483-ACTA_N

© 2021 EDIZIONI MINERVA MEDICA Acta Phlebologica 2021 mese;22:(0):000–000

Online version at http://www.minervamedica.it DOI: 10.23736/S1593-232X.21.00483-5

ORIGINAL ARTICLE

Our experience with vein and hemorrhoid surgery

14 months after introducing microwave thermoablation
Istvan ROZSOS *, Gergely VADÁSZ, Melinda GADÁCSI

Theta Health Centre’s Budapest, Pécs, Hungary

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*Corresponding author: Istvan Rozsos, Tettye 40, 7625 Baranya, Hungary. E-mail: istvanrozsos@gmail.com

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BACKGROUND: In the last 15-20 years, traditional venous surgical procedures have been supplemented in the early period by thermal radio-
frequency techniques, followed by laser technologies, and now the Microwave methods.
METHODS: Between December 2018 and December 2019, in 20 patients (CEAP III-VI) we used Microwave Vein Ablation System (ECO) for
surgery on one limb, treating the other limb with surgery performed with the laser (Biolitec) EVLA technique. Description of Duplex Control
UH has been made for all surgeries. At 2 weeks postoperatively, a questionnaire was completed to determine the outcome of the two limbs

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(pain, tightness, bleeding, sensory disturbance) and to indicate possible lateral differences. Between August 2019 and February 2020, another
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20 patients (surgery of both feet in 9 patients) underwent surgery of 29 feet (CEAP IV-VI) with Microwave technique. Between December 2018
and February 2020, we performed 14 laser and 12 microwave hemorrhoids ablatio surgery in 26 patients. In this surgical procedure, similar to

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venous patients, we compare the effectiveness not to the traditional surgical solution but to laser ablation.
RESULTS: In the case of the first 20 patients, the effectiveness of the two limbs was determined on the basis of the ultrasound finding and the
patient’s physical signs: pain, tightness, bleeding, sensory disturbance. For both methods, 100% closure without reflux in the two- and 12-week
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and already one-year cases was not significant in either parameter in the early period between the two methods. In the second 20 patients, this
did not change significantly but there was a decrease in bleeding and tightness. In the comparison of patients with hemorrhoids, the effectiveness
of the two methods – pain and bleeding in the recovery time – was not significant.
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CONCLUSIONS: Based on the comparative studies, it can be stated that in all respects – efficiency, safety, comfort – the new method corre-
sponds to the solutions based on thermal effect so far in practice.
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(Cite this article as: Rozsos I, Vadász G, Gadácsi M. Our experience with vein and hemorrhoid surgery 14 months after introducing microwave ther-
moablation. Acta Phlebol 2021;22:000-000. DOI: 10.23736/S1593-232X.21.00483-5)
Key words: Microwaves; Hemorrhoids, surgery; Ablation techniques.
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A s a result of changes in our lifestyle, varicose veins, The aim of our paper was to present the introduction of
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just like hemorrhoids, have become a common dis- a new method and its early results, hence the number of
ease worldwide. Congestive venous diseases require surgi- patients required for strict statistical analysis is not suf-
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cal intervention if conservative treatments fail, as disease
progression in time can result in significant complications.
Traditional surgical procedures were supplemented by
thermo-effect techniques in the last 15-20 years: in the early
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ficient. However, the spectacularly good patient results
make it necessary to publish the outcomes so more col-
leagues to learn about them, employ them in practice, and

join us in gathering valuable experience.

days, the first steps were taken with radio frequency method,
then the advent of laser technologies continued the devel-
Materials and methods
opment. In addition to venous treatments, the direction of
tumour ablation development was perhaps even more spec- V-1
tacular.1-3
The Microwave technique, a new stage of thermoabla- Between December 2018 and August 2019, we have used
tion methods, offers the necessary solution with lower oper- the Microwave Vein Ablation System (ECO) on one limb
ating temperatures and simpler technology (Figure 1, 2, 3). of 20 patients (CEAP III-VI) with an average age of 46

