Dr Marc Vuylsteke Sint-Andriesziekenhuis Tielt Belgium
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1 Endovenous Laser Treatment of non-gsv truncs Dr Marc Vuylsteke Sint-Andriesziekenhuis Tielt Belgium
2 Superficial venous insufficiency Very common Evolution to chronic venous insufficiency
3 Varicose Disease Reflux in the saphenous vein
4
5
6 Superficial venous insufficiency Incompetent GSV Incompetent SSV Incompetent ASV Incompetent Giacommuni Incompetent perforating veins Others
7 Preoperative duplexmapping
8 Preoperative duplexmapping
9 Preoperative duplexmapping
10 Operative technique 980nm Diode laser (Intermedic)
11 Access to the vein
12
13
14
15
16
17 Localise fibertip
18 Tumescent Anaesthesia Perivenous injection of fluid in the egyptian eye. 300ml Saline+2amp Xylocaine1% +adrenaline QuickTime en een -decompressor zijn vereist om deze afbeelding weer te geven. Saline at 4 C
19 Tumescent anaesthesia Spasm of the vein Better apposition of the fiber to the vessel wall Protection of perivenous tissue, injection of fluid at 4 c
20 Mechanism of action of EVLT Transfer of energy to the vessel wall by steam bubbels results in destruction of endothelium ulcerations and perforations QuickTime en een -decompressor zijn vereist om deze afbeelding weer te geven.
21
22 Vein diameter: 6-8 mm: 60 joules/cm QuickTime en een DV - PAL-decompressor zijn vereist om deze afbeelding weer te geven. vein diameter: 8-10mm: 80 Joules/cm Vein diameter: 10-12mm: 100 Joules/cm Vein diameter> 12mm: 120 Joules/cm
23 Operative technique Trendelenburg position? Manual Compression?
24
25 Complete treatment Foam sclerosis of collateral branches induction of spasm Transivein
26 Complete treatment Muller phlebectomie ligation of perforating veins Bilateral treatment
27 EVT of nonsaphenous veins ASV/SSV: always EVT Vena Giacomuni: EVT Incompetent side branches: only EVT of long nontortuous segments. recurrent varicose veins (after stripping) : revascularisation of the ASV
28 Recurrence of superficial incompetence Post-stripping: revascularisation of the anterior saphenous vein or a double GSV
29 Results: prospective trial September 2004-October patients 447 saphenous veins
30 Prospective trial Controles day 1 1 month 6 months GSV SSV ASV V Giacom Total (24 lost of control) 302(145 lost of control)
31 Occlusion rate (6 months) Total n=302 complete occlusion Partial recanalisation Complete recanalisation GSV (n=259) n=249 96,1% n=8 3,08% n=2 0,77% SSV (n=21) n=17 80,9% n=2 9,52% n=2 9,52% ASV (n=22) n=17 77,2% n=0 0% n=5 22,7% Chi-square:p<0,01
32 Paresthesias Paresthesias + GSV(n=362) n=13 3,59% SSV(n=29) n=3 10,3% ASV(n=34) n=0 0% Chi-square>/=0,1 (no significant difference between the two groups)
33 Why do we have these recanalisations? Energy? Thrombotic occlusion? QuickTime en een Microsoft Video 1-decompressor zijn vereist om deze afbeelding weer te geven. Device problem?
34 High energy treatment October 2005-april 2006 ASV:n=23 SSV: n=23 v. Giacom:n=2 How much energy do we need to prevent recanalisations?
35 Small saphenous vein day 1 1 month 6 months controled pt n=23 n=23 n=22 Complete occlusion n=23 n=22 n=17(77%) Part recan. n=0 n=1 n=5(23%) Compl rec n=0 n=0 n=0
36 Small saphenous vein Mean energy: 81 J/cm Mean Fluency: 51,5 J/cm2 mean fluency tot occlusion group: 57,5J/cm2 mean fluency recanalisation group: 32,4J/cm2
37 vein day 1 1 month 6 months controled pt n=23 n=23 n=20 Complete occlusion n=23 n=22 n=17(85%) Part recan. n=0 n=1 n=2(10%) Compl rec n=0 n=0 n=1(5%)
38 Anterior saphenous vein Mean energy: 85,19 J/cm Fluency=joules/cm2 =energy/3,14x diameter x length Mean Fluency: 47,55J/cm2 mean fluency tot occl group: 55,88 J/cm2 mean fluency rec group: 40,66 J/cm2
39 Energy proposal:fluency: minimal 50J/cm2 energy=50 x 3,14 x diameter energy(j)= 157 x diameter vein of 0,6cm====>94 J/cm
40 Energy High energy treatment is necessary to prevent recanalisations. Even with high energy, recanalisations can occur.
41
42 Catheter design
43 Catheter design bare fiber ====> stretches and hits vein wall====> uneven application of light energy. Ulcerations/perforations/ecchymosis/perivenous tissue damage Loss of energy.
44
45
46 Catheter Design Even application of energy ensures sufficient destruction of the vein wall with lesser energy (and less vein perforations)
47
48 Conclusion ELT is a good alternative for classical treatment in non-gsv truncs. High energy treatment is necessary. Results can ameliorate with new catheter design. Better results in treating GSV
49 Muchas gracias a todos
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