Incompetence of gastrocnemius vein (GCV) can cause acute symptoms (i.e. congestive dermatitis, lower extremity discomfort, and cramping) and if not appropriately managed, may lead to chronic venous insufficiency (CVI) with varicose veins or deep vein thrombosis (DVT). However, the incidence, clinical importance and optimal management of an incompetent GCV have rarely been discussed [1-3]. For a successful surgical stripping, tortuous and dilated GCV and its root should be fully exposed. However, the GCV draining site to the popliteal vein is difficult to identify because it is buried in the calf muscle and surrounded by the popliteal artery, the tibial nerve and fibrous tissue [4]. In the latest study regarding the treatment of incompetent GCV, surgical division at the level of popliteal skin fold was highly recommended [5]. In this case we treated varicose degeneration of the proximal and muscular parts of the left lateral GCV using concomitant endovenous laser ablation (EVLA) and ultrasound-guided foam sclerotherapy (UGFS).

A 39-year-old man visited our clinic with night cramping, calf pain, varicose veins, congestive dermatitis on the left leg. He had undergone ambulatory phlebectomy 10 years before. Venous duplex ultrasound showed varicose degeneration of left lateral GCV and GCV reflux from proximal part to distal muscular part (Fig. 1). For the implementation of therapeutic planning, the left lateral GCV was divided into 3 segments: 1. lateral gastrocnemius-popliteal vein junction and lateral main trunk. 2. horizontally degenerated segment. 3. vertically degenerated intramuscular segment (Fig. 2). The reflux of the third segment exited into distal small saphenous vein through perforating vein. Direct intraluminal access was conducted using 18-gauge angio-catheter and a ball-tip laser catheter introduced to the first segment, and performed focal tumescent anesthesia in the perivenous tissues. The use of small amount tumescent liquid (20 ml/cm) reinforces spasm of the vein and protects the perivenous tissues. Also by using an atraumatic blunt tumescent infusion needle, we prevent unnecessary muscle damage (Fig. 3). Only two points of focal EVLA (12 mm, 15 mm in length) was conducted along the dilated first segment. Simultaneously we injected 1% sodium tetradecyl sulfate (STS) into the second segment anticipating the sclerosing agent reach the first segment without being diluted (Fig. 4). Then, the distal third part of vertical intramuscular degeneration was punctured, and a diode laser catheter was introduced up to 7 cm in length. EVLA was conducted for the third segment, and concomitant UGFS was performed using 1% STS from distal small saphenous vein to intramuscular GCV. After three months, we checked duplex ultrasound scan from popliteal junction to distal axial intramuscular part, and we could ascertain that whole lateral GCV was completely occluded (Fig. 5). The patient did not report any symptoms, and the ankle dermatitis and discoloration were improving.

Figure 1. B-mode images of left lateral gastrocnemius vein. ① Main trunk. ② Horizontal segment. ③ Intramuscular segment.

Figure 2. An illustration of 3 segments for the implementation of therapeutic planning.

Figure 3. An atraumatic blunt tumescent infusion needle has five, spiral side holes.

Figure 4. B-mode images of combined treatment showed the collapsed vein and thickened intima with air density of STS.

Figure 5. B-mode and duplex ultrasound scan images of pre-procedure (left), post-procedure (right).

The combined use of using EVLA and UGFS for varicose vein treatment has been recently studied. A method of reducing the diameter by generating GSV spasms with UGFS without the use of a tumescent solution and then followed by EVLA with less energy has been suggested [6]. We utilized EVLA as a rotational tool to damage the vein wall during the MOCA procedure [7], focusing not on the use of tumescent anesthesia, but rather on maximizing the effect of STS on the dilated GCV, because UGFS shows a lower success rate due to the dilution of the sclerosant in the blood [8]. Most gastrocnemius varicose veins originate from the medial vein, but this case is unique in that it originated from the lateral vein [5]. Since the definite starting and end points of reflux were identified, it was certain that the vicious cycle should be interrupted. The deformation at the gastrocnemius-popliteal vein junction was so severe that it seemed likely that surgical approach or ligation and division would be incomplete. And above all, if the proximal main trunk and distal axial trunk were completely occluded, the long-term concern about recanalization or communication with surrounding veins was considered low. We believe that further studies are needed to compare this with conventional treatment through more patient cases. Focal laser treatment was performed using 3 watts of laser energy with an average LEED value of 20 J/cm. This is similar to the short-range laser use performed in the treatment of trans-luminal occlusion of perforating vein, but when using the laser in the gastrocnemius vein, it maximized the effect of STS with a relatively low concentration of about 1% and a total volume of 3 ml through blood steam bubble generation and intimal injury without inducing complete occlusion. The key to this treatment is to reduce the risk of muscle and nerve damage caused by laser thermal energy and to reduce the risk of DVT caused by STS.

The author declares no conflicts of interest.

This case report was presented at the 47th Annual Meeting of the Korean Society for Phlebology.