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ROZSOS VEIN AND HEMORRHOID SURGERY AFTER MICROWAVE THERMOABLATION

To 2 cm
below the Brunch vein
joint of (Reticular
femoral vein)
• Small saphenous vein and great
Runs along lateral aspect saphenous
of foot and through the calf vein
muscle
Drians into popliteal vein at
the knee Varicose
Great vein
saphenous
vein
• Great saphenous vein
Superficial and longest vein
in the body
Begins in common with
small saphenous vein in Insert from
ankle the joint

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Extends up medical side Small
saphenous
of calf, knee, and thigh. vein
Drains into the femoral vein

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Radiated area:
much more Treat inefficient brunch vein:
efficient

O Treat the great saphenous Treat the trunk of small use needle type antenna,

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vein: use thread type antenna, saphenous vein: use thread insert from the joint of
insert from the knee or ankle type antenna, insert from the brunch vein, and heating
to the groin ankle to the knee ablate 1 brunch by 1 brunch

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Figure 1.—Varicose vein treatment with microwave ablation.
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High-accuracy dynamic power
Varicosity 01
stabilizing system
Therapeutic System
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Lower temperature ablation

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technology (80-85 °C)
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Microwave intracavitary
radiators
6fr Probes for
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GSV and SSV

PTFE Teflon radiator, completely solve the
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problem of thermal adhesion

4fr Probes for branch veins

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Figure 2.—The microwave therapeutic system.

years (between 23-69). On the other limb we have utilized
laser (Biolitec) operation technique (EVLA) (Figure 4).
For each operation, a preoperative map was done with
ultrasound examination, based on which the procedure
was performed with Duplex control during the operation.
Description of the surgical technique
When working with laser technology, we used a Leonardo
dual generator with standard automatically controlled (10
watts - set to 80 J/cm) setting, using a single-use, single-
ring laser fiber.

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VEIN AND HEMORRHOID SURGERY AFTER MICROWAVE THERMOABLATION ROZSOS

Figure 3.—The microwave effect in process.

MW ANTENNA

The microwave radiator is directly acted on the

vein cavity to make the blood vessel gradually The temperature at the tip
fibrosis resulting complete occlusion of the MW probe is 85 °C and 60 °C
in the probe radiator

This precise use of microwave

energy initiates a blood vessel
contraction supporting the
occlusion of the tip

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The MW device was a generator developed by the com- two limbs (aspects asked in the questionnaire: pain, feel-
pany ECO and was set to 50 Watts power and automatic 5
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s/cm power. The special antenna (the fiber is cm marked to indicate possible lateral differences.
and flexible) lead-in was introduced using a 6 introducer. Follow-up of the first patients has now been more than
It is important to emphasize that in contrast to other meth- 1 year (14 months). During the postoperative follow-up

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ods, in this case there is heat dissipation not only at the end examinations, the results of the 2-week and 1-month ex-
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of the fiber but also along its entire length – so the cooling aminations already showed the effectiveness of the new
of the output must be continuously ensured.
Patients were informed by the used methods, but they
method.
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did not know on which limb the new (EVMW) technology
was applied (Figure 5). Between August 2019 and February 2020, another 20 pa-
At 2 weeks postoperatively, a questionnaire was com- tients, with an average age of 47.7 years (between 22-69
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pleted to determine the outcome of the procedure on the years) underwent surgery (both legs operated in the case
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VARICOSE VEIN TREATMENT VARICOSE VEIN TREATMENT

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WITH MICROWAVE ABLATION WITH MICROWAVE ABLATION

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Between dec 2018 and aug 2019 20 patients (40 limbs) were assigned
to endovenous microwave ablation (EMWA) on one leg (N.=20) and Treatment procedure
in comparison with endovenous laser ablation (EVLA) on the other
Preoperative
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leg (N.=20)
- Physical examination
- Duplex ultrasound planning and marking
Treatment group characteristics:
- Age (years) 46 (23-69) Operative
- Gender (F/M) 14/6 - General anesthesia (laryngeal mask narcosis)
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- Smoking 7/20 - EVLA - 1440 nm laser fibre (800 C) - BIOLITEC

- Hypertension 5/20 - EWMA - miscrowave energy 50 W
- Diabetes 1/20 - Treating GSV: below the knee - catheter tip 2 cm below the SFJ
- CEAP 3 (13/20 - 65%) - Continuous intraoperative duplex scanning
4 (6/20 - 30%)
5 (2/20 - 10%) Postoperative
6 (1/20 - 5%) - Early mobilization (approx 60 min after the surgery)
- Previous operation 6/20 (4 conventional surgery, - Compression stocking 2-4 weeks
2 EVRF) - Hesperidin-diosmine 4 weeks
- In all cases only GSV was treated - Health questionnaire (Aberdeen score system)

Figure 4.—The V-1 patient’s dates. Figure 5.—Treatment procedure.

