1. The document discloses that Dr. Elias has financial relationships as a consultant for Covidien Inc. and Vascular Insights LLC. 2. It provides information on the anatomy of the small saphenous vein and discusses techniques for endovenous laser ablation of the small saphenous vein, including access points, positioning, and avoiding injury to nerves. 3. Potential complications of endovenous laser ablation of the small saphenous vein discussed include nerve injury and deep vein thrombosis.

1. Disclosure
Steve Elias M.D.
I disclose the following financial relationship(s):
•Consultant/Advisory Board: Covidien Inc,
Vascular Insights LLC

2. Steve Elias MD FACS FACPh
Director,Vascular SurgeryVein Programs
NY Presbyterian Hospital
Columbia University Medical Center
Assistant Professor of Surgery
Columbia University NY

3. “The Treachery of Images”: Rene Magritte

5.  Veins
 Sources of problems
 Occlusion is goal
 Thermal, mechanical, chemical

6.  Anatomy
 Pathophysiology
 Treatment technique
 Complications

7.  Access points
 Positioning at SPJ
 Tumescence placement
 Distal points of treatment
 Avoid Injury - nerves, skin, DVT

9. 1.Giacomini’s vein
2.Profunda
Femoris vein
3.Perforating veins
from lateral thigh
4.Anterior lateral
branch of the
GSV

10. 1. GSV
2. Giacomini’s
vein
3. Calf plexus
4. SSV
5. communicating

11.  Variable termination vs. GSV
 Popliteal fossa - 70% time
 Femoral vein - 25%
 Below popliteal fossa - 5%
 Intersaphenous vein - branch to GSV
 Thigh Extension (TE) of SSV – no
popliteal connection
Cavezzi A et al. Duplex ulrasound investigation of the veins
In chronic venous disease - UIP Consensus Document.
Part II. Anatomy. Phlebology 2006;21:168-179.

12. Gibson KD et al. Endovenous laser treatment of the short
saphenous vein: Efficacy and complications. JVS 2007;
45:795-803.

13.  VV - Calf (SSV) and medial thigh
varicosities (GV) or TE of SSV
 Diameter – Elias 5.8 mm
- Kontothanassis 6.4 mm*
 VV - due to SSV 20% of the time**
**Gibson KD et al. Endovenous laser of the short saphenous
vein: Efficacy and complications. JVS 2007;45:795-803.
*Kontothanassis et al. Endovenous laser ablation of
SSV. JVS. April 2009

14.  Distal access - sural nerve
 Proximal positioning - nerves and PV
 Skin and nerve concerns

16. *King, T. Can saphenous and sural nerve
parathesia be prevented during ELT. Abstract
EVF 2010

18.  Sciatic nerve divides
into the tibial and
common peroneal
nerves, proximal to the
knee
 Peroneal crosses
posterior to lateral
head of
gastrocnemius, and
becomes
subcutaneous behind
head of fibula

19. Tibial Nerve
Anatomy
Popliteus muscle
Gastroc heads
Soleus muscle
Plantaris muscle

22.  Sural nerve - Kontothanassis – 2.2%
- Gibson - 1.6%
- Wang - 2%
- Huisman - 1.3%
- King – 0%
Inferior border gastroc and tumescence
Kontothanassis D. et al. Endovenous laser treatment of the
small saphenous vein. JVS April 2009
Huisman et al. Endovenous laser ablation of SSV:
Prospective analysis 150 patients. VascEndovasc Surg 2009

23.  Tibial nerve injury - plantar “push”
 Runners, jump etc. walking OK
 Visualize tibial nerve
 Higher nerve injury with open tx
 SPJ - Fascial curve (2-3cms avg.2.8 cm)
 Tumescence to push SPJ/Nerves deeper

24.  Range - 0% - 5.7%
 Ravi - 0% *
 Elias - 0.8%
 Kontothanassis – 0%
 Gibson - 5.7% (close to junction?)
 VV Surgery - 5.3% *
*Ravi R et al. Endovenous ablationof saphenous veins:a large
single center experience. J Endovasc Ther 2006;13:244-8
*Van Rij et al. Incidence of deep vein thrombosis after varicose
vein surgery. Br J Surg 2004;91:1582-85

25.  Distal - inferior border of gastrocnemius
muscle (sural nerve) ZOC
 Proximal - “fascial curve”2-3 cms. SPJ
(2.8 cm)*
 Perivenous tumesence - push sural nerve
and tibial nerve away
 Skin protection - 1-2 cms.
 Energy - same as GSV
*Wang XJ, Elias SM. Small saphenous vein ablation:
Reasons, risks,results. Poster session, AVF Annual
Meeting 2/07; San Diego , CA.

26.  15 - 20 % of all
litigation cases involve
nerve injury
 Even MIVS can cause
nerve injury
 Temporary or
permanent

27.  Nerve injury - tumescence and anatomy
awareness
 Nerve injury – not treatable and can be
permanent
 DVT - lower occurrence with proper
technique
 DVT - Treatable and temporary
 All may change with non thermal techniques
 Chemical, MOCA, Cyanoacrylate glue