1. Endo-venous laser ablation of small saphenous veinBy
Dr. Sohiel M.Ayman
2016

2. Agenda Introduction Aim of the study Patients & methods Procedure
Results
Conclusion
Discussion

3. Introduction
Small saphenous vein (SSV) reflux is an important and often overlooked cause of superficial venous insufficiency.
It is present in about one-sixth of patients with superficial venous insufficiency.
And its manifestations are often confused with reflux in the great saphenous vein (GSV).

4. Anatomy of superficial veins of the lower limb

5. Small Saphenous Vein (SSV)
Courses from lateral aspect of the ankle up to posterior aspect of the calf muscle.
Terminates in popliteal fossa at Saphenopopliteal Junction (SPJ) Variable confluence with Popliteal Vein (PV)
Proximal portion lies between superficial & deep fascial layers
SPJ
Pop V
SSV

6. ANATOMY
Knowledge of the precise anatomy of an incompetent pathway is crucial to the success of its treatment.
Sural nerve runs adjacent to the SSV at the inferior border of the gastrocnemius muscle and is more caudal, lateral and deeper than the SSV above this level.

7. Treatment
The goal of small saphenous ablation techniques is the same as great saphenous ablation:
“ permanent closure of the vein without complications.”
Course, Anatomic landmarks, Draining veins, Branches, and surrounding Nerves are unique and clearly different than the GSV.
These unique aspects make thermal ablation of the SSV different as well.

8. Aim of the study
The aim of this ablation procedures is to damage the inner vein wall without causing thrombosis nor a full-thickness burn and nerve damage.

9. Patients & methods
18 patients admitted to military hospital and minister of health hospitals with 1ry varicose veins involving small saphenous vein.
From May 1st 2014 – June 30th 2016.

10. Patients & methods All patients were subjected to: History
Clinical examination
Duplex evaluation
EVLT of small saphenous vein using
“1080 Diode laser”
Follow up (clinical & Duplex)

11. Inclusion criteria Preoperative ultrasound evaluation
Reflux > 0.5 seconds in superficial venous system
Assess SSV, noting:
Vein depth and maximum diameter
Presence of tortuous or aneurysmal segments
Other significant anatomy
Duplicate systems
Large side branches
Incompetent perforators or tributaries

12. Exclusion criteria
Venous Thrombosis

13. Pre-op Ultrasound Assessment
Map and mark
Maximum diameter
Tortuous segments
Aneurysmal segments
Areas where vein is very close to skin
Large branches or perforators
Potential access sites

14. Vein Mapping Make indentations in skin using a straw
Remove US gel from leg
Connect marks on leg with marker to identify pathway of vein and important anatomy

15. Procedure
The entry is usually at the level where the last incompetent tributary vein joins the SSV and below this point the SSV is normal in caliber and regains competence.

16. Procedure 2. Guide wire passage 3. 6Fr sheath insertion over the wire
4. Laser Catheter insertion through
The 6 Fr sheath
5. Locating Position
(The distal tip of the catheter should be
Positioned mm below the SPJ.)
Procedure

17. Infiltration Technique
Image courtesy of Carolyn Menendez, MD
Using 1% diluted Lidocaine.
We do not leave any vein segments unprotected
Re-scan to ensure:
>10 mm distance between skin surface and vein wall
Circumferential black “halo” appearance in fascial compartment
Perivenous vs. subcutaneous infiltration
During endovenous ablation procedure, if patient experiences discomfort, energy delivery can be stopped and additional tumescent fluid can be administered – as long as within patient’s dosage limits – and the procedure resumed
If dosage limit has been met, plain injectable saline may be used in place of tumescent anesthesia

18. After Relocating our position we start FIRING BANDAGE is a must

19. Results

20. Demographics Age: Range : 24 – 48 years X : 30.06 + 1.01 years Gender:
Male / female : 11 / 7
Side:
Right : 5 limbs
Left : 13 limbs
Vein affected:
Small Saphenous vein only : 15 LIMBS
Great & small saphenous veins : LIMBS.

21. Pre-Operative Duplex Assessment
Reflux is present with retrograde flow lasts for at least 1 sec. in all patients.
Range : sec.
X : ± 0.04

22. Detection of reflux Before After
No reflux in all patients One day post operative
Non significant reflux in 2 patients % 3 months post operative
Significant reflux in one patient 5.5% “ “ “ “

23. Complications DAY 90 DAY 1 TYPE 2 patients Hematoma Thrombosis Burn
2 patients
Hematoma
Thrombosis
Burn
One patient
Dysesthesia
Infection
Swelling
Pigmentation

24. Duration of the procedure Length of the treated vein segment
The average laser administration time was 77.2±24.8 seconds for SSV treatments (ranging from 25 to 122 seconds),
Length of the treated vein segment
The average length of vein treated was 16.1±5.1 cm for SSV treatments (ranging from 8 to 25 cm)

25. Energy
The average total energy in joules (J) delivered per treatment was 1,080.9±347.7 J for SSV treatments (ranging from 350 to 1,708 J) The laser fiber was withdrawn at an average rate of 2.2 mm per second.

26. CONCLUSIONS
The SSV has anatomical relationships that make evaluation and management decisions more complex when compared to the GSV.
-Treatment goals are similar:
eliminate reflux from its highest possible point and then eliminate the varicose outflow tracts to maximize clinical benefit and durability.
-Endo-venous thermal ablation is a preferred technique because it is efficient, highly successful and very safe.
- Thermal ablation of the SSV is similar to GSV treatment with some minor modifications based on the anatomy.

27. August 2009Volume 38, Issue 2, Pages 199–202

28. The prevalence of thrombosis and paresthesia is very low.
April 2009Volume 49, Issue 4, Pages 973–979.e1
Conclusion
Endo-venous laser ablation of the SSV has excellent early and midterm results.
The prevalence of thrombosis and paresthesia is very low.
Symptom relief is very good.

29. Thank you for your attention