1. Laser Therapy of Perforator Veins Michael F. Bardwil M.D.,F.A.C.S.

2. Current Treatment of Veins

3. Saphenous Veins Laser Ablation

4. Varicose Veins PhlebectomyPhlebectomy Foam SclerotherapyFoam Sclerotherapy

5. Telangectasia and Reticular Veins Sclerotherapy

6. Perforator Veins Next area in treatment of veins

7. Why does Vein Surgery Have Such a Bad Reputation? Historically the procedures were morbidHistorically the procedures were morbid High incidence of recurrence perceived as bad resultsHigh incidence of recurrence perceived as bad results Severe forms of venous insufficiency including refluxing perforators resulted in recurring stasis ulcers Severe forms of venous insufficiency including refluxing perforators resulted in recurring stasis ulcers

8. Perforators Give Veins A Bad Name Linton procedure had a reported 19% wound complication rateLinton procedure had a reported 19% wound complication rate

9. Perforators Give Veins A Bad Name Perforators are a more likely source for recurrent varicose veins than neo-vascularsationPerforators are a more likely source for recurrent varicose veins than neo-vascularsation Recurrence is perceived as bad resultsRecurrence is perceived as bad results

10. Perforators Give Veins A Bad Name Severe forms of venous insufficiency including refluxing perforator veins resulted in recurring stasis ulcersSevere forms of venous insufficiency including refluxing perforator veins resulted in recurring stasis ulcers

11. Significance of Perforator Veins Source for reflux in the superficial venous systemSource for reflux in the superficial venous system Reflux from perforator veins has been associated with venous stasis ulcersReflux from perforator veins has been associated with venous stasis ulcers Communication between deep and superficial venous SystemsCommunication between deep and superficial venous Systems Reflux from perforator veins can result in varicose veinsReflux from perforator veins can result in varicose veins

12. Communication Between Venous Systems Not all badNot all bad Allows patients to recover from vein insults such as injuries and DVTAllows patients to recover from vein insults such as injuries and DVT Allows us to perform vein ablative procedures on the saphenous and other superficial veinsAllows us to perform vein ablative procedures on the saphenous and other superficial veins

13. Communication Between Venous Systems Not all goodNot all good Source for reflux in the saphenous veinSource for reflux in the saphenous vein Associated with venous stasis ulcersAssociated with venous stasis ulcers Reflux from perforators can cause non saphenous varicose veinsReflux from perforators can cause non saphenous varicose veins Source for new and recurrent varicose veinsSource for new and recurrent varicose veins

14. Types of Perforators HunterianHunterian Dodd’sDodd’s BoydBoyd Cockett’sCockett’s New NomenclatureNew Nomenclature

16. Hunterian and Dodd’s Perforator Connect femoral and proximal popliteal perforators to the saphenous veinConnect femoral and proximal popliteal perforators to the saphenous vein Reflux from these perforator veins results in varicose veins in the middle and distal third of the medial thighReflux from these perforator veins results in varicose veins in the middle and distal third of the medial thigh Stripping reportedly interrupts all but 8%?Stripping reportedly interrupts all but 8%?

17. Boyd’s Perforators Perforator just distal to the kneePerforator just distal to the knee Connects saphenous veins to popliteal veinConnects saphenous veins to popliteal vein Varicose veins medial leg upper thirdVaricose veins medial leg upper third May appear as first place isolated refluxMay appear as first place isolated reflux New nomenclature Paratibial perforatorsNew nomenclature Paratibial perforators

20. Cockett’s Perforators Cockett’s I perforator posterior to medial malleolusCockett’s I perforator posterior to medial malleolus Cockett’s II perforator 7-9cm proximalCockett’s II perforator 7-9cm proximal Cockett’s III perforator 10-12 cm proximalCockett’s III perforator 10-12 cm proximal New nomenclature posterior tibial perforatorsNew nomenclature posterior tibial perforators

23. Less Discussed Perforators

26. Indications for Treatment Venous Stasis Ulcer associated with perforator vein 2-4 mm in sizeVenous Stasis Ulcer associated with perforator vein 2-4 mm in size

27. Indication for Treatment Large perforator vein 3-4mm noted at the time of saphenous ablationLarge perforator vein 3-4mm noted at the time of saphenous ablation Refluxing perforator 2-4 mm noted at saphenous ablationRefluxing perforator 2-4 mm noted at saphenous ablation

28. Indications For Treatment Perforator veins refluxing into varicose veins that are not associated with long or short saphenous refluxPerforator veins refluxing into varicose veins that are not associated with long or short saphenous reflux

29. Indications for treatment Recurrent varicose veins that appear to originating from refluxing perforatorRecurrent varicose veins that appear to originating from refluxing perforator

30. Indication for Treatment Perforator veins refluxing into varicose veins that are not associated with long or short saphenous vein refluxPerforator veins refluxing into varicose veins that are not associated with long or short saphenous vein reflux Large perforator veins 2-4mm noted at time of saphenous ablationLarge perforator veins 2-4mm noted at time of saphenous ablation Recurrent varicose veins that appear to be originating from perforatorRecurrent varicose veins that appear to be originating from perforator Stasis ulcers associated with perforatorStasis ulcers associated with perforator

32. History Standard questions regarding symptomsStandard questions regarding symptoms Previous vein surgeryPrevious vein surgery Stasis Ulcers and previous treatmentStasis Ulcers and previous treatment

