1. Endoluminal radiofrequency ablation and Endovenous laser therapy for the treatment of Varicose Veins: techniques and outcomes

2. Endoluminal radiofrequency ablation and Endovenous laser therapy for the treatment of Varicose Veins: techniques and outcomes
Clarify the indications for performing RFA and EVLT.
Explain the mechanisms, methods, of RFA and EVLT.
Outcomes of RFA and EVLT: response to treatment and
complications
Bola Pratt P&S MS 4

3. American Venous Forum February of 1994 and the creation of CEAP
Somewhere in Maui, Hawaii
klöf B, Rutherford RB, Bergan JJ, Carpentier PH, Gloviczki P, Kistner RL, Meissner MH, Moneta GL, Myers K, Padberg FT, Perrin M, Ruckley CV, Smith PC, Wakefield TW; American Venous Forum International Ad Hoc Committee for Revision of the CEAP Classification. Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg Dec;40(6): Review.
Bola Pratt P&S MS 4

4. Indications for EVLT or RFA: lessons from the American Venous Forum February of 1994 and the creation of CEAP
Clinical C0: No visible or palpable signs of venous disease C1: telangiectases or reticular veins C2: varicose veins C3: edema C4: skin changes ascribed to venous disease a. pigmentation or eczema b. lipodermatosclerosis or atrophie blanche C5: skin changes as defined previously with healed ulcer C6: skin changes as defined previously with active ulcer Etiologic: congenital, primary, secondary or none Anatomic: superficial, perforator, deep or none Pathophysiologic: reflux, obstruction, both or none
Most Common
klöf B, Rutherford RB, Bergan JJ, Carpentier PH, Gloviczki P, Kistner RL, Meissner MH, Moneta GL, Myers K, Padberg FT, Perrin M, Ruckley CV, Smith PC, Wakefield TW; American Venous Forum International Ad Hoc Committee for Revision of the CEAP Classification. Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg Dec;40(6): Review.
Bola Pratt P&S MS 4

5. Endoluminal radiofrequency ablation (RFA) of the great saphenous vein: mechanism
- By directing resistive radiofrequency energy through a vein, a narrow
rim of tissue less than 1mm is heated by an electrode.
- The amount of heating is modulated using both a microprocessor and
manual movement, resulting in controlled collagen contraction,
thermocoagulation and absorption of the vein.
Puggioni A, Kalra M, Carmo M, Mozes G, Gloviczki P. Endovenous laser therapy and radiofrequency ablation of the great saphenous vein: analysis of early efficacy and complications. J Vasc Surg Sep;42(3):
Bola Pratt P&S MS 4

6. Endoluminal radiofrequency ablation of the great saphenous vein: methods
Percutaneous access to the greater saphenous vein most commonly at the level of the knee under duplex ultrasound guidance
Photograph courtesy of VNUS medical Technologies, San Jose, CA.
Bola Pratt P&S MS 4

7. Endoluminal radiofrequency ablation of the great saphenous vein: methods
1) A guidewire is then advanced to the saphenofemoral junction over which the closure catheter is passed 2) catheter prongs are extruded to contact the intimal lining of the vessel wall 3) radiofrequency generator allows the tip of the catheter and the prongs to attain a temperature of 85 degrees C.
CFA = common femoral artery CFV = common femoral vein SEV= superficial epigastric vein SFJ = saphenofemoral junction
Photographs courtesy of VNUS medical Technologies, San Jose, CA.
Bola Pratt P&S MS 4

8. Endoluminal radiofrequency ablation of the great saphenous vein: results
1) Vein occlusion at 1 week documented by venous ultrasound success rate of 98% 2) None of the treated patients developed recanalization that was not seen at 6 weeks, with a successful outcome in 90%. 3) At the 24 month follow-up, 19 of 21 patients had complete disappearance of the treated saphenous vein, for a success rate of 90%. 4) Side effects were minimal, and no skin burns or thromboses were observed.
Weiss RA, Weiss MA. Controlled radiofrequency endovenous occlusion using a unique radiofrequency catheter under duplex guidance to eliminate saphenous varicose vein reflux: a 2-year follow-up. Dermatol Surg Jan;28(1):38-42.
Bola Pratt P&S MS 4

