Endovenous-Saphenous-and-Perforator-Vein-Ablation_2008_Operative-Techniques-in-General-Surgery.pdf

8/17/2019 Endovenous-Saphenous-and-Perforator-Vein-Ablation_2008_Operative-Techniques-in-General-Surgery.pdf

http:///reader/full/endovenous-saphenous-and-perforator-vein-ablation2008operative-techniques-in-general-surgery… 1/5

Endovenous Saphenous and Perforator Vein Ablation

Michael J. Singh, MD, and Cheryl Sura, LPN, RVT

Venous insufficiency is a common disorder. Approxi-mately 80 million people are affected; it is estimated that30% of women and 10% to 20% of men have varicose veins.Superficial varicosities are often caused by venous reflux be-cause of failure of the valves in the saphenous vein and at thesaphenofemoral junction. This reflux increases superficialvenous pressure, which then leads to the development of varicose veins. Transmission of pressure to the deep systemvia incompetent perforators (or intrinsic deep reflux) leads toclassic venous insufficiency, which is manifested by ankle

edema, leg fatigue, aching, purities, stasis dermatitis, lipoder-matosclerosis, or ulceration.

In a relatively short period of time, endovenous radiofre-quency ablation has emerged as the standard of care for manag-ing superficial and perforator vein reflux. For those who havefailed conservative treatment, endovenous ablation has beenshown to be an effective and efficient procedure for managingvenous insufficiency. Patients require minimal time for recoveryand pain is marked reduced when compared with traditionalsurgical techniques offered for venous insufficiency. En-dovenous laser ablation has similar success rates, but tends tohave a higher incidence of postoperative ecchymosis, thrombo-phlebitis, and pain that makes it a less attractive option.1-4

Indications

Radiofrequency ablation (RFA) is appropriate for virtuallyany saphenous vein, although certain anatomic criteria mustbe present. Most patients will have a Clinical Etiology Anat-omy Pathophysiology classification score of 2 to 6.5 Obvi-ously, the first requirement is that reflux exists in the saphe-nous vein. This is determined using duplex ultrasonographywith direct visualization of retrograde flow through incom-petent valves in response to gravity, compression, or Valsalvamaneuver. Starting at the groin of the symptomatic leg, alongitudinal view of the common femoral vein is obtained,with blue assigned as antegrade venous flow. The patient

performs a valsalva maneuver and the color-flow and Dopp-ler spectral changes are observed. The same steps are fol-lowed for the superficial femoral vein, saphenofemoral junc-tion and both saphenous veins (greater and small).

Finally, although not a medical requirement, most insur-ance companies will not provide coverage of venous proce-dures unless the patient has been compliant with a nonop-erative treatment regimen for at least 3 months; this includesthe use of compression stockings, leg elevation, exercise,weight loss, and anti-inflammatory medications.

Preoperative Evaluation

A preprocedure duplex ultrasound examination is initiallyperformed to document reflux in the system to be treated.This is also required to determine whether the patient has theproper anatomy for the procedure as discussed above; itshould assess patency of the entire lower extremity venoussystem (deep, superficial, and perforator). Routine hemato-logic or other laboratory studies are not typically performed,unless indicated by the health history (eg, anticoagulationtherapy would require checking an INR).

Procedure Technique

Endovenous procedures can be performed today in the officesetting, an outpatient surgical center, or operating room. In most

circumstances today, most procedures are performed in the of-fice, in part because of insurance company incentives. Using anoral anxiolytic combined with generous local tumescent anes-thesia, patient comfort, safety, and acceptance are excellent.6-7

Patients are premedicated with two 5 mg doses of diazepam,the first is administered 1 h before the procedure and the second just before initiating the endovenous procedure. The patient isplaced in reverse Trendelenberg position (5-10°), which dilatesthe venous system and aids percutaneous access. The knee isslightly flexed and externally rotated. After sterile preparation,the greater saphenous vein (GSV) is marked, mapped, and mea-sured with a portable ultrasound machine. A probe frequency of 7.5 MHZ or greater is beneficial during these procedures as a

shallow depth of field is helpful to optimize vessel resolution. Areas of angulation, tortuosity, large branch vessels, and aneu-rismal dilation are marked on the skin overlying the vein. Theoptimal access site is determined by ultrasound imaging andoften is below the level of the knee.

