoral block before the procedure (Group B) against the patients who did not receive femoral block (Group A). Postoperative VAS score was also lower in Group B as compared to Group A. Hakim Evaluated the pain response in 80 patients undergoing EVLA using tumescent anesthesia (Group A) and femoral and obturator nerve block (Group B). He also found that pain score in Group B was significantly lower as compared to Group A. Their study also concluded that patient and doctor satisfaction was greater in Group B. Similar findings were reported by Al Wahbi. Where they evaluated 60 patients divided in two Groups I and II. Group I was given tumescent anesthesia and Group II was given tumescent anesthesia and femoral nerve block before EVLA and study showed pain score was significantly lower in Group II as compared to Group I.
In the current study, the tumescent anesthesia was given by injecting diluted local anesthetic combined with epinephrine and sodium bicarbonate into the perivenous tissue until it becomes firm and tense (tumescent). The volume of tumescent anesthesia used in patients of Group B with significantly less than Group A, and similar results were reported in study of Hakim which in turn reduces chances of local anesthetic agent toxicity due to the smaller dose of the drug. No motor block was found postoperatively in Group A patients, all patients were able to mobilize early minimizing the risk of deep-venous thrombosis. Motor block was found in patients of Group B which was checked after half hour of procedure which delayed the early active mobilization of patient. However, no residual motor block was found in the delayed postoperative period (measured after 3 h of procedure). None of patients in this study developed deep-venous thrombosis which was checked on follow-up duplex scan done after 5 days of procedure. In this study, postoperative hospital stay was relatively longer in patients who underwent femoral block as they had motor block and delayed mobilization. However, all patients were able to mobilize after 3 h and discharged on the same day of procedure.
| Conclusion|| |
This study concludes that peri-operative pain score is significantly lower in patients undergoing EVLA under femoral nerve block as compared to tumescent anesthesia alone. Femoral nerve block under ultrasound guidance is relatively easy and safe procedure. It increases patient satisfaction by making procedure almost pain free. We recommend using ultrasound-guided femoral nerve block in EVLA patients due to technical feasibility, significant reduction in pain during procedure, and higher patient satisfaction without effecting the cost of the procedure.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Eberhardt RT, Raffetto JD. Chronic venous insufficiency. Circulation 2014;130:333-46.
Go SJ, Cho BS, Mun YS, Kang YJ, Ahn HY. Study on the long-term results of endovenous laser ablation for treating varicose veins. Int J Angiol 2016;25:117-20.
Fowkes FG, Evans CJ, Lee AJ. Prevalence and risk factors of chronic venous insufficiency. Angiology 2001;52 Suppl 1:S5-15.
Criqui MH, Denenberg JO, Bergan J, Langer RD, Fronek A. Risk factors for chronic venous disease: The San Diego Population Study. J Vasc Surg 2007;46:331-7.
Lin F, Zhang S, Sun Y, Ren S, Liu P. The management of varicose veins. Int Surg 2015;100:185-9.
Haefeli M, Elfering A. Pain assessment. Eur Spine J 2006;15 Suppl 1:S17-24.
Darwood RJ, Theivacumar N, Dellagrammaticas D, Mavor AI, Gough MJ. Randomized clinical trial comparing endovenous laser ablation with surgery for the treatment of primary great saphenous varicose veins. Br J Surg 2008;95:294-301.
Min RJ, Zimmet SE, Isaacs MN, Forrestal MD. Endovenous laser treatment of the incompetent greater saphenous vein. J Vasc Interv Radiol 2001;12:1167-71.
Hakim KY. Comparison of tumescent versus ultrasound guided femoral and obturator nerve blocks for treatment of varicose veins by endovenous laser ablation. Egypt J Anaesth 2014;30:279-83.
Bellam KP, Joy B, Sandhyala A, Naiknaware K, Ray B, Kumar V. Technique, efficiency and safety of different nerve blocks for analgesia in laser ablation and sclerotherapy for lower limb superficial venous insufficiency-A multicentre experience. J Clin Diagn Res 2016;10:C13-7.
Öztürk T, Çevikkalp E, Nizamoglu F, Özbakkaloğlu A, Topcu İ. The efficacy of femoral block and unilateral spinal anaesthesia on analgesia, haemodynamics and mobilization in patients undergoing endovenous ablation in the lower extremity. Turk J Anaesthesiol Reanim 2016;44:91-5.
Al Wahbi AM. Evaluation of pain during endovenous laser ablation of the great saphenous vein with ultrasound-guided femoral nerve block. Vasc Health Risk Manag 2017;13:305-9.