Great Saphenous Vein Thermal Ablation

Thomas M Proebstle

Disclosure

Thomas M. Proebstle, M.D. I disclose the following financial relationship(s):

•Consultant/Advisory Board: Sapheon

Background

for Thermal Ablation of Great Saphenous Veins

- High ligation and Stripping was a brilliant idea

more than 100 years ago

- Today, numerous prospective randomized trials

comparing thermal ablation to surgery show at

least non-inferiority for procedural success and

clinical results, but improved periprocedural QoL

Background

for Thermal Ablation of Great Saphenous Veins

- High ligation and Stripping was a brilliant idea

more than 100 years ago

- Today, numerous prospective randomized trials

comparing thermal ablation to surgery show at

least non-inferiority for procedural success and

clinical results, but improved periprocedural QoL

Advantages (personal selection)

of Thermal Ablation of Great Saphenous Veins

- Totally Outpatient

- No sutures to be removed

- Infections only sporadically reported

- No lymphatic damage in the groin

- Even Coumadin can stay at an INR of 2.0 – 2.5

- Immediate return to normal Life

Checkpoints

for Thermal Ablation of Great Saphenous Veins

- Indication

- Appropriate Outpatient Setting

- Ultrasound Technology available throughout

intervention

- Catheter and Local Anesthesia Placement Skills

- Heat Delivery Technology and Technique

- Post Tx Care, LMWH, Stockings as required

Indication

for Thermal Ablation

of Great Saphenous Veins

Pathological reflux in the GSV

linked to Venous Disease related

Clinical Signs or Complains

CEAP / VCSS

Thermal Ablation of

Great Saphenous Veins

Appropriate Outpatient Setting

- Minor OR providing Air Condition

- Tilt Table for Trendelenburg and reverse position

- Laser Safety if necessary

- Dimmable Lights for Ultrasound exams

- Organized Office staff, on-call phone numbers

Thermal Ablation

of Great Saphenous Veins

Ultrasound Technology must be

available during intervention

- 8 to 12 MHz or more Linear Scanner

- Color Duplex and PW-Mode

- Sterile Drapings for Probe and Ultrasound-Keyboard

Thermal Ablation of

Great Saphenous Veins

Catheter and Local Anesthesia Placement Skills

all injections to be performed ultrasound-directed

- Puncture Skills !!!

- placement of catheter or laser fiber at the SFJ not too

ambitious, today 2 cm distance recommended !!

Thermal Ablation of

Great Saphenous Veins

Tumescent Local Anesthesia

Saline with 0.05% Lidocaine

1 mg epinephrine per 1000 cc, 10cc bicarbonate 8.4%

- Pain Control

- Collapsing the GSV around the heat source

- Thermal insulation of the surrounding tissue

Rule #1

for Thermal Ablation of Saphenous Veins

durable success is linked to

sufficient dosing of Heat Energy

to the Vein Wall

Recanalization 12 months after thermal ablation

of the GSV with respect to the administered EFE 940 nm laser – bare fiber

Proebstle TM et al: Reduced recanalization rates of the great saphenous vein after

endovenous laser treatment with increased energy dosing: definition of a threshold for

the endovenous fluence equivalent. J Vasc Surg (2006) 44:834-9.

Question #1

for Thermal Ablation of Saphenous veins

How gentle can Heat Energy

be delivered to the Vein Wall ?

Which is the best System ?

Thermal Ablation of

Great Saphenous Veins

Heat Delivery Technology and Technique

> 10 years: RF old style

810, 940, 980 nm diode lasers

1064, 1320 nm Nd:YAG lasers

< 5 years: RF-Segmental

1470 nm diode lasers

pressurized overheated steam

New Fiber Tips: spherical, covered, radial

Hb H2O

8 W, 1 mm/s control 5 W, 0.5 mm/s

20 mm 13 mm 8 mm

control 15 W 30 W

940 nm 1320 nm

Thermal Ablation of Great Saphenous Veins

Water versus Hemoglobin absorbed Laser Wavelengths

Covered Fiber Tips ceramics bare fiber tip

metal

radial

RA Weiss, Dermatol Surg (2002) 28:56

RFA 1st generation versus 810 nm Diode Laser

Thermal Ablation of Great Saphenous Veins

Prospective Randomized Trials on Patients´ Recovery

Almeida JI et al. Radiofrequency endovenous ClosureFAST versus

laser ablation for the treatment of great saphenous reflux: a

multicenter, single-blinded, randomized study (RECOVERY study).

J Vasc Interv Radiol. 2009;20:752-9.

Shepherd AC et al. Randomized clinical trial of VNUS ClosureFAST

radiofrequency ablation versus laser for varicose veins.

Br J Surg 2010;97:810-8.

Segmental Thermal Ablation shows faster recovery

compared to 980 nm bare fiber ablation proven by

VCSS and QoL instruments

Disclosure

Standard Error below 1% at all times

95.7%

Disclosure

future Questions

for thermal Ablation of the Great Saphenous Vein

How does Segmental Ablation compare to

- water absorbed laser wavelengths ?

- Latest laser fiber tip technology ?

There are new concepts arriving:

is the end of the Age of Heat already in sight?

Will we turn to become gluers instead of burners?