1. Endovenous thermal ablation for varicose vein Joint Hospital Surgical Grand Round 16-4-2011 Wong Kwok Kei, Kwong Wah Hospital

2. Endovenous great saphaneous vein thermal ablation Laser Radiofrequency

3. Potential advantages of Endovenous thermal treatment “Minimally invasive” LA, day case Earlier return to normal activities

4. Limitation of Endovenous thermal treatment Not for vein >12mm diameter (?result inferior to surgery) Too tortuous Patient not ambulatory pacemaker, internal defibrillator, active implanted device for RFA EVLT & RFA mainly for GSV – ? Perforator

5. Endovenous thermal Treatment Endovenous thermal therapy Thrombosis Organization of thrombus RecanalizationFibrous cord

6. Endovenous laser therapy (EVLT) A laser is a device that emits light (electromagnetic radiation) through a process called stimulated emission

7. Endovenous Laser Therapy: mechanism Direct thermal: → carbonization of vein wall on direct contact → vein wall destruction → thrombosis → fibrosis Indirect thermal: → absorbed by Hb / water in blood (chromophore) → steam bubbles → vein wall destruction → thrombosis → fibrosis

8. Radiofrequency Ablation (RFA) Bipolar radiofrequency current Resistive heating – transmural death → thrombosis → fibrosis

9. Endovenous thermal ablation Procedure Bola Pratt P&S MS 4 GSV entered at the knee under USG guidance Longitudinal US visualization of sheath 1-2 cm distally to the SFJ Tumescent anesthesia Pull back of laser/ RFA fibre Need phlebectomy/ sclerotherapy for thigh and calf varicosities

10. Early technical success EVLT- duplex findings < 6 months Study end point

11. Early technical success RFA - duplex findings < 6 months Study end point

12. GSV thermal ablation long term results Study end point

13. Endovenous therapies of lower extremity varicosities: A meta-analysis Renate van den Bos, MD,a Lidia Arends, PhD,b,c Michael Kockaert, MD,a Martino Neumann, MD, PhD,a and Tamar Nijsten, MD, PhD,a Rotterdam, The Netherlands (J Vasc Surg 2009;49:230-9.)

14. RCT RFA vs surgery Perälä J, Rautio T, Biancari F et al Lurie F, Creton D, Eklöf B, et al Stötter L, Schaaf I, Bockelbrink A, et al Hinchcliff RJ, Ubhi J, Beech A, et al Number of patient 28852016 (bil recurrent VV after HL) Follow up3 years2 years1 year Less painRFA Less minor complication eg. Bruise, edema RFA Better QOLRFA Faster recoveryRFA 6.5 days; HL/S 15.6 days RFA Total societal costs RFA $1401; HL/S $1926 Operative timeRFA 25mins, HL/S 40mins

15. RCT EVLT vs surgery De Medeiros CAF, Luccas GC Vuysteke M, Bussche DVd, Audenaert EA et al. Rasmussen LH, Bjoern L, Lawaetz M, et al Ogawa T, Hoshino S, Makimura S, et al Kalteis M, Berger I, Messie-Werndl S, et al Darwood RJ, Theivacuma r N, Dellagramm aticas D, et al Number of patient2016412192100103 Laser810nm 980nm 810nm Follow up2 years9 months2 years6 months4 months1 year Less painsimilar EVLT Less minor complication EVLTsimilarEVLTsimilar Return to routine activities EVLT 8.6, HL/S 22.4 HL/S 14, EVLT 20 EVLT QOL at FUsimilar Hospital stayEVLT 1.5 HL/S 2.7

16. RCT RF vs EVLT Morrison NAlmeida J, Kaufman J, Makhoul R, et al Goode S, Crockett M, Richards T, et al Gale SS, Lee JN, Walsh WE et al. A. C. Shepherd,M. S. Gohel, L. C. Brown et al. Patient50, bil VV 8722, bil VV119131 EVL980nm810nm600nm980nm RFClosure-FastCelon RFiTTClosure PlusClosureFAS T Follow up1 year30 days14 days1 year6 weeks Less painSimilarRFA Less minor CxsimilarRFA Procedure timesimilarEVLT 19mins, RFA 13 mins QOL at FUsimilar

17. Is laser really inferior to RF in terms of post operative pain and minor complication? Comparison of 980 nm Laser and Bare-tip Fibre with 1470 nm Laser and Radial Fibre in the Treatment of Great Saphenous Vein Varicosities: A Prospective Randomised Clinical Trial S. Doganci*, U. Demirkilic Eur J Vasc Endovasc Surg (2010) 40

18. Advancement in EVLT: wavelength Wavelengths; 810, 940, 980, 1319, 1320,1470nm. Type of laser; Diode; 810, 940, 980,1470. Nd:YAG; 1319, 1320. Dominant chromophore; Hemoglobin; 810, 940, 980 Water (collagen in vein wall) ; 1319, 1320,1470

19. Advancement in EVLT: fibre jacket-tip fibers Glass Ceramic Radial Tulip-tip

20. Advancement in RFA 1999: Use of Radiofrequency to heat up long saphenous vein 2003: 2nd G RFA Cath (VNUS ClosurePlus) commercially a/v in HK 2006: FDA Approval of 3rd G RFA VV(VNUS ClosureFAST) 10/2007: first 3rd G RFA VV cath(VNUS ClosureFAST) in HK

21. Advancement in RFA 2nd generation VNUS ClosurePlus 85 degree Celsius Pull back 1cm per min for 5 min then 2-3 cm per min for remainder Impendence: 8Fr >100 OM 6Fr >150 OM Power 3-4 Watt VNUS ClosureFAST: 120 degree Celsius Automatic impedance and power 5-40watt 7cm treatment site The ClosureFAST catheter and the RFGPlus™ generator. 2nd generation RFA catheter

22. Conclusion Endovenous thermal ablation: 1.Occlusion rate comparable with surgery 2.Perform under local anesthesia; 3.same - day procedure; 4.less pain, discomfort and complications; 5.earlier return to normal activities

23. Conclusion RFA was associated with less postprocedural pain, minor complication (eg. Bruising, phlebitis) than EVLT.

24. Conclusion: Ideal RCT RCT comparing ablation of the incompetent GSV using surgery vs RF (Closure-Fast) vs laser (Jacket- tipped?1470 nm?) vs foamsclerotherapy. Participants stratified by the severity of symptoms and signs eg, CEAP classification Long follow-up, at least 5 years; Assess patient - important outcomes: – Varicose vein recurrence – Patient satisfaction Disability and QOL – Use standardized disease-specific scales for these outcomes (VCSS, AVVSSS) – Cost-effectiveness data.

25. The Comparison of LAaser, Surgery and foam Sclerotherapy (CLASS) trial HTA funded – started Summer 2008 UK multi centre RCT – 5 centres Outcomes; 6 wks, 6 mths & 5 yrs Primary: disease specific and general QoL changes Secondary: technical success, clinical success, cost effectiveness Sample size = 1015 pts (203 / centre)

26. Thank you!