Laser Therapy of Perforator Veins Michael F. Bardwil M.D.,F.A.C.S.

Current Treatment of Veins

Saphenous Veins Laser Ablation

Varicose VeinsPhlebectomyFoam Sclerotherapy

Telangectasia and Reticular Veins Sclerotherapy

Perforator VeinsNext area in treatment of veins

Why does Vein Surgery Have Such a Bad Reputation? Historically the procedures were morbid High incidence of recurrence perceived as bad results Severe forms of venous insufficiency including refluxing perforators resulted in recurring stasis ulcers

Perforators Give Veins A Bad NameLinton procedure had a reported 19% wound complication rate

Perforators Give VeinsA Bad Name Perforators are a more likely source for recurrent varicose veins than neo-vascularsationRecurrence is perceived as bad results

Perforators Give Veins A Bad NameSevere forms of venous insufficiency including refluxing perforator veins resulted in recurring stasis ulcers

Significance of Perforator VeinsSource for reflux in the superficial venous systemReflux from perforator veins has been associated with venous stasis ulcersCommunication between deep and superficial venous SystemsReflux from perforator veins can result in varicose veins

Communication Between Venous SystemsNot all badAllows patients to recover from vein insults such as injuries and DVT Allows us to perform vein ablative procedures on the saphenous and other superficial veins

Communication Between Venous Systems Not all goodSource for reflux in the saphenous veinAssociated with venous stasis ulcersReflux from perforators can cause non saphenous varicose veinsSource for new and recurrent varicose veins

Types of PerforatorsHunterianDoddsBoydCockettsNew Nomenclature

Hunterian and Dodds PerforatorConnect femoral and proximal popliteal perforators to the saphenous vein Reflux from these perforator veins results in varicose veins in the middle and distal third of the medial thighStripping reportedly interrupts all but 8%?

Boyds PerforatorsPerforator just distal to the kneeConnects saphenous veins to popliteal veinVaricose veins medial leg upper thirdMay appear as first place isolated refluxNew nomenclature Paratibial perforators

Cocketts PerforatorsCocketts I perforator posterior to medial malleolusCocketts II perforator 7-9cm proximal Cocketts III perforator 10-12 cm proximalNew nomenclature posterior tibial perforators

Less Discussed Perforators

Indications for TreatmentVenous Stasis Ulcer associated with perforator vein 2-4 mm in size

Indication for TreatmentLarge perforator vein 3-4mm noted at the time of saphenous ablationRefluxing perforator 2-4 mm noted at saphenous ablation

Indications For TreatmentPerforator veins refluxing into varicose veins that are not associated with long or short saphenous reflux

Indications fortreatmentRecurrent varicose veins that appear to originating from refluxing perforator

Indication for TreatmentPerforator veins refluxing into varicose veins that are not associated with long or short saphenous vein refluxLarge perforator veins 2-4mm noted at time of saphenous ablationRecurrent varicose veins that appear to be originating from perforatorStasis ulcers associated with perforator

History

Standard questions regarding symptomsPrevious vein surgeryStasis Ulcers and previous treatment

Examination

Physical exam with attention to pattern of varicose veinsUse the ultrasound as an extension of the physical examPhotograph markings of perforator to be treatedUlcers PPG to physiologically document venous insufficiency

Problems with Perforator RxLinton procedure problem with wound healingSEPS general anesthesia required inconsistent resultsUltrasound guided foam multiple sessions inconsistent results, non approved solution no code for reimbursement

Future Meets PastIn office procedure to treat perforatorsLess morbidAddresses non saphenous varicose VeinsAddresses sources of recurrenceAddresses stasis ulcers

Endoluminal Ablation Perforators

Endoluminal Ablation of PerforatorsMinimally invasive proceduresOffice basedLocal anesthesiaVNUS ClosureLaser ablationMy experience

VNUS ClosureDevice FDA approvedBilling Code recommendationRecommended protocol using ultrasound guidance and impedance to verify position

Disadvantage VNUS ClosureDevice awkward and expensive, especially for add on perforator veins Protocol less effective than thoughtImpedance less useful than flashIn general other closure procedures have inferior results to laser

Laser Perforator

Technically simplerLess expensive to perform; can treat perforator at time of other veins and not incur increase procedural costs Results should be superior to closure

Technical IssuesVisualizationBroad based neck Multiple perforator necksLong Perforator necks

Technique My ExperienceMicro puncture kitAngio cath catheter18 gauge thin wall angiogram needle25 gauge finder needle20 gauge needle with 400u fiber20 gauge needle with 600u fiber Laser settingUse of foam

Micro-IntroducerAdvantage theoretically similar ElasDisadvantage not enough room to place guide wire in far enough for introducer Dr. Murphy technique use stiff end of guide wire

AngiocathAdvantage: Able to place without guide wireDisadvantage: Needle may be in, but laser not. Work with VNUS device demonstrated proximity still only applies to horse shoes and hand grenades

18 gauge Angiogram Needle Advantage: Direct access to veinDisadvantage: Still bulky, at times difficult getting fiber through needle

20 Gauge Needle 400u FiberAdvantage: Easier to use technically to access vesselCan access vessel at more than one spotDisadvantage: Inconsistent delivery of Energy if Laser system made for 600u fiber

How I Do It

Always perform the venous duplex yourself Mark the vein with patient standing or sitting with feet dangling Strategically position patientPut the bed in reverse trendlenberg

How I Do ItRe-map and mark patient in new positionUse 25 gauge finder needlePlace previously 2 inch stripped fiber through 20 gauge needle and mark with steri-stripAccess vein with 20 gauge needle, use more than one needle if necessaryInject local anesthesia after you are in vein

How I Do ItLaser setting 15 watts intermittent 1.5 sec duration, 1 sec restLook for steam in vesselI usually deliver 200-300 joulesSteri strip applied. 4x4,kerlex, co-ban

Follow Up1-2 days remove wrap and ultrasoundLow threshold to use foam at time of this exam

Results In progress