Percutaneousultrasound guidedaccess is obtained using amicropuncture needle (Fig 1), and through a 7 Fr sheath theradiofrequency ablation catheter (ClosureFast; VNUS Medi-cal Technologies, San Jose, CA) is advanced to the saphe-nofemoral junction (SFJ) (Fig 2). In some cases, venous tortu-ousity or prior phlebitis may not permit catheter advancement.

Division of Vascular Surgery, University of Rochester Medical Center, Roch-

ester, NY.

Address reprint requests to Michael J. Singh, MD, Division of Vascular Sur-

gery, University of Rochester Medical Center, 601 Elmwood Avenue,

Rochester, NY 14642. E-mail: [email protected]

1311524-153X/08/$-see front matter © 2008 Elsevier Inc. All rights reserved.

doi:10.1053/j.optechgensurg.2008.09.004

mailto:[email protected]:[email protected]:[email protected]



These situations are handled by straightening the vein withexternal compression using the “skin stretch maneuver” and

ultrasound imaging. Alternatively, an over-the-wire tech-nique using a 0.018 or 0.025 angled hydrophilic guide wirewill aide the passage of the catheter. Longitudinal imagingwith the ultrasound probe will best define the location of theepigastric vein and SFJ in relation to the catheter tip. The tipof the catheter is drawn back and positioned 20 mm distal tothe SJF and distal to the superficial epigastric vein (Fig 3),which is important to maintain flow through the SFJ aftersaphenous closure.

Tumescent anesthesia, a large-volume, low-concentrationLidocaine solution (0.10-0.25%) is commonly used for en-dovenous ablation. This is a combination of 50 mL 1% Lido-caine with epinephrine and 5 mL of sodium bicarbonate in

500 mL of 0.9% normal saline. The tumescent infiltration is

extremely important for procedural success: it compressesthe vein around the catheter for improved contact, increases

the distance from the skin to the vein to minimize (ideallyeliminate)thermal skin injury, and eliminates pain. Adequatetumescent infiltration begins at the access site and extendsbeyond the catheter tip. The 22-gauge spinal needle is posi-tioned in the perivenous fascia and infiltration is guided byultrasound imaging. The goal is to circumferentially com-press the vein within the perivascular compartment, thuscreating a halo around the catheter and vein. To protect theskin, tumescent infiltration should separate the skin andcatheter by at least 10 mm.

The radiofrequency catheter tip position (20 mm distalto the SFJ) is confirmed by ultrasound and direct pressurealong the course of the vein is applied. The procedure is

initiated as per recommended protocol. The catheter has a

Figure 1 Lidocaine (1%) is locally infiltrated at thechosen site. Percutaneousultrasound guidedaccess is obtained using

a micropuncture catheter system. Using B-mode imaging, the vein is centered on thetransducer in a longitudinalplane(parallel to thevein). Theaccess needleis positioned bevel up at a 60°angle andthe anterior wall of thevein penetrated.

A longitudinal image provides excellent visualization of the tissue planes and anterior vessel wall as the needled isadvanced. After access is obtained, the micropuncture system is exchanged for an 11-cm 7 Fr introducer sheath using

themodified Seldingertechnique. Smaller veins andveinsin spasm canbe challenging.Accessin these situations is aided bythe placement of an elastic tourniquet proximal to the access site. Alternatively, a small surgical cut down (3-4 mm) will

provide direct visualization of the vein and elevation with a blunt tipped stab phlebectomy hook utilized. v. vein.

