1. Office Based Vein Procedures: Ablation and Sclerotherapy Dr
Office Based Vein Procedures: Ablation and Sclerotherapy Dr. Steven Abramowitz MedStar Washington Hospital Center Washington, DC

2. Steven Abramowitz, MD, RPVI
I have no relevant financial relationships

3. Venous Insufficiency
Venous reflux disease develops when the valves stop working properly and allow blood to flow backward (i.e. reflux) and pool in the lower leg veins.
Venous reflux disease is chronic and progressive.
If left untreated, symptoms can worsen over time and could lead to chronic venous insufficiency (CVI)
Reference: Medtronic

4. Reference: Medtronic

5. Reference: Medtronic

6. Risk Factors Risk increases with age Predisposing factors: DVT
Multiple pregnancies
Family hx – pattern suggestive of autosomal dominant inheritance with variable penetrance
Both parents +  90% risk of varicose veins
One parent +  25% risk male, 62% female
No family hx  < 20% risk

7. Evaluation of Venous Insufficiency
History:
Symptoms – heaviness, fatigue, swelling, itching, aching
Compression use
DVT / hypercoagulability, personal or family
Differential Dx: CHF, cirrhosis, renal failure, lymphedema, obesity, psoriasis, skin cancer
Physical Exam:
Tactile and visual exam for varicosities
Assess for skin discoloration, swelling
Assess distribution of varicosities to pinpoint site of venous dysfunction

10. Venous Imaging Imaging of choice = Doppler Ultrasound
Delineates anatomy
Mapping and planning therapy
Assess reflux and visualize valves
Assess for DVT, scarring, webs
Assess perforator veins
Can visualize nerves and surrounding structures
MUST BE PERFORMED STANDING!
Pic:

11. Ultrasound Testing
Aggressive Identifications of reflux, measure diameter, reflux time, relationship to varicosities
Anterior Accessory
Small saphenous
Duplicated saphenous
Saphenous or other refluxing
remnants after phlebectomy/stripping
Deep Veins
Map refluxing perforators
> 3.5 mm in CEAP 4-6 patients

12. Indications for Intervention
Failed Compression (20-30 mmHg x 3 mo)
Dilation to > 5 mm
Reflux time >0.5 sec
GSV
AAV
SSV
Perforators

13. Reference: Medtronic

14. Reference: Medtronic

16. Ablation Results • Prospective, multicentre, single-arm study.
• Purpose: To evaluate long-term effects of RF segmental ablation of GSV using the CLF catheter
• 326 patients (396 limbs) were treated with the ClosureFast™ catheter at 13 sites (8 Europe, 5 US)
• Follow up: Patients were evaluated at 3, 6, 12, 24, 36, and 60 months post-procedure. 278 limbs followed to 5 years
Results showed durable clinical efficacy rates through 5-years:
High occlusion rate of 90.0% at 5 years
Overall reflux-free rate of 93.7% at 5 years
Low complication rate
Dietzek A. RF Segmental ablation: 5-year data. Annual Symposium on Vascular and Endovascular Issues, Techniques, Horizons (Veith Symposium) New York City; November 19, 2013

17. Chemical Ablation
Polidocanol or Sodium Tetradecyl Sulfate mixed with air or CO2 in office (physician compounded)
Commercial prep (Varithena): 1% Polidocanol, O2, CO2 and trace nitrogen
Labeled for GSV ablation
Foam has lower vein closure rates than
thermal ablation (70-80%) with repeated
treatments
No anesthesia required
Able to treat tortuous or partially occluded veins
Side effects: Migraine, visual disturbance, fainting, DVT, stroke

18. Mechanochemical Endovenous Ablation (MOCA):Non-Thermal, Non-Tumescent
Self-contained unit consisting of wire abrasion combined with sclerosant
ClariVein

19. Position: Wire 5 cm from SFJ

20. Wire Agitation with STS Infusion

21. MOCA GSV Results: Dutch Series
224 Patients (all GSV)*
Closure: 95% 6 mo, 95% 1 year
No nerve, skin injury or DVT
50 Patients (all SSV)**
1 year 94% closure
VCSS decreased from 3 to 1
No DVT or nerve injury
*Reijnen M et al. J Endovasc Ther 2011;18: , update at Charing Cross 2014
**BoersmaD et al. Eur J Vasc Endovasc Surg. 2012

22. Cyanoacrylate Adhesive (CAA)
- Anionic substances such as plasma or blood cause polymerization of the adhesive upon contact, leading to occlusion
- Triggers an acute inflammatory reaction in the wall and surrounding tissues
- Damages the vascular intima and induces immunologic response

23. CAA
The VenaSeal® Sapheon Closure System (Medtronic)

25. Modern Venous Surgery Perform new stripping in the office
1-2 cm incision over proximal GSV
Puncture distal end and place 8F sheath
Use Pin stripper and pull out vein
Wrap immediately
No need to stop anticoagulation or aspirin
Invagination of proximal stump and ligation with permanent suture may reduce neovascularization
Microstab phlebectomy has minimal scarring
Phlebectomy of large varicosities (7 mm) has faster healing than injections

26. 3 wks post-op
incisions
Pre-Op

27. Clinical Outcome Comparisons
Randomized study of 500 legs. Compared:
Post op pain: RF and Foam less pain initially
Complications: 1 PE w/ foam, 1 DVT w/ stripping
> 30% of foam retreated at 3 years (P < .01)
No difference QoL
Immediate
Occlusion
Recanalization - 3yrs
New Veins yrs
EVLA
94%
6.8%
20%
RFA
95% 7%
14.9%
Foam
80%
26.4%
19.1%
Stripping
96%
6.5%
20.2%
Rasmussen et al Br J Surg 2011
Rasmussen et al JVS 2013

28. Sclerotherapy Ensure no superficial reflux with ultrasound
Injection of polidocanol or STS directly into vein
Solution irritates vein, causing it to collapse
Over time, the vessel scars

29. Side Effects
DVT
Larger veins that have been injected may become lumpy and hard; may require several months to dissolve and fade.
Staining may appear at the vein site.
Neovascularization may occur at the site of sclerotherapy treatment.

30. Conclusion Lots of good choices for Venous Disease
Excellent safety profiles
Easy to use, tolerate
Expect patients to have improved QoL
Better outcomes than ever before
Educate that venous disease is lifelong, and lifestyle changes may be needed