Endovenous Laser Ablation of Varicose Veins
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1 Endovenous Laser Ablation of Varicose Veins Dr Peter Chapman-Smith, FACP, FFMACCS Angela Browne, DMU sonographer GP Conference & Medical Exhibition, Rotorua, 2008
2 Disclaimer This presentation and all research quoted is self funded.
3 You would recognise these. After EVLA
4 Varicose veins may not be obvious
5 You might miss these VVs
6 Skin Lesion Presentation Biopsy scar Varicose eczema
7 Varicose Veins Common (40+ % of population) Many venous symptoms Underdiagnosed Poor cosmesis Long term - Public Rx funding poor ulcers, haemorrhage, eczema
8 Venous symptoms Aching Swelling Restless Legs Syndrome Cramps Burning sensation Itching, eczema Heaviness Tired legs Haemorrhage Ulceration Worse with: standing menses hot weather
9 Vein symptoms do not correlate with vein size.
10 Clinical Signs of VVs Visible veins ( not necessarily) Oedema Eczema Haemosiderin brown staining Ulcers, or scars from healed ulcers CVI telangiectasiae, cyanotic feet Lipodermatosclerosis Atrophie blanche Vulval aching / varices in pregnancy Pelvic congestion syndrome Lipodermatosclerosis
11 High pressure/volume/flow deep system Low pressure/volume/flow superficial system Venous flow downwards, distending vein walls, venous hypertension,... CVI
12 CEAP Classification Class 1: telangiectases and reticular veins Class 2: varicose veins Class 3: oedema Class 4: skin changes without ulceration, eg. eczema, pigmentation Class 5: healed ulcers Class 6: active ulcers GSV: : Great (long) Saphenous Vein SSV: : Small (short) Saphenous Vein Caggiati et al, J Vasc Surg 2002;36:
13 Varicose Veins - Costs Public health cost : 2% healthcare resources Ulcers $185 for years Treat the cause of DVI. Personal cost : Sx: Poor self image, and discomfort: Telangiectasiae, eczema, ulcers, bleeding.? wear shorts, togs, sandals.? housebound.
14 Historical Landmarks Vein Rx st hypodermic syringe- Rynd 1921 Hypertonic saline 1929 Tournay technique 1946 STD, STS, Fibrovein 1961 Polidocanol, Aethoxysclerol 1980 s Echo guided sclerotherapy 1989 Published UGS 1993 Laser fibre guided coagulation 1993 JR Cabrera industrial microfoam CO2 1990s RF ablation, VNUS 2001 Frullini- Cavezzi : duplex foam UGS
15 Treatment for VV s None - Ignore them Compression graduated class 2 hose Surgery - ambulatory phlebectomy, stripping, flush ligation, stab avulsion, endoscopy, morcillation. Sclerotherapy blind injection RF VNUS ELLE - Long catheter UGS External Lasers - poor UGS - foam ultrasound guided sclerotherapy EVLA - endovenous laser ablation Consider Efficacy, cost, recurrence rates, adverse outcomes
16 Assess fully Medical & venous hx FH or PH thrombophilia Examine CW Doppler Duplex US map mandatory? Thrombophilic screen
17 Reflux Augmentation Reflux > 0.5 second 17
18 Duplex map pre EVLA Red: incompetent, reflux Blue: competent flow
19 Non Surgical Options EVLA and UGS Popular Cheaper Quicker procedure, time off work Safer- low VTE risks, no GAs, no nerve damage, no scars Ambulant stat 1st choice most Western countries Repeatable SSV
20 Sclerotherapy - UGS Foreign substance vessel lumen endothelial damage thrombosis, TOTAL FIBROSIS.
21 Endothelial Effects Endothelial cells - swell, slough, spasm stat. Red thrombus forms - vessel wall reaction in 2 hrs, thrombus fills entire lumen within 15hrs. Spontaneous thrombolysis - endogenous /exogenous, and leucocyte migration, phagocytosis. Organising thrombus - Capillaries & fibroblasts develop, granulation, starts 24 hrs, lasts for wks. Endofibrosis - with scarring, partial or complete (6 weeks). Some segments completely resorbed.
