1. Combined techniques : How to ablate varices during endovenous surgery ? R.Milleret, D.Valean, M.Fodor

2. To treat During or After ? Conflicting studies but a majority is in favor of simultaneous treatment. It’s true that tributaries directly connected to the trunk will shrink, but we have no predictive technique which could be applied to an individual patient.

3. Treating Saphenous Tributaries 4 techniques available : Invasive : --- Mini-Phlebectomies --- Cryo-Phlebetomy Non Invasive : --- Foam sclerotherapy --- Steam Phlebectomy

4. Methods Mini – Phlebectomies : --- Tumescent anesthesia --- Needle puncture --- Hook grasping --- Sub cutaneous dissection, Varady spatula --- Suture or no suture ?

5. Cryo-Phlebectomy 1,5 mm rigid probes 10 to 15 cm length Incision with N°11 blade Tumescent anesthesia Catheterization when possible OR extraction by external freezing

12. Foam sclerotherapy Less concentration than usual, 0,5% to 1% Aetoxy. Echo guided, from the thigh to the ankle Catheter delivered if straight segments Compression Tumescence after injection ( Start technique, AA Ramelet )

13. Steam Phlebectomy Steam will travel through the tortuosities All introducers in place before heating General anesthesia or sedation more adapted Cooling tumescence before and after steam injection : compression of the vein. * Large veins can be treated

15. Catheter in the 17 G Venflon

20. Results NO STUDIES ABOUT RE OPENING OF VEINS 3 TO 6 MONTHS AFTER : --- Foam Sclerotherapy --- Mini Phlebectomies --- Cryo-Phlebectomy * Thousands of papers on Saphenous Trunks …

21. Steam : Trib vein study 3 centers : Nicolini, Hartung, Milleret 30 members on 26 patients Age : 54 +- 13 years Sexe : 55,2% women Anesthésie : General = 67,9%

22. Material 92 tributaries Diameters 6,4 +- 3,1 mm Length 8 cm+- 5,1 Pulse/cm 2,3 +-0,9 Entry Points : 4,9 +6 2,4 If Phlebectomies 13,1 +- 6,4 (P<0,0001)

23. Results Post Op Pain : 0,7/10 Occlusion : 95,7 % 3 months 95,7 % 6 months Patient’s evaluated cosmetic results : 92 % 3 months 100 % 6 months

24. Randomized study of Steam Phlebectomy versus Foam obliteration of superficial tributaries

25. Material 2 groups of 20 patients each,randomized. Location of varices : Anterior Accessory, Internal Calf Posterior Calf * Diameter of varices : 3 to 10, mean 6 mm.

26. Methods Foam : 1% Polidocanol, Tessari tourbillon technique, 6 to 10 cc in one session (Tegernsee) Steam : 3 to 6 pulses/location 3 to 6 18G / 20 G infusion catheters * Eccentric compression.

27. Post Op at 8 days Foam Steam Inflammation 6/20 0/20 Pain ( scale of 10 ) 2,4 0,5

28. Results at 1 month Foam Steam Blood extraction 12/20 6/20 Pigmentation 12/20 4/20

29. Results at 6 months Foam Steam Pigmentation 4/18 2/19 Cosmetic result 10/18 15/19 ( patient’s evaluation Good/very good)

30. Elements of choice Young woman, thin legs : Mini-Phlebectomies / Cryo phlebectomies Because risk of pigmentation with foam, Vein still palpable for some months after steam.

31. Opposite case Man with big bulging varicose veins Steam best option, painless, no diameter limit. Phlebectomies can be added as these veins are quite resistant and we can ablate long segments through one incision

37. Foam Combined with phlebectomies when all the veins cannot be removed : Accessory Anterior Saphenous trunk for intance. Foam then Tumescence then Phlebectomy Thus excess foam is removed through the phlebectomy incisions = less risk of pigmentation.

38. Specific problems Lipodermatosclerosis : avoid incisions, Steam = less inflammatory reactions can obliterate perforators Superficial thrombosis : phlebectomy thrombectomy but trunk can be treated by heating technique.

40. V Box : 1 Box, 2 techniques Segmental Radio-Frequency ablation for Saphenous trunks, Low Pressure Steam for Tributaries Just plug in to the mains, and connect the RF catheter or the Single Use Steam hand-piece

42. THE V box single use hand piece

43. Conclusion Choice of technique depends on the availability of the equipment : cryo, steam. Phlebectomy combined with Foam offers a cheap way to treat these veins. Scientific studies are far behind in this area as compared with Saphenous vein ablation.