1. Venous Ablation Therapy: When and How?
Keith M Horton, MD
Medstar Washington Hospital Center
Clinical Assistant Professor Radiology, Georgetown University Hospital
The information contained in this presentation includes content on VNUS Closure treatment. It is not intended to serve as an exclusive education or guide to patient treatment.

2. Keith M. Horton, MD
I/we have no real or apparent conflicts of interest to report.
Off-Label: Foam Sclerotherapy: can be produced only with detergents: sodium tetradecyl sulfate (STS) which is FDA-approved as Sotradecol™, and polidocanol ( POL) which is not yet FDA-approved.

3. It may seem that I am glossing over a lot of the details” and I am” but a lot of what I will be talking about you can find in this article written and in the Journal of interventional radiology
Journal of Vascular and Interventional Radiology, January 2010 Vol. 21, Issue 1, Pages 14-31

4. U.S. Epidemiology and Prevalence
Venous reflux disease is 2x more prevalent than coronary heart disease (CHD) and 5x more prevalent than peripheral arterial disease (PAD)1
Of the estimated 25 million people with symptomatic superficial venous reflux1:
Only 1.7 million seek treatment annually2
Over 23 million go untreated
Since I’m in a roomful of cardiologists I will try to explain this to you but maybe next familiar to you
The prevalence of venous reflux is actually twice as high as coronary heart disease and five times higher than peripheral arterial disease, though far fewer patients actually receive treatment
Statistics show that of the 25 million people in the U.S. who suffer from symptomatic reflux, only about 5% seek treatment annually; 2/3 of patients who do seek treatment have saphenous reflux
Sources: American Heart Association, SIR, Brand et al. “The Epidemiology of Varicose Veins: The Framingham Study”
US Markets for Varicose Vein Treatment Devices 2006, Millennium Research Group 2005.

5. Prevalence by Age and Gender
Female
Male 8% 1%
41%
24%
72%
43%
With advancing age, especially with females, the prevalence of venous disease grows
The typical female patient is in her 40’s and has had multiple pregnancies
Coon WW, Willis PW, Keller JB: Venous thromboembolism and other venous disease in the Tecumseh Community Health Study Circulation 1973;48:

6. Risk Factors Gender Age Heredity Pregnancy Standing occupation Obesity
Prior injury or surgery
Sedentary lifestyle
I have Already mentioned gender and age is a risk factors additional risk factors include
Gender: Approximately four times as many women as men are affected by varicose veins, suggesting that female hormones may be a risk factor.
Age: Generally, most elderly individuals show some degree of varicose vein occurrence.
Heredity: Weak vein walls and valves, as well as shortage of vein valves, seem to be inherited characteristics, and may play a role in determining who develops varicose veins and at what age
Pregnancy is associated with an increase in blood volume. Also, added pressure on the veins in the legs by the weight of the growing uterus and the relaxation effects of the hormones estrogen and progesterone on the vein walls contribute to the development of varicose veins during pregnancy.
Standing or prolonged sitting: causes a great amount of pressure to develop in the leg veins. The calf muscles are inactive and therefore can’t help push venous blood back up to the heart. This causes blood to pool in the veins, thus resulting in increased pressure on the vein walls.
Prior trauma or surgery to the leg could cause interruption of the normal blood flow channels.

7. Vein Valves
Blood propelled by calf muscle pump opens the valve in one direction
Blood moving with gravity closes the normal valve
With properly functioning valves, the blood has only one direction in which to go – toward the heart.
Image source:

8. Vein Valve Failure Normal vein: valve open and closed
The incompetent valves are
most often found in the great saphenous
vein (GSV) or small saphenous
vein (SSV) or in their tributaries. Until
recently, the main treatment strategy
for incompetence in these veins was to
remove them. Endovenous thermal
ablation (EVTA) of the saphenous
veins has been used by physicians
since the late 1990s as an alternative to
surgical removal.
Normal vein: valve open and closed
Dilated vein with non-functioning valve