132 M.J. Singh and C. Sura



7 cm long heater element that reaches 120°C for 20 s at atime; the tip is then drawn back at 6.5 cm increments andthe cycle repeated. At the completion of the procedure, afinal duplex scan is performed to confirm patency of theepigastric vein, SFJ, and deep venous system. The rate of immediate GSV occlusion at the SFJ is almost 100%; ul-trasound imaging will show a thickened vein wall with

absence of a flow lumen.

Bilateral GSVablation can easily be performed. Doubling theamount of tumescent solution is necessary; this has been showntobe safeat a concentrationof 35mg/kg. During bilateral VNUSClosure procedures, percutaneous ultrasound guided GSV ac-cess is obtained in each leg before the catheter insertion. Thistechnique minimizes access problems in the contralateral legbecause ofvasospasm.The more tortuous GSVis alwaysablated

first, which allows theuseof theover-the-wirecatheteradvance-

Figure 2 Percutaneousvenous access is obtained at or below thelevel of theknee.Thenew 7 Fr radiofrequency ablation

catheter (ClosureFast; VNUS Medical Technologies) comes in two lengths (60 cm and 100 cm). The catheter length ismeasured ex vivo and the catheter advanced to the saphenofemoral junction (SFJ). a. artery; v. vein.

Endovenous saphenous and perforator vein ablation 133



ment technique. Often the catheter lumen occludes during thefirst Closure procedure that prevents use of the over-the-wire

technique during the second procedure.Short saphenousvein (SSV) ablation is similar to that of thegreater saphenous vein.If performedsimultaneously the GSVis addressed first, followed by repositioning thepatient in theprone position. The SSV is marked, mapped, and measured.Percutaneous access is obtained in the mid to distal calf andthecatheter inserted andpositioned 20 mm below thesaphe-nopopliteal junction. Tumescent anesthesia is infiltrated andthe procedure started. Follow-up imaging and instructionsare identical to the GSV ablation.

After the procedure, access site(s) are covered with a sterilebandage and thigh high 20 to 30 mm Hg compression stock-ings applied and left in place for 24 h. A follow-up Duplexscan is performed 3 to 5 days after the procedure to docu-

ment absence of thrombus central to the SFJ or SPJ as appro-priate.

Perforator Vein Ablation

The traditional surgical Linton procedure has been replacedby subfascial endoscopicperforator surgery (SEPS, see articleby Iafrati MD in this issue) for treatment of incompetentperforators, and in turn SEPS may be soon replaced by per-cutaneous perforator ablation.The current treatmentmethodis a modification of GSV radiofrequency ablation, and can beperformed as a stand-alone procedure or along with GSVablation (Fig 4). A completion duplex scan should be per-

formed to confirm successful perforator closure and patency

of the deep venous system. RF perforator ablation can effec-tively treat incompetent perforator veins with minimal mor-

bidity and a closure rate of 70% to 80%.8

Results

Since its inception in 1998, it is estimated that over 250,000radiofrequencyablation procedures havebeenperformed. Aswith many industry-driven technologic procedures, harddata are somewhat lacking. Early trials demonstrated an un-acceptably high rate of cutaneous skin burns, but this prob-lem has largely been eliminated with the technique of tumes-cent anesthesia. An immediate closure rate of approximately85% is commonly quoted, but long-term follow-up is poor. When subjected to Kaplan-Meyer analysis, most failures (re-canalization) occur within the first year or so, and long-term

outcome after this is generally satisfactory. There is some datasuggesting that endovenous laser therapy hasa slightly betterclosure rate than radiofrequency ablation, but these data arederived using the first-generation RFA device. The second-generation device, ClosureFast (VNUS Medical Technolo-gies), has shortened pullback times to approximately 3 minand is associated with 100% closure at 6 months in prelimi-nary studies.9-11

Summary

Endoluminal radiofrequency ablation has many advantagesover the traditional high ligation and strippingprocedures. In

a short period of time, it has become a viable alternative and

Figure 3 Longitudinal imaging with the ultrasound probe will best define the location of the epigastric vein and SFJ in

relation to the catheter tip. The tip of the catheter is drawn back and positioned 20 mm distal to the SJF and distal tothe superficial epigastric vein, and the locking donuts are advanced to secure the catheter position. Preservation of the

SEV is of the utmost importance as it maintains flow through the SFJ after closing the GSV. a. artery; v. vein.

