Endovenous Radiofrequency Ablation for Varicose Veins Mr. Mark Grannell British Association of Day Surgery Meeting, Farmleigh House, Phoenix Park, Dublin 22nd October 2010

Varicose Veins Abnormal venous anatomy:  Varicose veins • • • • •

Familial tendency Standing vocation Associated with pregnancy Leg injury or surgery Generally progressive

 Often symptomatic • Tired, aching legs • Leg swelling • Phlebitis and thrombosis

Venous Disease  Distension  Oedema  Haemosiderin deposition  Lipodermatosclerosis  Ulceration

Signs of Venous Insufficiency

1

Varicose Veins

2

Edema

3

Skin Changes

4

Ulceration

Image sources: 1 Paul McNeill, MD 2 Rajabrata Sarkar, MD 3 missinglink.ucsf.edu/.../stasis_dermatitis.html 4 Amor Khachemoune, Catharine Lisa Kauffman: Management Of Leg Ulcers. The Internet Journal of Dermatology. 2002. Volume 1 Number 2

The Most Prevalent Symptomatic Vascular Disease

Annual U.S. Incidence U.S. Prevalence

Millions

Sources: American Heart Association, SIR, Brand et al. “The Epidemiology of Varicose Veins: The Framingham Study”

Varicose Veins • Symptomatic venous reflux patients – Underlying cause of most varicose veins – ~312,000 saphenous vein procedures annually in U.S (2009 estimate) • 290K endovenous ablation • 22K ligation & stripping

Treatment Options  Compression Hosiery (Class I – III)  Conventional Surgery • Saphenofemoral(popliteal) ligation, Stripping of long saphenous vein

 Minimally invasive treatments • RFA (VNUS Closure) • EVLT • Foam Sclerotherapy

The VNUS Closure® System The VNUS Closure System is a minimally invasive treatment alternative for patients with symptomatic superficial venous reflux and varicose veins Using a catheter-based approach, the VNUS Closure System delivers radiofrequency (RF) energy to the vein wall RF energy creates conductive heating that contracts the vein wall collagen, thereby occluding the vein

Collagen Contraction Controlled heating of the vein wall causes: Shortening and thickening of collagen fibrils Vein lumen diameter shrinkage Fibrotic sealing of the vessel

The VNUS® Closure Solution

Disposable Catheter Inserted into Vein; Energy Delivered

Procedure  Minimally-invasive procedure  Local anesthesia in treatment room or outpatient setting

Catheter Indexed to Next Segment; Proximal Segment Seals

Recovery  Rapid recovery  Minimal pain and bruising

ClosureFAST

Catheter

• Heating element treats 7 cm of vein at once – Segmental ablation technology

• Average treatment time: 3-5 min • For saphenous and SFJ tributary treatment

Indication and Contraindications  Indication • The ClosureFAST catheter is intended for endovascular coagulation of blood vessels in patients with superficial venous reflux

 Contraindication • Patients with thrombus in the vein segment to be treated

Choosing the Closure Candidate • Preoperative ultrasound evaluation – Reflux > 0.5 seconds in superficial venous system – Assess GSV, noting: • Vein depth and maximum diameter • Presence of tortuous or aneurysmal segments • Other significant anatomy – Duplicate systems – Large side branches – Incompetent perforators or tributaries

– Assess SSV

GSV Variables Tortuosity

Images courtesy of Olivier Pichot, MD

Side branches

GSV Variables Aneurysmal segments

Intra-operative Ultrasound • • • • •

Vein access Catheter navigation Tumescent fluid infiltration Final tip positioning Confirmation of procedure success

Closure System Method of Action  Vein wall heated via RF energy delivery to catheter heating element, resulting in: • Endothelial denaturation • Collagen contraction • Fibrotic sealing

Goat saphenous vein 12 wks post-ablation

3 Phases of the Closure Procedure 1. System and Patient Preparation 2. Treatment 3. Post-op Duplex Scan

Pre-Op Duplex Mapping  Exam best performed with patient in 15 - 30 reverse Trendelenburg  Leg externally rotated & bent at knee

Pre-Op Duplex Mapping  Identify and mark: • Saphenofemoral junction • Aneurysmal and segments

tortuous

• Large branches and perforators • Vein depths