9. With time these veins dialate, become tortuous and eventually and bulge and become visable..

11. Venous Reflux: A Serious Progressive Disease
Skin Ulcers
Skin Damage
Leg Swelling
500K
2-6 Million
Symptomatic Patients1
Varicose Veins
1White JV, Ryjewski C. Chronic venous insufficiency. Perspect Vasc Surg Endovasc Ther 2005;17:319-27
2Image courtesy of Paul McNeill, MD
3Image courtesy of Rajabrata Sarkar, MD
4Photo source: missinglink.ucsf.edu/.../stasis_dermatitis.html
5Photo source: Amor Khachemoune, Catharine Lisa Kauffman: Management Of Leg Ulcers. The Internet Journal of Dermatology Volume 1 Number 2.
20 Million
Increased pain and reduced quality of life
Serial testing of children over an 8 year period revealed abnormal venous flow and symptoms predated the appearance of varicosities
Progression of venous abnormalities goes from reticular veins to incompetent perforators to truncal varicosities
Patients with varicose veins are usually symptomatic- even if they are not fully aware. A good history and physical will detect problems secondary to the veins
>7 million Americans with highly symptomatic disease:
- Swollen limbs can be secondary to venous hypertension and sedentary lifestyles
- Progression of venous stasis hypertension affects the skin and appendages,
and are a precursor to ulceration
- Venous stasis ulceration is the most common cause of lower extremity ulceration
Overall, as the severity of the disease progresses, quality if life decreases

12. Duplex Ultrasound All patients should have Clinical and US
Must be familiar with Duplex US
Knowledge can be Acquired in many ways
All patients with CVD should undergo
a complete clinical and duplex US
evaluation before being considered a
candidate for EVTA. This evaluation
and subsequent treatment should be
performed by a physician who is appropriately
trained in the care of patients
with venous disorders. The body of
knowledge required by such a physician
includes a thorough understanding
of the anatomy, physiology, pathophysiology,
and clinical course pertaining to
these conditions. The physician should
be experienced in the performance and
interpretation of duplex US of the venous
system as well as conservative,
medical, and procedural approaches for
treating venous disorders. The requisite
knowledge, clinical, and procedural experience
required to care for patients
with venous disorders can be acquired
in a number of ways. Many physicians
will acquire the necessary knowledge
and skills through continuing medical
education and/or mentored clinical experiences
(11) after their postgraduate
medical training. The knowledge and
skills can also be obtained through postgraduate
medical training in an Accreditation
Council for Graduate Medical
Education–recognized (or approved)
postgraduate training program.

13. The Great Saphenous Vein
Images courtesy of Olivier Pichot, MD
GSV within the fascial envelope
Note the superficial or saphenous fascia above the vessel and the deep or muscular fascia below the vessel
Shown here is the GSV within the saphenous compartment – commonly referred to as the “saphenous eye”

14. Saphenofemoral Junction
Image courtesy of Gerald Niedzwiecki, MD
The GSV terminates in the Common Femoral Vein at the Saphenofemoral Junction
One to three sub terminal valves in the GSV: usually just one within one cm of the SFJ
There are generally 5 tributaries at the SFJ:
- AL = Anterolateral
- SCI = Superficial circumflex iliac
- SE (SEV) = Superficial epigastric
- SEP = Superficial external pudendal
- PM = Posteromedial
SFJ image source: Chandler JG et al. Defining the role of extended saphenofemoral junction ligation: A prospective comparative study. JVS 2000;32:941-53

15. Superficial System Exam: Great Saphenous Vein
Image courtesy of Gerald Niedzwiecki, MD
Image courtesy of Gerald Niedzwiecki, MD
Here we see pulsed wave Doppler images of a normal and refluxing great saphenous vein.
Normal valve closure time of <0.5 sec
Reflux of approximately 1.5 seconds

16. Reflux Assessment: Deep System Exam
Assess deep venous system and rule out DVT using compression, color flow and augmentation
Note areas of deep system incompetence at this time
Image courtesy of Gerald Niedzwiecki, MD
Vein in compression
The insufficiency study starts with assessment of the deep venous system.
Color and pulsed-wave Doppler, and maneuvers such as compression and augmentation, are used to determine the presence of obstruction and reflux
Although most radiologists are familiar with duplex ultrasound
(DUS) imaging of the deep system, DUS evaluation
of the superficial venous system is seldom performed
properly. In addition to its undeniable diagnostic
value, DUS is also a critical part of treatment of venous
reflux. Experienced practitioners may recognize common
clinical patterns of venous disease; however, DUS
will more reliably and accurately map out all of the
underlying sources of reflux. Treatment plans based
solely on physical examination will often result in inadequate
elimination of incompetent pathways or removal
of normal veins. Therefore, it is strongly recommended
that all patients undergoing evaluation for varicose
veins, edema or venous skin changes (CEAP clinical
stage 2-6) undergo DUS of the superficial venous system
prior to initiating treatment.
Normal flow in deep vein after augmentation