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ROZSOS VEIN AND HEMORRHOID SURGERY AFTER MICROWAVE THERMOABLATION
of 9 patients): altogether 29 limbs were treated (CEAP III-
VI.), this time using the Microwave technique only. Our
patients were screened according to previous practice: at
2-weeks following the surgery using the previously men-
tioned follow-up questionnaire and after the first month we
have conducted a Duplex check-up (Figure 6).
With regard to the results that can be determined on the
time axis, it is important to emphasize that although en-
dovenous techniques show many similarities, and previ-
ous experience and knowledge of laser or RF techniques
greatly simplify the application of the MW method, it is
still important to evaluate the learning period separately.
Nodus-1
Between December 2018 and February 2020, we per-
formed 14 laser and 12 microwave hemorrhoid surgeries.
The average age of the 26 patients was 45.8 years (be-
tween 19-67 years). In all the cases the hemorrhoid was
O pain, tightness, bleeding, and sensory disturbance.
advanced and caused constant pain (stad III.-IV.).
Description of the surgical technique
We have used a special anoscope and our chosen method
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was with laser (Leonardo generator) set on pulse mode
(300 J thread description) with a biopsy needle (Figure 7).
MW method: we have used a generator developed by
ECO, set to 30 Watts, 3 seconds, regionally 3 times (we
used the same for venous surgeries) using a short antenna -
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if heat caused damage in the surrounding area, we applied
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a biopsy needle (Figure 8).
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VARICOSE VEIN TREATMENT
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WITH MICROWAVE ABLATION
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Between aug 201 and feb 2020 20 patients (29 limbs) were assigned
to endovenous microwave ablation (EMWA) on one leg (N.=11) and
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two legs (N.=9)
Treatment group characteristics:
- Age (years) 47,7 (22-69)
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- Gender (F/M) 13/7
- Smoking 4/20
- Hypertension 5/20
- Diabetes 2/20
- CEAP 3 (11/29 - 38%)
4 (14/29 - 48%)
5 (2/29 - 7%)
6 (2/29 - 7%)
- Previous operation 429/20 (4 conventional surgery)
- 26 cases only GSV was treated, 3 cases SSV
Figure 6.—The V-2 patient’s dates.
4 Acta Phlebologica Mese 2021
In the postoperative period, patients were examined af-
ter 1 week and then after 3 months. We recorded their heal-
ing with a range of cessation of bleeding and pain.
In this study, we compare the effectiveness of the MW
technique not to the traditional surgical solution but to
the laser ablation,4 given that the developments of recent
years have already proven the benefits of thermal inter-
ventions, so we do not need to examine the advantages
compared to traditional methods, only to modern meth-
ods’ results.
Results
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V-1
In case of the first 20 patients, the effectiveness of the dif-
ferent methods on the two limbs was determined based on
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the Duplex tests and the patient’s physical signs, such as:
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For both methods, after 6 and 12 weeks we found 100%
closure in the saphenous-femoral juncture, without re-
flux. During the early period (one year) the two methods
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(EVLA and EVMW) did not show significant differences
in neither of the parameters (Figure 9).
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We can conclude in connection with the surgical results
of the operation done on the 29 limbs performed on 20
patients, that the favorable postoperative results did not
differ significantly compared to the patients treated with
the previous MW method, but there was a solid decrease in
bleeding and tightness. The significance of this is that the
results of the learning period are not worse than of patents
undergoing surgery in later periods (Figure 10, 11).
The burns included in the results are due to technical
errors. The skin in the puncture channel inlet area may be
damaged if there is no adequate cooling or the operator
also coagulates in the inlet opening. Burns healed sponta-
neously. There were no other complications.
N-1
When looking at the evaluation of the results of patients
with hemorrhoids we can conclude that the effectiveness
of the two methods in comparison is not significant when
we are observing the difference between the two groups
concerning recovery time determined by the pain and
bleeding. These methods have an average recovery time of
2-4 weeks, which is significantly better than the recovery
of conventional surgeries, which can take 6-8 weeks (Fig-
ure 12, 13, 14, 15).
VEIN AND HEMORRHOID SURGERY AFTER MICROWAVE THERMOABLATION ROZSOS

