A. KURSAT BOZKURT, MDA. KURSAT BOZKURT, MDUniversity of Istanbul University of Istanbul

Cerrahpasa Medical FacultyCerrahpasa Medical Faculty20112011

Current status of endovenous ablationfor the treatment of venous

insufficiency

Candidates of varicose vein treatmentCandidates of varicose vein treatment

2 billion people > 30 years old2 billion people > 30 years old 20% x 2 billion= 400 million20% x 2 billion= 400 million 1% x 400 million = 4 million1% x 400 million = 4 million

New Fibres in Laser ablation. J-L Gerard. In: Controversies New Fibres in Laser ablation. J-L Gerard. In: Controversies and updates in vascular surgery 2009and updates in vascular surgery 2009

In FranceIn France

Cataract operation: 300 000/yearCataract operation: 300 000/year

High ligation+stripping and/or High ligation+stripping and/or phlebectomy: 200 000/yearphlebectomy: 200 000/year

Truncal varicose veins Truncal varicose veins Current Therapeutic OptionsCurrent Therapeutic Options

SurgerySurgery

Endovenous obliteration Endovenous obliteration proceduresprocedures• LaseLaserr• RadiofrequencyRadiofrequency• SclerotherapySclerotherapy

Surgery!Surgery!NoNott PerfectPerfect Solution Solution

Surgical stripping and ligationSurgical stripping and ligation

LongLong Convalescence Convalescence Spinal or gSpinal or general anesthesiaeneral anesthesia• HospitalizationHospitalization• CosmesisCosmesis

Is Surgery More Curative?Is Surgery More Curative?Success of Vein Stripping & LigationSuccess of Vein Stripping & Ligation

% of patients with no % of patients with no reflux after treatment:reflux after treatment: 91% at 1 year 91% at 1 year 87% at 2 years 87% at 2 years 71% at 5 years71% at 5 years

91% 87%

71%

0%

20%

40%

60%

80%

100%

1 2 5Years

US Varicose Vein Procedures (000)US Varicose Vein Procedures (000)

0

50

100

150

200

250

300

350

2003 2004 2005 2006 2007 2008 2009 2010

Surgery

RF

Laser

Sources: Millennium Research Group, Nov 2005 & MedTech Insight, Oct 7, 2005

Clinical and technical outcomes from a randomized clinical trial of endovenous Clinical and technical outcomes from a randomized clinical trial of endovenous laser ablation compared with conventional surgery for great saphenous laser ablation compared with conventional surgery for great saphenous

varicose veins Carradice D, varicose veins Carradice D, Academic Vascular Surgical UnitAcademic Vascular Surgical Unit, , Hull, UKHull, UK. Br J . Br J Surg. 2011, 98(8):1117-23Surg. 2011, 98(8):1117-23

280 patients were randomized equally 280 patients were randomized equally using sealed opaque envelopes to two using sealed opaque envelopes to two parallel groups: surgery and EVLAparallel groups: surgery and EVLA

The clinical recurrence rate at 1 year was The clinical recurrence rate at 1 year was lower after EVLA: 4.0 versus 20.4 per cent lower after EVLA: 4.0 versus 20.4 per cent (P < 0.001)(P < 0.001)

Rasmussen LH. Br J Surg. 2011;98(8):1079-87Rasmussen LH. Br J Surg. 2011;98(8):1079-87Randomized clinical trial comparing endovenous laser ablation, Randomized clinical trial comparing endovenous laser ablation,

radiofrequency ablation, foam sclerotherapy and surgical stripping for radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose veins.great saphenous varicose veins.

500 consecutive patients (580 legs)500 consecutive patients (580 legs) EVLA (980 and 1470 nm, bare fibre), RF EVLA (980 and 1470 nm, bare fibre), RF

ablation, US-guided foam sclerotherapy or ablation, US-guided foam sclerotherapy or surgical strippingsurgical stripping

The technical failure rate was highest after The technical failure rate was highest after foam sclerotherapy. Both RF and foam foam sclerotherapy. Both RF and foam were associated with a faster recovery and were associated with a faster recovery and less postoperative pain than EVLA and less postoperative pain than EVLA and stripping stripping

Laser or radiofrequency?Laser or radiofrequency?