17. Treatment for Venous Insufficiency
First line is conservative management
What patient can do
Exercise daily
Elevate legs often
Wear medical grade compression stockings 1 2 3
Leg elevation helps to drain the excess blood that pools in the calf and ankle area
Exercise and compression stockings assist the function of the calf muscle pump
Image sources: 1: 2: 3:

18. Compression Therapy for Venous Insufficiency
First step in management of SVI
Payors usually require several weeks or even months
Doesn’t alter anatomy of venous insufficiency patient; treats symptoms but is not curative
Accelerates venous return
Compression reduces lumen diameter of superficial and deep veins
Helps calf muscle pump work more effectively
Underlying cause must still be addressed
Very useful in post-treatment regimens
SVI = Superficial venous insufficiency
Compression stockings can relieve symptoms while worn but are not curative

19. Indications For Endovenous Procedure
Failed conservative therapy
Signs and symptoms of venous insufficiency
Impact of symptoms on ADLs often not realized until after problem corrected
Reflux proven by duplex scan
Anatomic defect that will lead to worsening of natural history
Should be corrected on its own merit
Document the signs and symptoms via history and physical
Prescribe conservative therapy and document results
Refer the patient to a physician with a vein practice or a laboratory for a duplex work-up
ADL’s: activities of daily living
Venous
hypertension caused by incompetent
valves in the superficial veins is
by far the most common cause of this
condition. The incompetent valves are
most often found in the great saphenous
vein (GSV) or small saphenous
vein (SSV) or in their tributaries.

20. Traditional Therapy For SVI
GSV stripping and ligation
Groin incision to ligate and divide GSV tributaries and SFJ at CFV
Stripper passed through GSV at groin, retrieved at knee incision
Stripper pulled from groin to knee, stripping vein and avulsing branches
Significant morbidity associated with vein avulsion
There are variations to this basic method; however, the steps generally include:
- Groin incision
- Tributary ligation and division
Physical removal of the saphenous vein
Until
recently, the main treatment strategy
for incompetence in these veins was to
remove them. Endovenous thermal
ablation (EVTA) of the saphenous
veins has been used by physicians
since the late 1990s as an alternative to
surgical removal. This document will
review the appropriate means by
which the ablative techniques are to be
used to maximize benefit and mini-
Image source: Goldman MP, et al eds. Varicose veins and telangiectasias: Diagnosis and treatment. 2nd ed. St. Louis: Quality Medical Publishing, Inc.; 1999.

21. Modern Therapy For SVI Endovenous ablation Radiofrequency or laser
Great and small saphenous veins
Accessory saphenous veins
Giacomini or Thigh Extension veins
Perforators
Modern Therapy: Address pathophysiology without the disfigurement and trauma associated with traditional surgery
Throughout this document, the procedure
under discussion will be referred
to as EVTA for incompetent truncal (ie,
saphenous) veins. This procedure is
used to ablate incompetent truncal veins
in patients with SVI. The underlying
mechanism of this procedure is to deliver
sufficient thermal energy to the
wall of an incompetent vein segment to
produce irreversible occlusion, fibrosis,
and ultimately resorption of the vein.
The currently available devices used to
accomplish this have been evaluated
and approved by the Food and Drug
Administration of the United States and
use radiofrequency (RF) or laser energy
(of a variety of different wavelengths) to
deliver the required thermal dose. The
thermal energy is delivered by a RF
catheter or a laser fiber inserted into the
venous system, either by percutaneous
access or by open venotomy.

22. Radiofrequency Ablation
RF generator heats catheter tip coil, which conducts heat into vein wall
Denudes intimal lining
Collagen molecules contract
Acute inflammatory response leads to eventual fibrotic occlusion of vessel
Treatment temperature at 120C
System uses least amount of energy necessary to maintain temperature
Continuous system feedback ensures adequate thermal dose
Throughout this document, the procedure
under discussion will be referred
to as EVTA for incompetent truncal (ie,
saphenous) veins. This procedure is
used to ablate incompetent truncal veins
in patients with SVI. The underlying
mechanism of this procedure is to deliver
sufficient thermal energy to the
wall of an incompetent vein segment to
produce irreversible occlusion, fibrosis,
and ultimately resorption of the vein.
The currently available devices used to
accomplish this have been evaluated
and approved by the Food and Drug
Administration of the United States and
use radiofrequency (RF) or laser energy
(of a variety of different wavelengths) to
deliver the required thermal dose. The
thermal energy is delivered by a RF
catheter or a laser fiber inserted into the
venous system, either by percutaneous
access or by open venotomy.

