endothermal ablation for venous insufficiency · how i do endothermal ablation for venous...
TRANSCRIPT
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How I do Endothermal Ablation for Venous
InsufficiencyDr. Sanjoy KunduThe Vein Institute of TorontoScarborough Vascular GroupScarborough Vascular UltrasoundScarborough Vascular InstituteToronto Endovascular CentreScarborough Hospital
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Disclosure
Consultant:– Bard™ Canada– Boston Scientific ™ Canada– Edwards Life Sciences ™– Baylis™ Canada– Sigmacon ™– Diomed™– Dornier™
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Objective: Remove the GSV from the
Circulation
1. Surgical - HL & stripping
2. Chemical – sclerotherapy
3. Thermal – RF & Laser
Thermal ablation has emerged.Surgical stripping is no longer
the gold-standard
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Invagination stripping of LSV
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Prospective randomized studies of recurrent V V
after high ligation & stripping
28% 26%(2 – 5 yrs)
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Neovascularization at SFJ causes recurrence
Van Rij, JVS 2004
Chaotic nest of new veins at SFJ reconstituteaxial vein remnants downstream in the thigh
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Treatment Goals
Ablate veinAvoid complications– DVT– Nerve injuries– Skin burns
Minimize recurrence
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Treatment Plan
Understanding anatomy is key to successful outcomesPreprocedure US evaluation is critical in determining treatment plan
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Anatomy&
Ultrasound
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Great Saphenous Vein
Circumflex Iliac Vein
Intersaphenous Vein
Popliteal Vein
Small Saphenous Vein
Dorsal VenousArch of Foot
Common Femoral Vein
Superficial Femoral Vein
Posterior CircumflexVein of Thigh
Anterior AccessorySaphenous Vein of Thigh
Anterior CircumflexVein of Thigh
Posterior AccessorySaphenous Vein of Calf
Great Saphenous Vein
Posterior AccessorySaphenous Vein of Thigh
Saphenofemoral Junction
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Compartments of the Thigh
SC, Superficial compartment; DC, deep compartment.
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Great Saphenous Vein Anatomy
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Common Patterns of VV
GSV DoddPudendal Giacomini
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R.V. & S.V.
V.V.
C1C2
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Origin?
Incompetent perforator refluxThermal ablation is not the treatment of choiceTreatment of GSV, SSV, etc is not indicated
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Great SaphenousVein Ultrasound
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Saphenous Canal
LSV SSV
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Vein Entry&
Catheter Position
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Vein Entry
Site of GSV entry is somewhat controversial– Knee level entry has lead to higher
recurrence rates– Below knee entry may lead to
parasthesiasSite of SSV entry is typically mid calf
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Saphenous nerve& GSV
Sural nerve &SSV
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Vein Entry
Is it just like a PICC line?– Beware of spasm– Calming environment– Warm environment– Reverse trendelenburg position
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Micropuncture Kit
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Leg Position & Vein Entry
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Vascular Sheath
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Puncture & Sheath
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Catheter Tip Position
Start distal to SEV
– Allows abdominal wall drainage into SFJ
No propagation of thrombusNo neovascularization
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Catheter Tip Position-Ultrasound Image
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Tumescent Anesthesia
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Tumescent Anesthesia
Key to procedural success– Heat sink– Analgesia– Compression of vein– Displace adjacent structures.05-.1% (.5-1gm/liter)– 6-7mg/kg has been listed as max dose– However liposuction studies have shown
dosages of 35mg/kg have been safe
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Tumescent Anesthesia
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Tumescent Anesthesia
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Tumescent Anesthesia
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Radiofrequency Ablation
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Closure® Procedure (Radiofrequency)
Catheterinserted
inrefluxing vein
Catheter Positioned, Electrodesdeployed
RF Energyheats andcontractsvein wall
Catheter slowly
withdrawn,closing vein
Denudedvein
is physicallynarrowed
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Resistive Heating-direct contact with
vein wall
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Animal Research: Acute histologic effects of RF heating.
Denude endothelial lining Contraction & thickening of vein wall Necrosis of smooth muscle and vein wall componentsShrinkage of collagen fibrils
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Animal Research: Post Treatment Effects
Extensive growth of fibroblasts New collagen synthesis Further thickening of vein wall Fibrous plug
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Absence of reflux 407/458
89%
211/240
88%
103/119
87%
93/107
87%
31/37
84%
Absence of varicose
veins
360/458
79%
191/240
79%
99/119
83%
81/107
76%
29/37
78%
1 Year 2 Years 3 Years 4 Years 5 Years
92% of limbs that are reflux-free at 1 year continue to be reflux free at subsequent follow-up (to 5 years)
5- year registry data: RF ablation
Merchant RF & The Closure Group. Long term outcome of endovascular radiofreqency obliteration for treatment of primary chronic venous insufficiency – five years follow up of a multicenter prospective study. European Society for Vascular Surgery XVIII Annual Meeting. Sept. 2004, Innsbruck, Austria
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Endovenous Laser
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Endovenous Laser Treatment
There are 4 FDA approved devices 810 nm, 940 nm, 980nm & 1320nm.
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Endovenous Laser Position
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Endovenous Laser Energy Deposition
Objectives:– Adequate Energy Deposition– Ensure Long Term Ablation with no
recanalizationTechnique:– Utilize Continuous Mode– Slow Pull Back– Energy Deposition of 2500 to 5500 J
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Steam bubbles
Absorption of laser energy
by hemoglobin & water
results in the formation
of steam bubbles.
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Endovenous Laser: Long-Term results
Robert J. Min, MD
Several single center reports with vein closure rates 93 – 99%
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Post Endothermal Ablation Care
Compression Stockings for two weeks– 30-40 mmHg of Compression
Follow-up Ultrasound in 6 weeksFollow-up Sclerotherapy for branch varicose veins at 6 week and 12 week follow-up
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The End Result!
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ConclusionsProper treatment plan and evaluation is criticalAdequate tumescent anesthetic is keyAttention to procedural details (avoid spasm) is importantBoth RF and Laser have excellent results and have supplanted stripping as the primary treatment of incompetent veins
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