Evaluation of Patients With Venous Insufficiency

Endovenous Laser Ablation:
Equipment, Technical Tips & Tricks
Sanjoy Kundu
MD, RVT, RPVI FRCPC, FASA, FCIRSE, FSIR, FACPh
Certified by the American Board of Phlebology
The Vein Institute of Toronto
Scarborough Vascular Ultrasound
Scarborough Hospital
www.scarboroughvascular.com
Disclosures

None
Objectives

To become familiar with the current laser
equipment

To learn about the advantages of laser

To learn tips and tricks on performing EVLA
Background
What is Endothermal
Venous Ablation?

Definition: Application of thermal
energy for the purpose of ablating
a incompetent target vein
– Endovenous Laser
– Endovenous Radiofrequency
– Endovenous Cryotherapy

What veins can we treat?
Great
Saphenous
Vein or
Tributary
Branches
Small
Saphenous
Vein or
Tributary
branches
Current Laser Equipment
Endovenous Laser

A number of different technologies &
techniques utilized to date
– Wavelengths
– Power settings
– Energy settings

Acts by mechanism of nonthrombotic venous occlusion of the
target vein
Animal Research:
Post Treatment Effects


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Extensive growth
of fibroblasts
New collagen
synthesis
Further thickening
of vein wall
Fibrous plug
Endovenous Laser
Wavelengths

Number of different wavelengths available:
– 810 nm; 940; 980; 1064; 1320; 1470

Minimal literature to date comparing different
wavelengths
– Kabnick et al. J Vasc Surg 2006;43:88-93
 Compared 810 vs 980 nm
–
–
–
–
Randomized, prospective, blinded study
Less bruising in 980 nm group after 1 week
Less itching in 810 nm group at 3 weeks
Lower levels of pain intensity and varicose vein ratings
at 4 month follow-up in 980 nm group


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No major complications
10.5% incidence of paresthesia
Less post-procedural pain with LEED less than 100 J/cm
Energy Absorption
Why Target Water?



Target vein intima by targeting water
as the chromophore
Increase heating of vein wall with
reduction in collateral heating
Theoretical suggestions with no clinical
proof in level 1 studies!
Endovenous Lasers
Advantages of Endovenous
Laser
Laser Advantages




Lower post-procedure bruising,
haematomas and pain compared with
surgery
Lower rate of paresthesia compared with
surgery and RFA
Lower rate of post-procedure
neovascularization (1% vs 18% for surgery)
Lower recurrence rate compared with
surgery
Neovascularization at
SFJ causes recurrence
Chaotic nest of new veins at SFJ reconstitute
axial vein remnants downstream in the thigh
Van Rij, JVS 2004
Laser Advantages



Lower complication rate than surgery
or RFA
Higher pooled success rate at 3 years
compared with RFA or surgery
Superior to RFA, surgery and
Ultrasound guided sclerotherapy to
eliminate saphenous vein
incompetence
References
1.
2.
3.
4.
5.
Luebke T, Brunkwall J. Systematic review and meta-analysis of
endovenous radiofrequency obliteration, endovenous laser therapy,
and foam sclerotherapy for primary varicosis. J Cardiovasc Surg
2008;49:213-33
van den Bos R, Arends L, Kockaert M et al. Endovenous therapies of
lower extremity varicosities: a meta-analysis. J Vasc Surg.
2009;49:230-39
Leopardi D, Hoggan BL, Fitridge RA et al. Systematic review of
treatments for varicose veins. Ann Vasc Surg 2009;23:264-76.
Hoggan BL, Cameron AL, Maddern GJ. Systematic review of
endovenous laser therapy versus surgery for the treatment of
saphenous varicose veins. Ann Vasc Surg 2009;23:277-87.
Al Samaraee A, McCallum IJ, Mudawi A. Endovenous therapy of
varicose veins: a better outcome than standard surgery? Surgeon
2009;7:181-86
Technical Tips & Tricks
Procedure Steps
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Obtaining Access
Placement & Positioning of Vascular Sheath &
Ablation Device
Tumescent Anesthesia
Endovenous Laser Ablation Parameters
Adjunctive Treatments
Obtaining Access