LASER APPLIKATUM

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Figure 7.—Hemorrhoidal treatment by laser.

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MICROWAVE INSTRUMENT HEMORRHOID SURGERY
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Figure 8.—Hemorrhoidal treatment by MW.

The burns shown in the results are clearly the result cosa and was damaged by heat. In addition, the inlet area
of technical errors. In the initial period, excessive tilting of the puncture canal may be damaged if we coagulate
of the thermal fiber resulted in the proximity of the mu- with the free area after the biopsy needle that provides

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ROZSOS VEIN AND HEMORRHOID SURGERY AFTER MICROWAVE THERMOABLATION

VARICOSE VEIN TREATMENT NODUS TREATMENT

WITH MICROWAVE ABLATION WITH MICROWAVE ABLATION AND LASER

Results (follow-up period 2-4-12 weeks) Results (follow-up period 2-4-12 weeks)

EWMA EVLA MV Laser

- Occlusion 100% 100%
- Skin burns 4/0/0 6/0/0
- 1. Pain 2/0/0 3/0/0
- 2. Tightness 6/0/0 7/0/0
- 3. Ecchymosis 3/0/0 6/0/0
- 4. Paresthesia 3/2/1 4/2/2
- Skin burns 1 1
- 1. Pain 2/1/0 3/1/0
- 2. Pain after defecation 2/1/0 3/1/0
- 3. Bleeding 3/2/0 4/2/0
- 4. Bleeding after defecation 3/1/0 4/2/0

- DVT 0/0/0 0/0/0 Figure 12.—Hemorrhoidal treatment results: MW (microwave) and

Laser technic: pain, pain only after defecation, bleeding, bleeding only

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after defecation: after 2, 4, 12.

Figure 9.—V-1 patient’s results at 2, 4, 12 weeks.

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LASER

VARICOSE VEIN TREATMENT

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WITH MICROWAVE ABLATION

Results (follow-up period 2-4-12 weeks)

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EWMA -V-2 29 limbs
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- Occlusion 100% 100% 100%
- Skin burns 2 1 0

- 1. Pain
- 2. Tightness
2
5
0
0
0
0
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- 3. Ecchymosis 3 0 0
- 4. Paresthesia 3 1 1
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- DVT 0 0 0
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Figure 10.—V-2 patient’s results at 2, 4, 12 weeks. Figure 13.—Hemorrhoidal treatment by laser.

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EVMW VARICECTOMY MICROWAVE

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Figure 11.—The procedure by introducer same the other thermo abla- Figure 14.—Hemorrhoidal treatment by MW.
tion.

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VEIN AND HEMORRHOID SURGERY AFTER MICROWAVE THERMOABLATION ROZSOS

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Before After

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Figure 15.—Before and after hemorrhoidal treatment.

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Comparison

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Endovenous RF Endovenous laser Endovenous microwave ablation

Principle
Heat conduction, from surface of vessel
wall to the centre of tissue
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Heat conduction, from surface of
vessel wall to the centre of tissue
Tissue inner heating, complete
ablation
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Quantity of surgery 1 1 or more 1
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Reccurance rate
MW < RF < Laser
(6 months)
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Ecchymosis MW < RF < Laser

Edema MW < RF < Laser

Pain after treatment MW < RF < Laser

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Risk MW < RF < Laser

Safety MW > RF > Laser
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1. The effect of vein closure in closed 1. Uncompleted ablation No

related with the compression of 2. Obvious skin burn and
tumescent fluid paralysis complications
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Defects 2. High requirements on healthy

environment and operation
3. The blood is over burned and stick on
the tip
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Figure 16.—Comparison the different technic.