134 M.J. Singh and C. Sura



possibly standard of care for the management of saphenousvein insufficiency. This less invasive technique has beenshown to have a high technical success rate, low morbidity if performedproperly, andhigh patient satisfaction, andis verysuccessfully performed in an office setting.

References1. Pannier F, Rabe E: Endovenous laser therapy and radiofrequency abla-

tion of saphenous varicose veins. J Card Surg 47:3-8, 2006

2. Stirling M, Shortell CK: Endovascular treatment of varicose veins. Se-min Vasc Surg 19:109-115, 2006

3. Almeida JL, Raines JK: Radiofrequency ablation and laser ablation in

the treatment of varicose veins. Ann Vasc Surg 20:547-552, 2006

4. Hirsch SA, Dillavou E: Options in the management of varicose veins.

J Card Surg 49:19-26, 2008

5. KunduS, LaurieF, Millward SF:Recommendedreportingstandards for

endovenous ablation of the treatment of venous insufficiency: Joint

statement of the American Venous Forum and the Society of

Interventional Radiology. J Vasc Inter Rad 18:1073-1080, 2007

6. Bush RL, Constanza RM: Endovenous saphenous and perforator vein

ablation. Sem Vasc Surg 21:50-53, 2008

7. Roland L, Dietzek AM: Radiofrequency ablation of the great saphenousvein performed in the office: tips for better patient convenience and

comfort and how to perform it in less than an hour. Pers Vasc Surg

Endovasc Ther 19:309-314, 2007

8. Peden EK, Lumsden AB: RF ablation of incompetent perforators. Endo

Today 1:15-17, 2007 (suppl)

9. Dietzek AM: Endovenous radiofrequency ablation for the treatment of

varicose veins. Vasc 15:255-261, 200710. Luebke T, Gawenda M, Heckenkamp J, et al: Meta-analysis of en-

dovenous radiofrequency obliteration of the great saphenous vein in

primary varicosis. J Endovasc Ther 15:213-223, 2008

11. Proebstle TM, Vago B, Alm J, et al: Treatment of the incompetent great

saphenous vein by endovenous radiofrequency powered segmental

thermal ablation: first clinical experience. J Vasc Surg 47:151-156,

2008

Figure 4 The leg is positionedand the perforator veins marked andmapped with ultrasound imaging; distance from the

medial malleous is documented to guide follow-up imaging. The leg is prepped and draped and the perforator veinlongitudinally visualized. Placing the transducer parallel to the perforator vein and using B-mode imaging improves

visualization and simplifies vessel access. One percentage Lidocaine is locally injected and a 12 gauge angiocathinserted at a 60° angle. Intraluminal placement is confirmed by noting dimpling of the anterior vessel wall and

aspiration of blood. The RFS catheter is inserted and beaded catheter tip advanced to a subfascial segment of the

perforator vein. Thefinal position of thetip shouldbe 5 mm from thedeep system, which reduces theincidence of deepvein thrombosis. Catheter placement is confirmed and tumescent anesthesia locally administered. Direct pressure is

applied over the catheter and vein using the ultrasound probe. A four-quadrant closure technique at 85 degree Celsiusis used. To ensure adequate wall contact, the closure is performed over 4 min (1 min per quadrant). Impedance levels

should range from 150 to 350 Ohms; levels over 400 Ohms suggest extraluminal catheter placement. After the 4-mincycle is complete, the catheter is pulled back 5 to 10 mm and a second 2-min treatment performed. v. vein.

Endovenous saphenous and perforator vein ablation 135

Endovenous-Saphenous-and-Perforator-Vein-Ablation_2008_Operative-Techniques-in-General-Surgery.pdf

Documents

Transcript of Endovenous-Saphenous-and-Perforator-Vein-Ablation_2008_Operative-Techniques-in-General-Surgery.pdf