endoluminal radiofrequency ablation and endovenous laser therapy for the treatment of varicose...

Endoluminal radiofrequency ablation and Endovenous laser therapy for the treatment of Varicose Veins: techniques and outcomes

Endoluminal radiofrequency ablation and Endovenous laser therapy for the treatment of Varicose Veins: techniques and outcomes

Bola Pratt P&S MS 4

- Clarify the indications for performing RFA and EVLT.

- Explain the mechanisms, methods, of RFA and EVLT.

- Outcomes of RFA and EVLT: response to treatment and complications

American Venous ForumFebruary of 1994 and the creation of CEAP

klöf B, Rutherford RB, Bergan JJ, Carpentier PH, Gloviczki P, Kistner RL, Meissner MH, Moneta GL, Myers K, Padberg FT, Perrin M, Ruckley CV, Smith PC, Wakefield TW; American Venous Forum International Ad Hoc Committee for Revision of the CEAP Classification. Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg. 2004 Dec;40(6):1248-52. Review.

Bola Pratt P&S MS 4

Somewhere in Maui, Hawaii

Indications for EVLT or RFA: lessons from the American Venous Forum

February of 1994 and the creation of CEAPClinical C0: No visible or palpable signs of venous disease C1: telangiectases or reticular veins C2: varicose veins C3: edema C4: skin changes ascribed to venous disease a. pigmentation or eczema b. lipodermatosclerosis or atrophie blanche C5: skin changes as defined previously with healed ulcer C6: skin changes as defined previously with active ulcer Etiologic: congenital, primary, secondary or noneAnatomic: superficial, perforator, deepor nonePathophysiologic: reflux, obstruction, both or none


Bola Pratt P&S MS 4

Most Common

Endoluminal radiofrequency ablation (RFA) of the great saphenous vein:

mechanism

Bola Pratt P&S MS 4

Puggioni A, Kalra M, Carmo M, Mozes G, Gloviczki P. Endovenous laser therapy and radiofrequency ablation of the great saphenous vein: analysis of early efficacy and complications.J Vasc Surg. 2005 Sep;42(3):488-93.

- By directing resistive radiofrequency energy through a vein, a narrow rim of tissue less than 1mm is heated by an electrode. - The amount of heating is modulated using both a microprocessor and manual movement, resulting in controlled collagen contraction, thermocoagulation and absorption of the vein.

Endoluminal radiofrequency ablation of the great saphenous vein: methods

Photograph courtesy of VNUS medical Technologies, San Jose, CA.

Percutaneous access to the greater saphenous vein most commonly at the level of the knee under duplex ultrasound guidance

Bola Pratt P&S MS 4

Endoluminal radiofrequency ablation of the great saphenous vein: methods

Photographs courtesy of VNUS medical Technologies, San Jose, CA.

1) A guidewire is then advanced to the saphenofemoral junction over which the closure catheter is passed

2) catheter prongs are extruded tocontact the intimal lining of the vessel wall

3) radiofrequency generator allows the tip of the catheterand the prongs to attain a temperature of 85 degrees C.

CFA = common femoral arteryCFV = common femoral veinSEV= superficial epigastric veinSFJ = saphenofemoral junction

Bola Pratt P&S MS 4

Endoluminal radiofrequency ablation of the great saphenous vein: results

Bola Pratt P&S MS 4

1) Vein occlusion at 1 week documented by venous ultrasound success rate of 98%

2) None of the treated patients developed recanalization that was not seen at 6 weeks, with a successful outcome in 90%.

3) At the 24 month follow-up, 19 of 21 patients had complete disappearance of the treated saphenous vein, for a success rate of 90%.

4) Side effects were minimal, and no skin burns or thromboses were observed.

Weiss RA, Weiss MA. Controlled radiofrequency endovenous occlusion using a unique radiofrequency catheter under duplex guidance to eliminate saphenous varicose vein reflux: a 2-year follow-up.Dermatol Surg. 2002 Jan;28(1):38-42.

Endovenous laser therapy (EVLT): mechanism

Bola Pratt P&S MS 4

Proebstle TM, Lehr HA, Kargl A, Espinola-Klein C, Rother W, Bethge S, Knop J. Endovenous treatment of the greater saphenous vein with a 940-nm diode laser: thrombotic occlusion after endoluminal thermal damage by laser-generated steam bubbles.

J Vasc Surg. 2002 Apr;35(4):729-36.

- Thermal reaction after laser exposure is essential.

- Damages endothelial, intimal internal elastic lamina, and to some degree the media. Adventitia is rarely affected. - In vitro studies suggest that energy results in ‘boiling of blood’ and and generation of ‘steam bubbles’ that indirectly, homogenously affect the varicose vein.

Endovenous laser therapy: methods

van den Bos RR, Kockaert MA, Neumann HA, Nijsten T.Technical review of endovenous laser therapy for varicose veins. Eur J Vasc Endovasc Surg. 2008 Jan;35(1):88-95. Epub 2007 Oct 24. Review.