22 Foam Ultrasound Guided Sclerotherapy is well established, not a new treatment. European Consensus Meeting 2003 European Consensus Meeting 2003 (25 international experts)
23 Before/after UGS 3yrs post
24 Note prior surgical scars 6 months post UGS
25 Endovenous Laser Ablation (EVLA)
26 Seldinger Technique with US guidance Minimally invasive J guide-wire to below junction (SFJ, SPJ) Catheter over guide-wire Tumescent local anaesthesia Laser fibre tip placed 2 cm distal to junction Position : US, transillumination, saline flush. Relaxed warm patient ideal 26
27 Mark vein to be treated Iodine skin prep 27
28 19g vascular access needle J wire 28
29 Vein Access Aspirate blood 29
30 J wire inserted into access needle 30
31 Catheter sheath with stiffener 31
32 J wire removed & laser fibre inserted 32
33 Tumescent Anaesthesia 1. Local anaesthesia/analgesia 2. Displaces perivenous tissues 3. Heat sink for thermal energy 4. Vein compression to empty vessel 33
34 Saphenous (Egyptian) Eye CFV Saphenous Fascia GSV GSV GSV Deep Fascia
35 Laser fibre in GSV Tumescent LA Saphenous Fascia Needle in fascial compartment
36 EVLA Fibre withdrawal HeNe aiming laser 36
37 Klein formula TA Procedure Data Lignocaine 0.08% + 10mls of NaBicarb 8.4% + 1ml of Adrenaline 1:10001 per litre Infiltrate volume ml Power watts continuous Automated pullback 0.5-1mm/second 37
38 Combined with foam UGS Distal trunks and tributaries Repeat as required days later Air/sclerosant (Fibrovein 3%) ratio 3:1 Cavezzi-Tessari foam technique Clexane SC if thrombophilic risk 38
39 Post EVLA Rx Class 2 compression Ambulate stat, exercise daily Avoid straining, long haul flights Serial duplex US surveillance (objective) Annual patient assessment (subjective) 39
40 Vaporisation Effect High temperatures Threshold reached (2.4kJ/cm2) Water to steam, expands Micro-explosions Vaporisation + coagulation Causes collagen shrinkage 40
41 1320nm
42 Endovenous Laser Ablation Intra/extra fascial veins treated Excellent for SSV (surgery difficult) Minimum mm diameter VV s Patient friendly Safe
43 Competent SFJ 1 mth after EVLA
44 EVLA 68yrs, Ca Prostate, CVI +++, 1 o VVs. Pre Rx 3 months 12 months 2 yrs
45 Same High Risk Patient - EVLA Pre Rx 6 mths 2 yrs 45
46 53 yr farmer, ulcer present 2 yrs. No previous VV Rx. Ulcer pre Rx 3mths post EVLA 6 months post Rx
47 32 yr woman attends 3 day scout camp same day Bilateral EVLA before/6mths post
48 53 yr active female VV surgery 25 yrs prior Before months Note improved quads and tan
49 EVLA 3yr prospective study 2 nd nd prize poster ACP, Tucson, Arizona, USA patients 459 limbs 499 vessels GSV 71.3 % 100 SSV 20 % 43 AASV 8.6 % Follow up attendance rate 83% 49 Updated June 2008
50 Results Patient Self Assessment POST EVLA Year 1 Year 2 Year3 Improvement in symptoms & appearance 100% 100% 100% Would undergo again if necessary 97% 96% 100% Would have preferred to have surgery 1% 2% 0% Would recommend to friends 95% 96% 100% Rated EVLA a successful treatment 96% 98% 100% Any pain 16% 14% 6% 50
51 Sapheno-Femoral Junction - Year 3 EVLA UGS 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Closed Open, competent Open, incompetent
52 Great Saphenous Vein - Year 3 EVLA UGS 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 86 Closed Open, competent Open, incompetent
53 Sapheno-Popliteal Junction - Year 3 Sapheno-Popliteal Junction - Year 1 EVLA UGS 100% 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 56% 63% % 29% 42% % Closed Open, competent Open, incompetent 40 Closed Open, competent Open, incompetent UGS EVLA
54 Small Saphenous Vein - Year 3 EVLA UGS 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Closed Open, competent Open, incompetent
55 Complications of EVLA n = 459 limbs Note * = caused by UGS N numbers Pain 2.6 % 12 STP * 5.2 % 24* Haemosiderin staining * 6.5 % 30* Swelling 2.4 % 11 BK deep vein sclerosis * 0.65 % 3* Tongue of thrombus 0.87 % 4 Ulceration * 0.2 % 1* Sepsis 0.4 % 2 Transient hypoaesthesia * 0.65 % 3* PE 0.2 % 1 DVT, death zero 0 55
56 Disadvantages Laser cost User and patient laser risks Disposable costs ( NZD approx. $650/case) Cost UGS < EVLA < Surgery Day stay theatre cost More trained staff 56
57 Benefits Physiologic result High efficacy and safety No upper size limit veins treatable Popular with patients No scars, no downtime 1320nm less power, less side effects 57
58 Combined EVLA and UGS Safe effective treatment for incompetent varicose vein trunks and tributaries Junctions reduce diameter to function physiologically Need long term efficacy results 58
59 No point just treating what is visible
60 Thanks References available on request. 60
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