23. Endovenous Laser Laser generator and generic diode laser fiber
Peak treatment temperature reaches ~700C
Heated blood in vein generates steam bubble which indirectly heats vein wall, causing thrombotic occlusion
Image source:

24. Anatomy GSV 70-80% SSV 10-20% Non Saph 10-15% Anatomy
Superficial veins.—The veins of the
lower extremity that are superficial
to the fascia surrounding the muscular
compartment are considered the
superficial veins. These include innumerable
venous tributaries known
as collecting veins, as well as the
GSV and SSV and their major named
tributaries (Fig).
Deep veins.—The deep veins are
those that are found deep to the muscular
fascia. These include the tibial, peroneal,
popliteal, femoral, and iliac veins,
as well as the intramuscular sinusoidal
and perforating veins.
GSV.—An important component of
the superficial venous system, the GSV
begins on the dorsum of the foot and ascends
along the medial aspect of the leg to
ultimately drain into the femoral vein
near the groin crease. This vein resides in
a space deep to the superficial and superficial
to the deep fascia. This location is
known as the saphenous space. The word
“great” replaces “greater” or “long” by
international consensus (1,2; Fig).
SSV.—Another important superficial
vein, the SSV begins on the lateral
aspect of the foot and ascends up
the midline of the calf. In as many as
two thirds of cases, it drains into the
popliteal vein, and in at least one
third of cases more cephalad into the
posterior thigh. The SSV also resides
in the saphenous space. The word
“small” replaces “lesser” or “short”
by international consensus (1,2; Fig).
Anterior and posterior accessory GSVs.—
The anterior and posterior accessory
GSVs are located in the saphenous
space and travel parallel and anterior or
posterior to the GSV. The anterior accessory
GSV is much more common (Fig).
Giacomini vein.—This intersaphenous
Giacomini vein is a communication
between the GSV and SSV. It represents
a form of SSV thigh extension
that connects the SSV with the posterior
circumflex vein of the thigh, a posterior
tributary of the proximal GSV (Fig).
Truncal veins.—This term “truncal
veins” refers to the saphenous veins and
their intrafascial straight primary tributaries
(Fig).
CVD.—CVD is the clinical entity that
results from chronic venous hypertension
(3). The overwhelming majority of
patients with stigmata of venous hypertension
have primary (or idiopathic)
disease of the vein wall with resultant
valvular dysfunction in the superficial
veins, which leads to reflux (4). This
subset of CVD is known as SVI. Pathophysiologically
significant reflux in the
GSV or one of its primary tributaries is
present in 70%–80% of patients with
CVD. SSV reflux is found in 10%–20% of
patients and nonsaphenous superficial
reflux is identified in 10%–15% of patients
(5,6). Venous obstruction, deep
vein reflux, muscular pump failure, and
congenital anomalies are much less
common causes. Venous obstruction is
the most common of these other causes
of CVD and is almost always the result
of prior deep vein thrombosis (DVT). It
is initially an obstructive disease but
usually progresses to a combination of
obstruction and superficial and deep reflux
(7). Reflux or outflow vein obstruction
leads to an increase in pressure in
the veins. The veins themselves can dilate
if unconstrained, and the pressure
causes stretching of receptors in the vein
wall that leads to discomfort to the patient.
The pressure itself can adversely
affect local tissues and metabolic processes,
leading to damage in the vein
wall, the skin, and subcutaneous tissues.

25. Pre-op Mapping & Marking
Significant anatomy to note:
Depth of vein from skin surface
Maximum vein diameter
Duplicate saphenous system
Areas with:
Tortuous and aneurysmal segments
Tributaries, branches and perforators
Potential vein access sites
Nitropaste
Image courtesy of Joseph Smith, MD
The treatment vein anatomy should be assessed pre-operatively and the following factors evaluated and noted:
The depth of the vein from the skin surface
Vein diameter
Duplicate system
Significant anatomy such as tortuous or aneurysmal segments, duplicate systems, and tributaries, perforators, or large branches
Potential vein access sites should be identified

26. Tilt table
Ultrasound machine
Warming blanket

27. RF machine
Laser
Klein Pump
Pandora

28. Vein Access
Treatment vein accessed percutaneously under ultrasound guidance or with small cut down
Needle
Image courtesy of Darcy Kessler, RVT
Most often, a percutanous approach is used to access the vein, though a small cut down incision may be used with good cosmetic result.

