Published on September 14, 2014
ENDOVENOUS ABLATION OF VARICOSE VEINS Dr.Saurabh Joshi, MD, FNVIR www.veincenter.in
ABNORMAL FLOW = VENOUS REFLUX • Superficial vein disease always starts with abnormal valves and interruption to normal flow called venous reflux
PATHOGENESIS OF CVI • Changes in the vein wall destruction of valves • Thrombosis • Extra-vascular factors (failure of muscle pump, limited movement in joints, connective tissue disease) • Congenital venous malformations Reflux Obstruction Venous HTN
Venous HTN Failure of Microcirculation Inflammation, dil of capillaries & vessels Soft venous swelling Failure of Lymphatic drainage Tough lymphatic swelling Dil of Capillaries Microthrombi Skin Necrosis Venous Ulcer
INTRODUCTION Lower limb varicose veins are one of the most common vascular problems encountered in practice. The most common site for reflux is great saphenous vein (GSV) . The standard intervention for GSV reflux is Sapheno Femoral junction (SFJ) ligation with GSV stripping. Radiofrequency ablation (RFA),minimally invasive technique, as an alternative to conventional surgery in varicose vein treatment. RFA operates by resistive heating of the vein wall.
DIAGNOSIS OF VENOUS DISEASE Physical exam Appearance Trendelenburg test Palpation Duplex Examination R/O DVT Size of veins Map out superficial veins Locate the site of reflux Reflux 0.5 sec in GSV 1 sec in deep system Find refluxing perforators
CEAP SCORE CATEGORY CLNICAL FEATURES O No visible or palpable signs of venous disease I Telangiectases, reticular veins, malleolar flare II Varicose veins III Edema IV Skin changes ascribed to venous disease V Skin changes in conjunction with healed ulceration VI Skin changes in conjunction with active ulceration
SUBJECTS AND METHODS: Patient selection criteria: Doppler evidence of incompetent SFJ and reflux into GSV for more than 0.5 seconds were included for treatment. Exclusion criteria: 1. Deep venous thrombosis, 2. Deep vein reflux 3. Extremely tortuous GSV identified during pre procedure USG, 4. Inability to ambulate 5. Pregnancy.
CelonLab POWER radiofrequency generator unit Celon AG Medical instruments,Teltow,Germany Power: 20 -250 watts Application Time Impedance control
Bipolar RFITT applicator CelonProCurve 1200-S15 • Diameter: 2 mm • Active length: 15 mm • Flexible shaft: 115 cm • semispherical tip
Vein ablation steps Vein is accessed 6F long sheath over the wire Guide wire is inserted RF probe inserted co-axially Energy delivered over a set period, withdraw cm/sec
GUIDE WIRE INSERTION
PLACEMENT OF SHEATH
POSITION OF SHEATH CONFIRMATION
PROCEDURE DETAILS • PUNCTURE SITE : SITE NO. OF PATIENTS PERCENTAGE ABOVE KNEE 38 58 KNEE 10 15 BELOW KNEE 17 27 • ENERGY : 0.53 – 3.3 KJ. (Average – 1.7KJ) • POWER LEVEL : 20 WATTS • TIME TAKEN : 0.55 – 6.90 min .(Average – 3.30 min) • After ablation single dose of LMWH 40 given SC
RESULTS: Total number of patients : 61 Total number of limbs treated : 65 L (29 ) R ( 36) Age : 24 – 72 yrs . (Average – yrs) Follow up at 1 week, 3 weeks, 90 days and 180 days
• CEAP SCORE : CEAP SCORE NO. OF LIMBS PERCENTAGE 2 18 3 14 20 4 12 18 5 5 7 6 16
RESULTS : 1 WK F/U • Out of 65 veins , follow up at 1 week – 65 veins Thrombosis of ablated segment – 65 Complications : Thrombus prolapsing into FV- 1 Thrombophlebitis – 1 Segmented fluid collection in vein – 1
RESULTS : 3 WK F/U • Follow up at 3 weeks – 56 veins • All had thrombosed GSV • Perforators were as they were – mostly below knee
LATER F/U Follow up at 90 days – 39 veins No recanalizations Follow up at 180 days – 30 veins No recanalizations One patient for whom the short saphenous vein was ablated, had complete recanalization at 12 months
Presentation 3 weeks 90 days
Presentation 3 weeks 90 days
CONCLUSION: • Endovenous ablation is a safe, effective and preferred alternative to the surgical procedures in the treatment of the varicose veins.
• Contact : • Dr.Saurabh Joshi : +919967368256 ( Mon – Sat, 9:00 – 19:00, India Standard Time) • firstname.lastname@example.org
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