Access Options:
– Minicutdown +/- phlebectomy hook
– Percutaneous Ultrasound Guided Access
18” vs 19” access with .035” wire
 21” micropuncture access with .018” wire



Very little literature on access to date
Goals:
– Obtain rapid access
– Minimize trauma
– Maximize patient comfort
Obtaining Access
18 “ or 19” needle


Advantages:
– Cheaper
– Some users report a “better
feel”
Disadvantages:
– Greater trauma to vein
– Usually only get “one shot”
– Patients may report greater pain
with puncture
21” needle & .018” wire
Advantages:
-Less traumatic to target vein
-Allows two to four puncture attempts at
target vein
-Can use micropuncture needle for
tumescent anesthesia
Disadvantages:
-More expensive
-.018 mandril wire can become
“mangled”, requiring new kit
Tip: Use long 5 French micropuncture kit to allow passage of laser fiber
Obtaining Access
New Technical Developments
Long Micropuncture Kit
-Eliminates need for vascular
sheath and second .035”
exchange wire
-May shorten procedure time
-45 or 60 cm length
Location of Access



Most studies of EVTA discuss access in the
distal thigh or proximal calf
Mid and lower calf avoided due to possible
nerve injury
In patients with GSV reflux to medial
malleolus; above knee EVTA has led to
incomplete resolution of symptoms
– Access above medial malleolus with one or two
access sites, has led to partial or complete
resolution of symptoms
– However, there is a 8% risk of paresthesia
Timperman PE. JVIR 2007; 18: 1495-1499.
Placement of Vascular
Sheath

Pitfalls to reach Saphenofemoral (SFJ)
or Saphenopopliteal junction (SPJ)
– Abrupt caliber changes in target vein
– Valve leaflets
– Acute angulations & tortuosity
– Fenestrations or partial occlusion

What are the solutions?
Placement of Vascular
Sheath

Solutions:
– Angled Vascular
Sheath
– 3 mm curve J
wire
– Angled
hydrophilic wire,
with floppy tip
– Focal palpation
– Straightening leg
Positioning of Tip of
Ablation Device
Flush Ablation
vs
Ablation 1 or 2cm distal to
saphenofemoral junction
-No demonstrated difference in
incidence of DVT or PE
between techniques
-Difference in future recanalization
or recurrence?
Tumescent Anesthesia

Key to procedural success
– Heat sink
– Analgesia
– Compression of vein around ablation device
– 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
Tumescent Anesthesia

Optimizing the tumescent anesthesia
– Use liberal volumes & maximize amount
of tumescent anesthetic
– Use a mechanical pump
Decrease number of needle sticks for patient
 Maximize volume of tumescent
 Minimize repetitive hand injury

– Use dynamic ultrasound guidance to
ensure, accurate deposition of tumescent
Tumescent Anesthesia
Tip: Raise a small bleb with 0.5 cc of 2% Xylocaine
at sites of tumescent puncture, to minimize pain
Compartments of the Thigh
SC, Superficial compartment;
DC, deep compartment.
Endovenous Laser Ablation
Parameters

Pulsed or Continuous Wave
– Continous wave is current standard of practise, due to decreased
risk of adverse events

Fluence
– Quantifys the amount of energy deposited in target vein (J/cm)
– A minimum of 60 to 100 J/cm required to destroy intimae
irreversibly


Mordan et al. Biomed Eng Online 2006;5:26
Wattage
– Variable reports, with no randomized control trials
– 30 W (63J/cm) more effective than 15 W (24 J/cm) with greater
occlusion at 3 months (100% vs 90.3%)
– However, perforations more frequent and carbonisation more
evident at 15 vs 11 W
Adjunctive Procedures



Treating surface branch varicose veins
Key to good outcomes & patient
satisfaction
My personal preference:
– Foam sclerotherapy at time of EVLA

Guidance
– Visual
– Light
– Ultrasound
The End Result!
Conclusions

EVLA has demonstrated excellent short and
mid-term results
– Shorter recovery time
– Decreased recurrence rates
– Decreased post-procedure pain

Technical optimization is critical!!
– Decreased procedure time
– Improved outcomes
– Increased patient satisfaction
For Slides
visit
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