29. Vein Access
Vein access achieved percutaneously or through small cutdown
An introducer sheath is placed in vein
Image courtesy of Joseph Smith, MD
The vein is accessed percutaneously with ultrasound guidance or through a small cutdown
The optimal vein access site is close to the surface of the skin, free from any branches or tortuosity, and at least 4mm in diameter.
An introducer sheath is placed in the vein, through which the catheter will be inserted
Image courtesy of Joseph Smith, MD

30. Catheter Tip Position
Catheter tip is positioned 2.0cm distal to the SFJ to
Avoid heating too close to deep venous system
Preserve epigastric vein patency
SEV
Catheter
CFV
SFJ
Image courtesy of Thomas Proebstle, MD
Careful measurement of the distance from the catheter tip to deep system is performed to ensure that heating will not occur too close to the deep system

31. Indexing and Treatment
1. Apply external compression and deliver energy to vein segment; two 20-second RF cycles delivered at segment closest to SFJ
Withdraw catheter to next shaft marker, apply compression and deliver energy
The sequence of indexing and treatment is as follows:
Apply external compression and deliver energy to the vein segment then
Index the catheter to the next shaft marker, re-apply compression and deliver energy
Remember that there is a 0.5cm treatment overlap between segments
Repeat catheter indexing, compression, and treatment until the last treatment segment is reached
3. Repeat withdrawal, compression and treatments until desired length treated
Note: Aneurysmal segments and areas with large tributaries or perforators may benefit from two treatment cycles

32. Perivenous Tumescent Infiltration
Dilute local anesthetic infiltrated into saphenous compartment (perivenously) using duplex imaging
Infiltration of a dilute lidocaine solution begins at the access site and advances proximally toward the sahenofemoral junction.
The goal is to inject into the saphenous compartment very close to the vein and create a 360 degree fluid halo around the vein.
The halo appears black because fluid is a poor reflector of ultrasound transmission, as is blood in a normal patent vein.
At the SFJ, a sufficient volume of fluid should be infiltrated to thoroughly compress the vein around the heating element.
Perivenous infiltration technique: note 360 “halo” of fluid around vein

33. Tumescent Infiltration
Dilute local anesthetic infiltrated around treatment vein under ultrasound imaging
Catheter
A dilute local anesthetic is infiltrated into the saphenous compartment to encircle the treatment vein to protect surrounding soft tissue from thermal injury, compress the vein around the catheter, and provide patient comfort
Image courtesy of Michael Vasquez, MD
Note fluid encircling vein

34. Tip Position Verification
Catheter tip is positioned 2.0cm distal to SFJ under ultrasound guidance
Image courtesy of Joseph Smith, MD
The final tip position of the catheter should be confirmed with duplex ultrasound to ensure the device is not in the deep venous system.
The correct catheter tip position is 2 centimeters from the saphenofemoral junction
A longitudinal or oblique view of the common femoral vein, saphenofemoral junction, and great saphenous vein provides the most accurate visualization of the tip placement. Because there are no expanding electrodes as a landmark it is important to perform a secondary verification of tip position by scanning from proximal thigh to SFJ in transverse to detect the true distal end of the catheter and see the transition where the catheter disappears from the image.
Once proper catheter tip placement is confirmed, tumescent fluid is injected around the SFJ.

35. Compression and Exsanguination
Just prior to treatment, vein is compressed around catheter using combination of:
Tumescent infiltration
Trendelenburg position
External compression

36. Radiofrequency Ablation Procedure Video
Radiofrequency Ablation of GSV:
Vein is accessed near the knee
No groin incision
SFJ tributaries are left intact
The procedure
is generally performed on an ambulatory
basis with local anesthetic and
typically requires no sedation. The patients
are fully ambulatory following
treatment and the recovery time is short.

38. Post-Ablation US Follow-up
Follow duplex performed w/in 72 hours
Rule out DVT
Assess vessel occlusion
Periodic duplex follow up of the patient recommended
The patient returns for a duplex study within 72 hours after the procedure to rule out the presence of DVT and assess the occlusion status of the treated vessel
In our practice, the patient also returns for follow up ultrasound scans at __ week(s), __ months, and annually thereafter for longer term tracking of treatment results

39. Post-Ablation Duplex Assessment
Image courtesy of Michael Vasquez, MD
No flow present
Thickened vein walls
This image represents a typical acute post-op result.
There is flow present from the superficial epigastric vein but no flow seen in the proximal GSV. Additionally, the vein walls are very thick, indicating the inflammatory response to treatment which will lead to eventual fibrotic occlusion and sonographic disappearance

40. Summary Can’t underestimate the value of Duplex
WHEN is much more important than HOW!!

41. Summary Anyone can drill a Well
It’s where you drill it that makes the difference!!!