9. Endovenous laser therapy (EVLT): mechanism
- Thermal reaction after laser exposure is essential.
- Damages endothelial, intimal internal elastic lamina, and to some
degree the media. Adventitia is rarely affected.
- In vitro studies suggest that energy results in ‘boiling of blood’ and
and generation of ‘steam bubbles’ that indirectly, homogenously
affect the varicose vein.
Proebstle TM, Lehr HA, Kargl A, Espinola-Klein C, Rother W, Bethge S, Knop J. Endovenous treatment of the greater saphenous vein with a 940-nm diode laser: thrombotic occlusion after endoluminal thermal damage by laser-generated steam bubbles. J Vasc Surg Apr;35(4):
Bola Pratt P&S MS 4

10. Endovenous laser therapy: methods
1) GSV entered at the knee 2) Guidewire passed through hollow needle into the vein can be difficult if: a. tortuosities b. local venous spasm c. sclerotic fragments 3) Needle removed 4) 3mm cutaneous incision made 5) Introducer sheath placed over guide wire 6) Guidewire removed when at the SFJ 7) Longitudinal US visualization of sheath 1-2 cm distally to the SFJ
van den Bos RR, Kockaert MA, Neumann HA, Nijsten T.Technical review of endovenous laser therapy for varicose veins. Eur J Vasc Endovasc Surg Jan;35(1): Epub 2007 Oct 24. Review.
Bola Pratt P&S MS 4

11. Endovenous laser therapy and radiofrequency: methods
Tumescent anesthesia (5 ml epi, 5 ml bicarb, 35ml 1% lidocaine in 500ml saline) is administered to the perivenous space resulting in a) reduction in pain b) protection of perivenous tissue through cooling c) increase in surface area of laser tip and vein wall
van den Bos RR, Kockaert MA, Neumann HA, Nijsten T.Technical review of endovenous laser therapy for varicose veins. Eur J Vasc Endovasc Surg Jan;35(1): Epub 2007 Oct 24. Review.
Bola Pratt P&S MS 4

12. Endovenous laser therapy and radiofrequency: specifics
Pulsed vs. continuous: pulsed mode is associated with higher adverse events Wavelengths: Higher wavelengths (1320nm) reported less postoperative pain, and less likely to have ecchymoses Fluence (J/ cm2): Single most important parameter to quantify above J/ cm2 for durable GSV occlusion Wattage: high, short duration wattage vaporizing effect low prolonged wattage coagulating effect Pullback Speed: if performed at fixed wattage then energy is solely dependent on pullback speed
Bola Pratt P&S MS 4

13. Endovenous laser therapy and radiofrequency: results
Pretreatment: an incompetent SFJ
Posttreatment: occlusion of GSV
Puggioni A, Kalra M, Carmo M, Mozes G, Gloviczki P. Endovenous laser therapy and radiofrequency ablation of the great saphenous vein: analysis of early efficacy and complications. J Vasc Surg Sep;42(3):
Bola Pratt P&S MS 4

14. Endovenous laser therapy and radiofrequency: results
van den Bos RR, Kockaert MA, Neumann HA, Nijsten T.Technical review of endovenous laser therapy for varicose veins. Eur J Vasc Endovasc Surg Jan;35(1): Epub 2007 Oct 24. Review.
Bola Pratt P&S MS 4

15. EVLT vs. RFA of the great saphenous vein: outcomes, complications
Burden of repeated treatment and complications ?
EVLT
RFA
Bola Pratt P&S MS 4

16. Indications for EVLT or RFA: lessons from the American Venous Forum February of 1994 and the creation of CEAP
Clinical C0: No visible or palpable signs of venous disease C1: telangiectases or reticular veins C2: varicose veins C3: edema C4: skin changes ascribed to venous disease a. pigmentation or eczema b. lipodermatosclerosis or atrophie blanche C5: skin changes as defined previously with healed ulcer C6: skin changes as defined previously with active ulcer Etiologic: congenital, primary, secondary or none Anatomic: superficial, perforator, deep or none Pathophysiologic: reflux, obstruction, both or none
Most Common
klöf B, Rutherford RB, Bergan JJ, Carpentier PH, Gloviczki P, Kistner RL, Meissner MH, Moneta GL, Myers K, Padberg FT, Perrin M, Ruckley CV, Smith PC, Wakefield TW; American Venous Forum International Ad Hoc Committee for Revision of the CEAP Classification. Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg Dec;40(6): Review.
Bola Pratt P&S MS 4