Radiofrequency Endovenous ClosureFASTversus Laser Ablation for the Treatment of

Great Saphenous Reflux: A Multicenter,Single-blinded, Randomized Study

(RECOVERY Study)Jose I. Almeida, et al. Vasc Interv Radiol 2009; 20:752–759

From March through December 2007 87 veins in 69 patients the ClosureFAST RF catheter or 980-

nm Laser Prospective, randomized, single

blinded Five American sites and one

European site.

EVL group was treated with a 980-nm wavelength in the continuous mode at 12 W of power with a linear endovenous energy density of 80 J/cm.

Vein occlusion and elimination of truncal reflux were achieved in 100% of limbs irrespective of treatment modality at 1 month

Proebstle TM Proebstle TM , , J Vasc Surg. 2011;54(1):146-52J Vasc Surg. 2011;54(1):146-52Three-year European follow-up of endovenous radiofrequency-Three-year European follow-up of endovenous radiofrequency-

powered segmental thermal ablation of the great saphenous vein with powered segmental thermal ablation of the great saphenous vein with or without treatment of calf varicosities.or without treatment of calf varicosities.

A total of 256 of 295 treated GSVs A total of 256 of 295 treated GSVs (86.4%) were available for 36 months of (86.4%) were available for 36 months of follow-up.follow-up.

OOcclusion was 92.6% and the no reflux cclusion was 92.6% and the no reflux was 95.7%, and 96.9% of legs remained was 95.7%, and 96.9% of legs remained free of clinically relevant axial reflux.free of clinically relevant axial reflux.

The average VCSS score improved from The average VCSS score improved from 3.9 ± 2.1 before treatment to 0.9 ± 1.5 at 3.9 ± 2.1 before treatment to 0.9 ± 1.5 at 3 months (P < .0001) and stayed at an 3 months (P < .0001) and stayed at an average <1.0 during the complete 36 average <1.0 during the complete 36 months of follow-up. months of follow-up.

Proebstle TM Proebstle TM , , J Vasc Surg. 2011;54(1):146-52J Vasc Surg. 2011;54(1):146-52

At 36 months, 189 of 255 legs At 36 months, 189 of 255 legs (74.1%) showed an improvement in (74.1%) showed an improvement in CEAP class compared with the clinical CEAP class compared with the clinical assessment before treatment (P < .assessment before treatment (P < .001). 001).

CONCLUSION: RSTA showed a high CONCLUSION: RSTA showed a high and durable success rate in vein and durable success rate in vein ablation in conjunction with ablation in conjunction with sustained clinical efficacy.sustained clinical efficacy.

Our experienceOur experience

In the last 7 years we performed In the last 7 years we performed 2420 EVTA procedures in the 2012 2420 EVTA procedures in the 2012 patients under tumescent patients under tumescent anesthesia. anesthesia.

Only ClosureFAST radiofrequency Only ClosureFAST radiofrequency and endovenous 980-nm laser and endovenous 980-nm laser ablation were carried out. ablation were carried out.

Occlusion rate at 6 months was achieved Occlusion rate at 6 months was achieved in 99.4% with no recanalisationin 99.4% with no recanalisation and and were were not statistical significant different between not statistical significant different between laser and RF laser and RF groups groups

The complete occlusion rates at The complete occlusion rates at 2424 months months were were 95.5% for 95.5% for RFRF and 93.1% for 980 and 93.1% for 980 nm). Most of the non-occluded veins had a nm). Most of the non-occluded veins had a filiform internal lumen and did not show filiform internal lumen and did not show reflux. reflux.

There was significant difference in the There was significant difference in the postoperative appearance of ecchymosis postoperative appearance of ecchymosis in favor in favor of RF of RF (P=0.09). (P=0.09).

Patients treated with Patients treated with RFRF had less induration had less induration around the treated vein (P=0.00around the treated vein (P=0.001818), less need to ), less need to take analgetics (1.take analgetics (1.44 days versus 2. days versus 2.88 days) and days) and had a better postoperative quality of life had a better postoperative quality of life (P=0.018).(P=0.018).

