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CHOOSING THE APPROPRIATE TRUNCALVEIN CLOSURE DEVICE
Steve Elias MD FACSDirector, Center for Vein Disease
Director, Wound Care CenterEnglewood Hospital and Medical Center NJ
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THE ANSWER:
• The one that works
• The one you are familiar with
• The one you own
• The least expensive
• None of the above
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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
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Choices: 2014
• 810 nm• 940 nm• 980 nm• 1320 nm• 1470 nm• Radiofrequency• Polidocanol Endovenous Microfoam • Mechanochemical – MOCA• Cyanoacrylate glue• Steam• V Block
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Occlusion Devices: Two Categories*
• TT (Thermal, Tumescent)
• NTNT (Non Thermal, Non Tumescent)
*Elias S. Emerging Endovenous Technologies. Endovasc Today. March 2014.
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Thermal Tumescent: TT
• Laser – HSLW, WSLW, radial/jacketed, etc
• Radiofrequency
• Steam – not in US
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Non Thermal, Non Tumescent: NTNT
• Mechanochemical
• Cyanoacrylate glue
• Polidocanol Endovenous Microfoam
• V Block
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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
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SIZE
• Big (>12mm) – TT
• Small – NTNT or TT
• Really big – TT, SFJ/SPJ ligation?
• Really small – NTNT or “should I do this?”
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LENGTH
• Short segment – RF 3 cm, laser, foam, MOCA
• Short – maybe not CAG (cost?)
• Long - anything
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LOCATION
• AK – anything
• BK GSV and SSV – NTNT before TT
• Suprafascial – MOCA, TT but consider skin/ cord, hyperpig
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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
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PATIENT TYPE
• Fat – TT over NTNT
• Thin – NTNT over TT
• Anxious, Nervous – NTNT over TT
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ANTICOAGULATION
• INR 2.0 – 2.5 – anything
• INR > 2.5 - TT
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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
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CONCLUSIONS
• Need one TT and one NTNT
• Tailor the technique to the situation
• All veins are not the same