Endovenous laser ablation
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Endovenous laser ablation Endovenous laser ablation Presentation Transcript

  • EndoVenous Laser Ablation DR DILIP S.RAJPAL MS, MAIS, FICS(USA), FMAS, Dipl. In Laproscopic surgery, Fellow in Robotic & Adv Lap. Colo-Rectal Surgery (korea univ.) CONSULTANT GEN. SURGEON LAPROSCOPIST & COLOPROCTOLOGIST HON. SURGEON NOVA MEDICAL CENTER HON. SURGEON GODREJ MEMORIAL HOSPITALHON. ASS PROF GRANT MED.COLLEGE & HON. SURGEON JJ HOSPITAL EX-ASST. PROF L.T.M.GEN. HOSPITAL
  • Definition  Telangiectasias - are a confluence of dilated intradermal venules less than one millimeter in diameter.  Reticular veins - are dilated bluish subdermal veins, one to three millimeters in diameter. Usually tortuous.  Varicose veins - are subcutaneous dilated veins three millimeters or greater in size. They may involve the saphenous veins, saphenous tributaries, or nonsaphenous superficial leg veins.DR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Abnormal Veins Telangiectasias Varicose vein Reticular veinsDR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & View slide
  • Common Questions  Are they dangerous?  How do they form?  Why does it happen?  Did I inherit it?  What tests can we use?  What treatments are available?DR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & View slide
  • Superficial veins Great saphenous – formed by the union of the dorsal digital vein of the great toe and the dorsal venous arch.  Ascends anterior to the medial malleolus, posterior to the medial condyle of the femur. It freely communicates with the small saphenous vein.  Proximally it traverses the saphenous opening in the fascia to enter the femoral vein.DR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Small saphenous vein  Formed by the union of the dorsal digital vein of the 5th digit and distal venous arch.  Runs posterior to the lateral malleolus, lateral to the calcaneal tendon.  Runs superiorly medial to the fibula and penetrates the deep fascia of the popliteal fossa, ascends between the heads of the gastrocnemius muscle to join the popliteal vein.DR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Perforating veins  Penetrate the deep fascia, tributaries of the saphenous veins, valves are located just distal to penetration of the deep fascia.  Veins cross the deep fascia obliquely  Muscle contraction causes the valves to close prior to venous compression so blood is forced proximally (musculo-venous pump).DR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Deep Veins  Usually paired with named arteries inside a vascular sheath, this allows arterial pulsation to force blood proximally.  The popliteal vein joins the femoral vein in the popliteal fossa  Femoral vein is joined by the deep vein of the thigh. The femoral vein passes deep to the inguinal ligament to become the external iliac vein.DR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Etiology  Reflux 80%  Venous obstruction 18-28%  Resultant edema and skin changes = Postthrombotic syndrome  Muscle Pump DysfunctionDR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Stasis Pathophysiology  Usually associated with venous incompetence  Primary and secondary reflux  Edema  Vein wall dilatation  Inflammation/Pigmentation (Hemosiderin deposits)  “Fibrin cuffing”  UlcerationDR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Risk factors  Age: Aging causes wear and tear. Eventually, that wear causes the valves to malfunction.  Sex: Women > Men. Hormonal changes during pregnancy or menopause. Progesterone relaxes venous walls. OCP may increase the risk of varicose veins.  Genetics  Obesity: Increases venous HTN.  Standing for long periods of time. Prolonged immobile standing impairs venous return.DR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Strong familial component  Not well studied  Twin studies 75% identical, 52% non identical  If both parents VVS - 90% of children VVs  If one parent was affected 25 percent for men and 62 percent for womenDR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Symptoms  Achy or heavy feeling, burning, throbbing, muscle cramping and swelling.  Prolonged sitting or standing tends to intensify symptoms.  Pruritis  Painful skin ulcersDR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Complications  Extremely painful ulcers may form on the skin near varicose veins, particularly near the ankles.  Brownish pigmentation usually precedes the development of an ulcer.  Occasionally, veins deep become enlarged.  Bleeding  Superficial thrombophlebitisDR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • 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 Most a. pigmentation or eczema Common b. lipodermatosclerosis or atrophie blanche C5: skin changes as defined previously with healed ulcer C6: skin changes as defined previously with active ulcerEtiologic: congenital, primary, secondary or noneAnatomic: superficial, perforator, deepor nonePathophysiologic: reflux, obstruction, both or none