The Venous Clinical Severity Score was The Venous Clinical Severity Score was significantly improved at 6significantly improved at 6 and 24 and 24 months months compared with the baseline onecompared with the baseline one, but not different , but not different between laser and RFbetween laser and RF. .

No serious adverse events except No serious adverse events except one mild pulmonary embolus one mild pulmonary embolus in laser in laser group group were detected. were detected.

Patients treated with the Patients treated with the ClosureFAST catheter experienced ClosureFAST catheter experienced significantly less post-procedure significantly less post-procedure pain, bruising and tenderness when pain, bruising and tenderness when compared to laser ablationcompared to laser ablation

Personel viewPersonel view

LSV + SSV + PerforatorsLSV + SSV + PerforatorsCatheter thermoablation replaced Catheter thermoablation replaced open surgeryopen surgeryPersonel experience > 2000 Personel experience > 2000

patients! patients! Foam is a good option Foam is a good option →→ needs to needs to

prove safety and >5 years efficacy prove safety and >5 years efficacy ? for routine usage (Neurogical ? for routine usage (Neurogical

complications?)complications?)

Peter GloviczkiPeter Gloviczki et al. J et al. J Vasc Surg. 2011 Vasc Surg. 2011 May;53(5 Suppl):2S-48SMay;53(5 Suppl):2S-48S

The care of patients with The care of patients with varicose veins and associated varicose veins and associated

chronic venous diseases: chronic venous diseases: Clinical practice guidelines of Clinical practice guidelines of

the Society for Vascular the Society for Vascular Surgery and the American Surgery and the American

Venous ForumVenous Forum

For treatment of the incompetent great For treatment of the incompetent great saphenous vein (GSV), we recommend saphenous vein (GSV), we recommend endovenous thermal ablation endovenous thermal ablation (radiofrequency or laser) rather than high (radiofrequency or laser) rather than high ligation and inversion stripping of the ligation and inversion stripping of the saphenous vein to the level of the knee saphenous vein to the level of the knee (GRADE 1B).(GRADE 1B).

FFoam sclerotherapy as an option for the oam sclerotherapy as an option for the treatment of the incompetent saphenous treatment of the incompetent saphenous vein (GRADE 2C).vein (GRADE 2C).

To decrease the recurrence of venous To decrease the recurrence of venous ulcers, we recommend ablation of ulcers, we recommend ablation of the incompetent superficial veins in the incompetent superficial veins in addition to compression therapy addition to compression therapy (GRADE 1A).(GRADE 1A).

We recommend phlebectomy or We recommend phlebectomy or sclerotherapy to treat varicose sclerotherapy to treat varicose tributaries (GRADE 1B) tributaries (GRADE 1B)

We recommend against selective We recommend against selective treatment of perforating vein treatment of perforating vein incompetence in patients with simple incompetence in patients with simple varicose veins (CEAP class C2; GRADE varicose veins (CEAP class C2; GRADE 1B), 1B),

WWe suggest treatment of pathologic e suggest treatment of pathologic perforating veins (outward flow duration perforating veins (outward flow duration ≥500 ms, vein diameter ≥3.5 mm) ≥500 ms, vein diameter ≥3.5 mm) located underneath healed or active ulcers located underneath healed or active ulcers (CEAP class C5-C6; GRADE 2B).(CEAP class C5-C6; GRADE 2B).

SOLUTION?SOLUTION?

ENDOVENOUS OBLITERATIONENDOVENOUS OBLITERATION

IF THE SURGEONS DO NOT PERFORM, IF THE SURGEONS DO NOT PERFORM, OTHER SPECIALISTS (RADIOLOGY, OTHER SPECIALISTS (RADIOLOGY, ANGIOLOGY, DERMATOLOGY etc.) ANGIOLOGY, DERMATOLOGY etc.)

ARE READY!!!!ARE READY!!!!

IT IS A PRIVILAGE TO BE IN TURKEY

ASVS – 2013 will be carried out in Turkey

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