17. Puggioni et al 2005: Retrospective review of 92 patients, 130 limbs
All had: symptomatic varicose veins by CEAP criteria Women Clinical Presentation: C2-4 Etiology: primary
EVLT RFA
Veins of all sizes:
14 W; 810nm; 3mm/s withdrawing speed
Veins mm:
Temp ; 3cm/min withdrawing speed
Puggioni A, Kalra M, Carmo M, Mozes G, Gloviczki P. Endovenous laser therapy and radiofrequency ablation of the great saphenous vein: analysis of early efficacy and complications. J Vasc Surg Sep;42(3):
Bola Pratt P&S MS 4

18. EVLT and RFA analysis of early complications: Puggioni et al 2005
Puggioni A, Kalra M, Carmo M, Mozes G, Gloviczki P. Endovenous laser therapy and radiofrequency ablation of the great saphenous vein: analysis of early efficacy and complications. J Vasc Surg Sep;42(3):
Bola Pratt P&S MS 4

19. Puggioni et al 2005 conclusion
EVLT was associated with a somewhat higher occlusion rate, but post-op complications were more frequent - All patients should undergo early post-operative duplex to rule out proximal extension of thrombus, exclude distal DVT, and confirm occlusion
Puggioni A, Kalra M, Carmo M, Mozes G, Gloviczki P. Endovenous laser therapy and radiofrequency ablation of the great saphenous vein: analysis of early efficacy and complications. J Vasc Surg Sep;42(3):
Bola Pratt P&S MS 4

20. RFA and DVT analysis: Hingorani et al 2004
DVT in 12 limbs (16%) - no difference in DVT between men and women - catheter size: no difference in DVT - anesthesia: no difference in DVT - higher incidence of DVT with RFA and vein excision
Hingorani AP, Ascher E, Markevich N, Schutzer RW, Kallakuri S, Hou A, Nahata S, Yorkovich W, Jacob T. Deep venous thrombosis after radiofrequency ablation of greater saphenous vein: a word of caution. J Vasc Surg Sep;40(3):500-4.

21. Summary
EVLT and RFA are associated with a high degree of success with minimal side effects most of which can be prevented or minimized with minor modifications of technique. - All patients should undergo early post-operative duplex to rule out proximal extension of thrombus, exclude distal DVT, and confirm occlusion. - The advantage EVLT has over RFA is the lower cost per patient and possibly faster treatment than RF closure.
P&S

22. References
klöf B, Rutherford RB, Bergan JJ, Carpentier PH, Gloviczki P, Kistner RL, Meissner MH, Moneta GL, Myers K, Padberg FT, Perrin M, Ruckley CV, Smith PC, Wakefield TW; American Venous Forum International Ad Hoc Committee for Revision of the CEAP Classification. Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg Dec;40(6): Review.
Proebstle TM, Lehr HA, Kargl A, Espinola-Klein C, Rother W, Bethge S, Knop J. Endovenous treatment of the greater saphenous vein with a 940-nm diode laser: thrombotic occlusion after endoluminal thermal damage by laser-generated steam bubbles. J Vasc Surg Apr;35(4):
Puggioni A, Kalra M, Carmo M, Mozes G, Gloviczki P. Endovenous laser therapy and radiofrequency ablation of the great saphenous vein: analysis of early efficacy and complications. J Vasc Surg Sep;42(3):
van den Bos RR, Kockaert MA, Neumann HA, Nijsten T.Technical review of endovenous laser therapy for varicose veins. Eur J Vasc Endovasc Surg Jan;35(1): Epub 2007 Oct 24. Review.
Weiss RA, Weiss MA. Controlled radiofrequency endovenous occlusion using a unique radiofrequency catheter under duplex guidance to eliminate saphenous varicose vein reflux: a 2-year follow-up. Dermatol Surg Jan;28(1):38-42.
P&S