  • Patient Assessment  History  History of symptoms and onset  History of venous complications  Desire for treatment  Comorbidities  Rule out secondary cause including DVT and HEART Failure  Examination  Patient in general  Pedal pulses  Groins  Veins Trendelenburg Test Venous claudicationDR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Investigation  All get a Duplex scan  Examines – Deep veins – Superficial veins – Incompetence and patency Other Tests Physiologic testing Phlebography Intravascular UltrasoundDR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Duplex scan  Vast majority have superficial incompetence only.  Sensitivity 95 % for identifying the competence of the saphenofemoral and saphenopopliteal junctions.  Less sensitive for identifying incompetent perforators (40 to 60 percent) .DR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Treatment  Conservative Leg elevation Exercise Compression stockings Treatment of other underlying conditions NothingDR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Vein ablation therapies Classified by method of vein destruction: 1. Chemical (sclerotherapy) 2. Thermal (laser or endovenous ablation) 3. Mechanical (surgical excision or stripping)DR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Who gets sclerotherapy  Small non-saphenous varicose veins (less than 5 mm),  Perforator veins  Residual or recurrent varicosities following surgery  Telangiectasia  Reticular veinsDR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Who gets Sclerotherapy  Who else – Good control with Trendelenburg – Recurrent veins – Frail with resistant/healed ulcersDR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Sclerosing Agents  Sodium tetradecyl sulfate  Hypertonic Saline  Polidocanol  Monoethanolamine oleate  Glucose combinations  Damage endothelium leading to thrombosis of the vein.  Pressure to try and reduce the amount of thrombus.DR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Microsclerotherapy  30 g butterfly needle  0.2% STD  Several courses required benefit compressionDR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • TelangiectasiasDR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Foam Sclerotherapy  1:4 Sclerosant (1% or 3%): Air  Why foam? – Induces spasm – Disperses further – Enhanced sclerosis Breu, FX, Guggenbichler, S. European Consensus Meeting on Foam Sclerotherapy, April, 4-6, 2003, Tegernsee, Germany. Dermatol Surg 2004; 30:709.DR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • DR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Spider veinsDR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Foam Sclerotherapy: Complications  Phlebitis  Skin staining  Failure  Residual lumps  Matting  Embolus (CVA)  DVT  Ulceration (rare)  Anaphylaxis (very rare)DR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Foam Sclerotherapy Results  Variable depending on series  Long-term recurrence rates are as high as 65 percent in five years, however, patients can also be retreated when veins recur  Large veins can be a problem  Currently randomized trialDR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Catheter-based Treatments  Endovenous laser EVLA  Radiofrequency ablation RFA  Primarily to treat saphenous insufficiency (great or small)  EVLA and RFA, are equally efficacious & have similar recanalization rates.DR DILIPEndovascular Surg 2008; 42:235. JT. High ligation of the saphenofemoral junction in endovenous obliteration of varicose RAJPAL Boros, MJ, OBrien, SP, McLaren, JT, Collins, veins. VascCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Radiofrequency ablation Radiofrequency ablation devices (ClosureFast™, RFiTT®, ClosureRFS™) generate a high frequency alternating current in the radio range of frequency.DR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Mechanism RFA - 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.DR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Endoluminal radiofrequency ablation of the great saphenous vein: methods Percutaneous access to the greater saphenous vein most commonly at the level of the knee under duplex ultrasound guidanceDR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Endoluminal radiofrequency ablation of the great saphenous vein: methods 1) A guidewire is advanced to the SF junction over which the closure catheter is passed 2) catheter prongs are extruded to contact the intimal lining of the vessel wall 3) radiofrequency generator allows the tip of the catheter and the prongs to attain a temperature of 85 degrees C.DR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Varicose veinsDR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Endovenous LaserDR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Endovenous Laser  Devices (EVLT®, ClosurePlus™)  Use a bare tipped optical fiber which applies laser light energy to the vein.  