choosing the appropriate truncal vein closure device

CHOOSING THE APPROPRIATE TRUNCALVEIN CLOSURE DEVICE

Steve Elias MD FACSDirector, Center for Vein Disease

Director, Wound Care CenterEnglewood Hospital and Medical Center NJ

THE ANSWER:

• The one that works

• The one you are familiar with

• The one you own

• The least expensive

• None of the above

CONSIDERATIONS:

• Size – big, small• Length - short• Location – AK, BK, Suprafascial• Multiple veins – GSV, SSV, AAGSV• Disease state – C5, C6, SVT• Patient type – fat, thin, anxious, friend, foe• Special – MD, spouse of MD, attorneys

Choices: 2014

• 810 nm• 940 nm• 980 nm• 1320 nm• 1470 nm• Radiofrequency• Polidocanol Endovenous Microfoam • Mechanochemical – MOCA• Cyanoacrylate glue• Steam• V Block

Occlusion Devices: Two Categories*

• TT (Thermal, Tumescent)

• NTNT (Non Thermal, Non Tumescent)

*Elias S. Emerging Endovenous Technologies. Endovasc Today. March 2014.

Thermal Tumescent: TT

• Laser – HSLW, WSLW, radial/jacketed, etc

• Radiofrequency

• Steam – not in US

Non Thermal, Non Tumescent: NTNT

• Mechanochemical

• Cyanoacrylate glue

• Polidocanol Endovenous Microfoam

• V Block

Modern Era of Endovenous Ablation: MEEVA

• Percutaneous, outpatient, local anesthesia

• TT:• RF/Laser - >90% ablation rate @ 4yrs• Steam - >90% at 1 year (Europe)

• NTNT : • MOCA – 95% ablation at >2 years• Foam – 85% at 2 years• Glue – 95% at 1 years• V Block – 100% at 4 months

SIZE

• Big (>12mm) – TT

• Small – NTNT or TT

• Really big – TT, SFJ/SPJ ligation?

• Really small – NTNT or “should I do this?”

LENGTH

• Short segment – RF 3 cm, laser, foam, MOCA

• Short – maybe not CAG (cost?)

• Long - anything

LOCATION

• AK – anything

• BK GSV and SSV – NTNT before TT

• Suprafascial – MOCA, TT but consider skin/ cord, hyperpig

DISEASE STATE

• C5, C6 – AK GSV & BK GSV – TT or NTNT

• C5, C6 – BK GSV residual – retrograde NTNT and foam ulcer bed (MOCA) tumescence an issue

• Previous SVT – TT – need more energy

PATIENT TYPE

• Fat – TT over NTNT

• Thin – NTNT over TT

• Anxious, Nervous – NTNT over TT

ANTICOAGULATION

• INR 2.0 – 2.5 – anything

• INR > 2.5 - TT

SPECIAL SCENARIOS

• MD or Spouse – RF, MOCA

• Friend – RF, WSLW (1470), MOCA

• Foe – HSLW (810/980) or stripping

• Attorney – 810/980 with 150 joules/cm and no tumescence

CONCLUSIONS

• Need one TT and one NTNT

• Tailor the technique to the situation

• All veins are not the same