Mechanochemical Ablation: MOCA2 year follow up, lessons learned
Steve Elias MD FACS FACPhDirector, Division of Vascular Surgery Vein ProgramsColumbia University and Medical Center, NY
Assistant Professor of SurgeryColumbia University
Disclosure:
Vascular Insights LLC – Advisory Board
Covidien Inc. – Advisory Board
What Is It? MOCA
How Does It Work:
Combination – endovenous mechanical and chemical
Mechanical – wire > rotates > intimal damage
Chemical – liquid > penetrates > scar
End result – venous occlusion
Mechanical Component
Chemical Component
Mechanochemical Together
Access: MOCA
Percutaneous ultrasound guided
4 fr. micropunture sheath
18 gauge IV access
No further wires or larger sheath exchange
Position: Wire exposed
Position: Wire 2 cm SFJ
Treat: MOCA Pullback 1.o – 1.5 mm. per second
Inject during pullback
Sodium tetradecyl sulfate 1.5% liquid (or equivalent sclerosant)
Volume dependent on size/length
Treat SFJ: Rotate and Inject
Treat Mid GSV: Wire/Sclerosant Mix
Treat: Injection & Pullback
MOCA: Mechanism of action
Elias FIM: Clinical Trial 2/09* 30 limbs GSV only C2 – 24 C3 – 2 C4 – 4 Avg. 55 years Treat GSV only (no treatment VV or
IPV) 1 yr. follow up to complete trial No tumescence or sedation
*Elias S, Raines JK. Mechanochemical tumescentless endovenous ablation: final results of the initial clinical trial.Phlebology;27:67-72.
Procedure Statistics: MOCA GSV size – 8.1 mm.
GSV length treated – 36 cm.
GSV treatment time – 5 min.
Overall treatment time - 14 min
Completed Trial *
All closed except 1st patient – btw 3-6mos
6 month – 29/30 (96%)
12 month – 29/30 (96%)
24 month – 27/28 (96%) ( 1 died, 1 no US yet)
*Elias S, Raines JK. Mechanochemical tumescentless endovenous ablation: final results of the initial clinical trial.Phlebology;27:67-72.
Complications
Subcutaneous ecchymoses – 3 pts.
Side branch tear?
No DVT
No nerve injury
No skin injury
224 GSV’s
C2 (13%) C3 (67%) C4 (20%)
GSV diameter 7 mm
GSV length 41 cm
treatment time 16 min
GSV Results: Dutch seriesMichel Reijnen/ Jean Paul DeVries
Ramon RJP, van Eekeren MD et al. Endovenous mechanochemical ablation ofgreat saphenous vein incompetence using the ClariVein device: a safety study.J Endovasc Ther 2011; 18:328-334.
Dutch MOCA: Results
6 weeks – 182/185 closed 98%
6 months – 40/42 closed 95%
No nerve/skin/DVT
MOCA 2012: Results Summary
6,000 cases worldwide (GSV/SSV) > 90% occlusion rate – various
intervals Chaloner – 92% at 1 yr. QoL – improves as any successful
EVA DVT - < 1% No nerve/skin injury No tumescence – longest part of
short procedure
What We Have Learned: Technique
Rotate 1st (spasm/vortex) then inject slow
Catheter ON = Catheter MOVING
Two handed technique – 1 pulls – 1 injects
Tendency: Pull too fast, inject too slow
What We Have Learned: Volume Volume originally 12 cc (1.5%STD)
for all
Volume now based on diameter/length
Volume tends to be less
Table available
GSV – 6-10 cc SSV – 2-4 cc PPV – 1cc
What We Have Learned: Concentration
Stronger is better
STD 1.5% - 2% 93-96% 1% < 90% (Chaloner UK)
PLD – 2 – 3 % (volume based on weight)
Lower volume, maximum concentration
What We Have Learned: Duplex Slower contraction and scarring
No flow but appears sponge like (color flow)
Can take up to 1 year for contraction
If some flow – reimage 3 months
Post MOCA 1 month
Advantages: MOCA
No thermal injury – nerves, skin
SSV, BK GSV, PPV
Ulcers – retrograde
Eliminates tumescence – patient and MD
Conclusions MOCA: 2012
It works, It is safe – 96% at 2 years
Learning curve - 5 – 8 cases
No tumescence – the future, only one now Glue, PEM, TAHOE (RF)
Another good option for ablation (95% pts.)
Words To Live By:
Respect the elders, Embrace the new,
Encourage the improbable and impractical
Without bias