Therapy based on photothermolysis (light induced thermal damage).  Laser light heats the target tissue inducing thermal injury  Wavelength of light is chosen based on the target structures chromophore. Bush, RG, Shamma, HN, Hammond, K. Histological changes occurring after endoluminal ablation with two diodeDR DILIP RAJPALCONSULTANT GEN. SURGEON changes to 4 months. Lasers Surg Med 2008; 40:676. lasers (940 and 1319 nm) from acuteLAPROSCOPIST &
  • Endovenous laser therapy (EVLT): mechanism - 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 generation of ‘steam bubbles’ that indirectly, homogenously affect the varicose vein.DR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Endovenous laser therapy: methods1) GSV entered at the knee2) Guidewire passed through hollow needle into the veincan be difficult if: a. tortuosities b. local venous spasm c. sclerotic fragments3) 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 tothe SFJ
  • Endovenous laser therapy and radiofrequency: methodsTumescent anesthesia (5 ml epi, 5 ml bicarb, 35ml1% lidocaine in 500ml saline) is administered to theperivenous space resulting ina) reduction in painb) protection of perivenous tissue through coolingc) increase in surface area of laser tip and vein wall
  • Wavelengths of light used for venous laser therapyDR DILIP RAJPALCarmo, M, et al. Extension of saphenous thrombus into the femoral vein: a potential complication of new endovenous Mozes, G, Kalra, M,CONSULTANT GEN. SURGEON ablation techniques. J Vasc Surg 2005; 41:130.LAPROSCOPIST &
  • Endovenous laser therapy and radiofrequency: specificsPulsed vs. continuous: pulsed mode is associated with higher adverse eventsWavelengths: Higher wavelengths (1320nm) reported less postoperative pain, and less likely to have ecchymosesFluence (J/ cm2): Single most important parameter to quantify above 60-100 J/ cm2 for durable GSV occlusionWattage: high, short duration wattage vaporizing effect low prolonged wattage coagulating effectPullback Speed: if performed at fixed wattage then energy is solely dependent on pullback speed
  • Surface laser therapy  Telangiectasias, reticular veins and small varicose veins <5mm  Not used for larger varicose veinsDR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Post op care  Graduated compression stockings are worn following the procedure.  F/U duplex ultrasound is performed within one week to evaluate for thrombus in the common femoral vein.  Pt recovery averages two and four days  Significantly shorter interval than is seen with surgical ligation and strippingDR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Endovenous complications  Pain, bruising, hematoma  Skin changes: burns, induration, pigmentation, matting, dysesthesia, & superficial thrombophlebitis.  Nerve injury  DVT  Wound infectionMozes, G, Kalra, M, Carmo, M, et al. Extension of saphenous thrombus into the femoral vein: a potential complication of new endovenous ablationDR DILIP RAJPAL 41:130.techniques. J Vasc Surg 2005;CONSULTANT GEN. DE Roos, SP, Nijsten, T. Endovenous laser ablation-induced complications: Review of the literature and newVAN DEN Bos, RR, Neumann, M, SURGEONLAPROSCOPISTcases. Dermatol Surg 2009; &
  • Which is Better ???  Endoluminal thermal ablation versus stripping of the saphenous vein: Meta- analysis of recurrence of reflux.  ES Xenos, G Bietz, DJ Minion, et alDR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Endoluminal thermal ablation versus stripping of the saphenous vein: Meta-analysis of recurrence of reflux.  Method: Systematic search of Medline/Pubmed, OVID, EMBASE, CINAHL, Clinicaltrials.gov and Cochrane central register  1966-2009 in all lanuagesDR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Method  Randomized prospective clinical trials with > 365 days f/u.  Analyzed outcomes included recurrence of varicosities and reflux, as documented by duplex ultrasound, and recurrence of signs and symptomsDR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Results  8 randomized controlled trials were included  497 patients total  226 L/S  271 endoluminal thermal ablation  F/U 584 SD182 days.DR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Conclusion  Catheter-based treatments and traditional venous stripping with high ligation have similar long-term results  Catheter-based treatments have a decreased post op pain, shorter recovery time to work and normal activity.DR DILIP RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST &
  • Questions ?