the insulation. All two cases occurred during the first 10
interventions and then did not. There were no other com-
plications.
Based on the comparative studies, it can be stated that
in all respects, i.e. efficiency, safety and comfort the new
method corresponds to the solutions based on thermal
techniques, which have become widely used in practice
so far. The fact that MW energy has the same effect on a
lower temperature level (85° C) can be the basis for the
observation that the degree of heat damage is significantly

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ROZSOS VEIN AND HEMORRHOID SURGERY AFTER MICROWAVE THERMOABLATION

In addition to keeping the endovenous principle in

VARICOSE VEIN TREATMENT
WITH MICROWAVE ABLATION
mind, the adhesive technique, and the foam sclerotherapy
treatment are also among the options, so the most optimal
solution can be chosen for each patient.7
Conclusion
Conclusions
PROS:
- Good visibility via ultrasound
- Easy to handle set The development of venous surgery in the last 15 years
- High occlusion rate has required a very serious paradigm shift. Due to the di-
- Aesthetic result
- 85 °C at the tip of the microwave probe ~120 °C EVRF versity of the disease and the variability of clinical pro-
~800 °C EVLA cesses, we need to collect data and identify current and
CONS: ideal solutions at every new developmental stage. Among
- No LED laser (yet) the changes and improvements, I have experienced over

- Skin burns (sheath overheating! - short brake after every 5 min
treatment period helps the wire recooling)
- Short follow-up period - further multicentr studies required
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the past 30 years of vascular surgery, the introduction of
laser and microwave methods have been the highlights
and are currently the optimal choice for the vast majority

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Figure 17.—The microwave method- pros and cons.
of patients.

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lower. We can count on the microwave technique not only
in the solution of tumor ablations but also in the treatment References
of our venous and hemorrhagic patients (Figure 16, 17).

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1.  van den Bos RR, Milleret R, Neumann M, Nijsten T. Proof-of-prin-
ciple study of steam ablation as novel thermal therapy for saphenous
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varicose veins. J Vasc Surg 2011;53:181–6.
Discussion

The author of the article was the first in Hungary to per- E

form Endovenous Laser Therapy on September 23, 2005,
then known as EVLT, with a 980 nm Biolitec device and
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2.  Yang L, Wang XP, Su WJ, Zhang Y, Wang Y. Randomized clinical
trial of endovenous microwave ablation combined with high ligation
versus conventional surgery for varicose veins. Eur J Vasc Endovasc
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Surg 2013;46:473–9.
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straight, open laser fiber.5, 6 Cancer Res 2018;7:283–9.

4. Karahaliloğlu AF. Laser hemorrhoidoplasty (LHP): A new surgical
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Since then, more than 1600 EVLAs have been per-
formed, with state-of-the-art ring fibers and a 1470nm
Leonardo device. Due to the need to master the technique
he has completed 150 RF surgeries too, when he learned
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procedure for the treatment of advanced hemorrhoidal illness. Coloproc-
tology 2010;32:116–23.
5.  Rozsos I, Ferenczy J, Szabó SZ. és Mtsai. Az endovénás lézer terá-
pia (varicectomia) az ulcus cruris ellátásában. Sebkezelés-Sebgyógyulás

2008;11:4–8.
the microwave (EVMW) method.
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6.  Rozsos I, Vadász G. Following and comparing my endovenous tech-

In December 2018, he was the first in Europe to perform niques of curing venous ulcers. UIP World congress of phlebology. Mel-
the first two EVMW surgeries, the number of cases treated bourne, February 4-8, 2018.
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7. Bihari I, Rozsos I, Szabó A, Menyhei G, Sipka R. Endovénás

with the technique reached up to 50 limbs at the time of visszérműtét hazai iskolája Érbetegségek, 2020. XXVI. évfolyam 2.
this article. Szám.
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Conflicts of interest.—The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript.
Authors’ contributions.—All authors read and approved the final version of the manuscript.
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History.—Article first published online: _____. - Manuscript accepted: April 22, 2021. - Manuscript revised: April 20, 2021. - Manuscript received: Septem-
ber 30, 2020.

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