Bola Pratt P&S MS 4

1) GSV entered at the knee2) Guidewire passed through hollow needle into the vein can be difficult if:

a. tortuosities b. local venous spasmc. sclerotic fragments

3) Needle removed4) 3mm cutaneous incision made5) Introducer sheath placed over guide wire6) Guidewire removed when at the SFJ7) Longitudinal US visualization of sheath 1-2 cm distally to the SFJ

Endovenous laser therapy and radiofrequency: methods


Bola Pratt P&S MS 4

Tumescent anesthesia (5 ml epi, 5 ml bicarb, 35ml 1% lidocaine in 500ml saline) is administered to the perivenous space resulting in

a) reduction in pain

b) protection of perivenous tissue through cooling

c) increase in surface area of laser tip and vein wall

Endovenous laser therapy and radiofrequency: specifics

Bola Pratt P&S MS 4

Pulsed vs. continuous:pulsed mode is associated with higher adverse events

Wavelengths:Higher wavelengths (1320nm) reported less

postoperative pain, and less likely to have ecchymoses

Fluence (J/ cm2):Single most important parameter to quantifyabove 60-100 J/ cm2 for durable GSV occlusion

Wattage:high, short duration wattage vaporizing effectlow prolonged wattage coagulating effect

Pullback Speed:if performed at fixed wattage then energy is solely

dependent on pullback speed

Endovenous laser therapy and radiofrequency: results

Bola Pratt P&S MS 4

Puggioni A, Kalra M, Carmo M, Mozes G, Gloviczki P. Endovenous laser therapy and radiofrequency ablation of the great saphenous vein: analysis of early efficacy and complications. J Vasc Surg. 2005 Sep;42(3):488-93.

Pretreatment: an incompetent SFJ

Posttreatment: occlusion of GSV

Endovenous laser therapy and radiofrequency: results

Bola Pratt P&S MS 4


EVLT vs. RFA of the great saphenous vein: outcomes, complications

Bola Pratt P&S MS 4

EVLT

RFA

Burden of repeated treatment and complications

?

Indications for EVLT or RFA: lessons from the American Venous Forum

February of 1994 and the creation of CEAPClinical C0: No visible or palpable signs of venous disease C1: telangiectases or reticular veins C2: varicose veins C3: edema C4: skin changes ascribed to venous disease a. pigmentation or eczema b. lipodermatosclerosis or atrophie blanche C5: skin changes as defined previously with healed ulcer C6: skin changes as defined previously with active ulcer Etiologic: congenital, primary, secondary or noneAnatomic: superficial, perforator, deepor nonePathophysiologic: reflux, obstruction, both or none


Bola Pratt P&S MS 4

Most Common

Puggioni et al 2005: Retrospective review of 92 patients, 130 limbs

EVLT RFA

All had: symptomatic varicose veins by CEAP criteriaWomen

Clinical Presentation: C2-4Etiology: primary

Veins of all sizes: 14 W; 810nm; 3mm/s withdrawing speed

Veins 2 - 12mm: Temp 82- 90; 3cm/min withdrawing speed

Bola Pratt P&S MS 4

Puggioni A, Kalra M, Carmo M, Mozes G, Gloviczki P. Endovenous laser therapy and radiofrequency ablation of the great saphenous vein: analysis of early efficacy and complications. J Vasc Surg. 2005 Sep;42(3):488-93.

EVLT and RFA analysis of early complications: Puggioni et al 2005


Bola Pratt P&S MS 4

Puggioni et al 2005 conclusion


Bola Pratt P&S MS 4

- EVLT was associated with a somewhat higher occlusion rate, but post-op complications were more frequent

- All patients should undergo early post-operative duplex to rule out proximal extension of thrombus, exclude distal DVT, and confirm occlusion

RFA and DVT analysis: Hingorani et al 2004

Hingorani AP, Ascher E, Markevich N, Schutzer RW, Kallakuri S, Hou A, Nahata S, Yorkovich W, Jacob T. Deep venous thrombosis after radiofrequency ablation of greater saphenous vein: a word of caution.

J Vasc Surg. 2004 Sep;40(3):500-4.

- DVT in 12 limbs (16%)

- no difference in DVT between men and women

- catheter size: no difference in DVT

- anesthesia: no difference in DVT

- higher incidence of DVT with RFA and vein excision

Summary

P&S

- EVLT and RFA are associated with a high degree of success with minimal side effects most of which can be prevented or minimized with minor modifications of technique.

- All patients should undergo early post-operative duplex to rule out proximal extension of thrombus, exclude distal DVT, and confirm occlusion.

- The advantage EVLT has over RFA is the lower cost per patient and possibly faster treatment than RF closure.

References


Proebstle TM, Lehr HA, Kargl A, Espinola-Klein C, Rother W, Bethge S, Knop J. Endovenous treatment of the greater saphenous vein with a 940-nm diode laser: thrombotic occlusion after endoluminal thermal damage by laser-generated steam bubbles.J Vasc Surg. 2002 Apr;35(4):729-36.



Weiss RA, Weiss MA. Controlled radiofrequency endovenous occlusion using a unique radiofrequency catheter under duplex guidance to eliminate saphenous varicose vein reflux: a 2-year follow-up.Dermatol Surg. 2002 Jan;28(1):38-42.

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endoluminal radiofrequency ablation and endovenous laser therapy for the treatment of varicose...

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