33. Examination Physical exam with attention to pattern of varicose veinsPhysical exam with attention to pattern of varicose veins Use the ultrasound as an extension of the physical examUse the ultrasound as an extension of the physical exam Photograph markings of perforator to be treatedPhotograph markings of perforator to be treated UlcersUlcers PPG to physiologically document venous insufficiencyPPG to physiologically document venous insufficiency

36. Problems with Perforator Rx Linton procedure problem with wound healingLinton procedure problem with wound healing SEPS general anesthesia required inconsistent resultsSEPS general anesthesia required inconsistent results Ultrasound guided foam multiple sessions inconsistent results, non approved solution no code for reimbursementUltrasound guided foam multiple sessions inconsistent results, non approved solution no code for reimbursement

37. Future Meets Past In office procedure to treat perforatorsIn office procedure to treat perforators Less morbidLess morbid Addresses non saphenous varicose VeinsAddresses non saphenous varicose Veins Addresses sources of recurrenceAddresses sources of recurrence Addresses stasis ulcersAddresses stasis ulcers

38. Endoluminal Ablation Perforators

39. Endoluminal Ablation of Perforators Minimally invasive proceduresMinimally invasive procedures Office basedOffice based Local anesthesiaLocal anesthesia VNUS ClosureVNUS Closure Laser ablationLaser ablation My experienceMy experience

40. VNUS Closure Device FDA approvedDevice FDA approved Billing Code recommendationBilling Code recommendation Recommended protocol using ultrasound guidance and impedance to verify positionRecommended protocol using ultrasound guidance and impedance to verify position

41. Disadvantage VNUS Closure Device awkward and expensive, especially for add on perforator veinsDevice awkward and expensive, especially for add on perforator veins Protocol less effective than thoughtProtocol less effective than thought Impedance less useful than flashImpedance less useful than flash In general other closure procedures have inferior results to laserIn general other closure procedures have inferior results to laser

42. Laser Perforator Technically simplerTechnically simpler Less expensive to perform; can treat perforator at time of other veins and not incur increase procedural costsLess expensive to perform; can treat perforator at time of other veins and not incur increase procedural costs Results should be superior to closureResults should be superior to closure

43. Technical Issues VisualizationVisualization Broad based neckBroad based neck Multiple perforator necksMultiple perforator necks Long Perforator necksLong Perforator necks

44. Technique My Experience Micro puncture kitMicro puncture kit Angio cath catheterAngio cath catheter 18 gauge thin wall angiogram needle18 gauge thin wall angiogram needle 25 gauge “finder” needle25 gauge “finder” needle 20 gauge needle with 400u fiber20 gauge needle with 400u fiber 20 gauge needle with 600u fiber20 gauge needle with 600u fiber Laser setting Laser setting Use of foamUse of foam

45. Micro-Introducer Advantage theoretically similar ElasAdvantage theoretically similar Elas Disadvantage not enough room to place guide wire in far enough for introducerDisadvantage not enough room to place guide wire in far enough for introducer Dr. Murphy technique use stiff end of guide wire Dr. Murphy technique use stiff end of guide wire

46. Angiocath Advantage: Able to place without guide wireAdvantage: Able to place without guide wire Disadvantage: Needle may be in, but laser not. Work with VNUS device demonstrated proximity still only applies to horse shoes and hand grenadesDisadvantage: Needle may be in, but laser not. Work with VNUS device demonstrated proximity still only applies to horse shoes and hand grenades

47. 18 gauge Angiogram Needle Advantage: Direct access to veinAdvantage: Direct access to vein Disadvantage: Still bulky, at times difficult getting fiber through needleDisadvantage: Still bulky, at times difficult getting fiber through needle

48. 20 Gauge Needle 400u Fiber Advantage: Easier to use technically to access vesselAdvantage: Easier to use technically to access vessel Can access vessel at more than one spotCan access vessel at more than one spot Disadvantage: Inconsistent delivery of Energy if Laser system made for 600u fiberDisadvantage: Inconsistent delivery of Energy if Laser system made for 600u fiber

49. How I Do It Always perform the venous duplex yourselfAlways perform the venous duplex yourself Mark the vein with patient standing or sitting with feet danglingMark the vein with patient standing or sitting with feet dangling Strategically position patientStrategically position patient Put the bed in reverse trendlenbergPut the bed in reverse trendlenberg

50. How I Do It Re-map and mark patient in new positionRe-map and mark patient in new position Use 25 gauge “finder” needleUse 25 gauge “finder” needle Place previously 2 inch stripped fiber through 20 gauge needle and mark with steri-stripPlace previously 2 inch stripped fiber through 20 gauge needle and mark with steri-strip Access vein with 20 gauge needle, use more than one needle if necessaryAccess vein with 20 gauge needle, use more than one needle if necessary Inject local anesthesia after you are in veinInject local anesthesia after you are in vein

51. How I Do It Laser setting 15 watts intermittent 1.5 sec duration, 1 sec restLaser setting 15 watts intermittent 1.5 sec duration, 1 sec rest Look for steam in vesselLook for steam in vessel I usually deliver 200-300 joulesI usually deliver 200-300 joules Steri strip applied. 4x4,kerlex, co-banSteri strip applied. 4x4,kerlex, co-ban

52. Follow Up 1-2 days remove wrap and ultrasound1-2 days remove wrap and ultrasound Low threshold to use foam at time of this examLow threshold to use foam at time of this exam

53. Results In progressIn progress