practical aspects of endovenous laser ablation of

Uldis Maurins

PRACTICAL ASPECTS OF ENDOVENOUS LASER ABLATION OF VARICOSE VEINS

UDK 615.84(612.15)(616.14) Ma 918

Uldis Maurins

Financial support for the printing of this book was generously provided by

and also by

Imprint Uldis Maurins Practical Aspects of Endovenous Laser Ablation of Varicose Veins ISBN 978–9934–14–363–2 Designed by R KVADRATA Printed by Laima Print Copyright © Uldis Maurins 2014 Kokneses prospekts 18A, LV–1014 Riga, Latvia www.venucentrs.lv [email protected]

PRACTICAL ASPECTS OF ENDOVENOUS LASER ABLATION OF VARICOSE VEINS

Contents

Foreword

Recently endovenous laser ablation (EVLA) has undergone an incredibly rapid development. In the developed countries it has become the current gold standard for varicose vein treatment, entirely replacing crossectomy and stripping. Only 15 years have passed since the first EVLA, which is why there is still a major deficit of information among doctors about this technology and its everyday application in practice. A clear sign of this is the popularity of the workshops and congresses organized by the Baltic Society of Phlebology. In all of these events doctors have exhibited active interest in different technical details of EVLA. Consequently this book aims at summarizing the important practical information necessary for a successful performance of EVLA. I hope that you will find this book an interesting and useful read and it will help you in your everyday practice when treating patients with different forms of varicose veins. Also, I would appreciate any proposals and suggestions for future editions of the “Practical aspects of Endovenous Laser Ablation of Varicose Veins”.

Yours sincerely, Uldis Maurins President of the Baltic Society of Phlebology

Introduction .

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Treatment guidelines .

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Pre-operative duplex ultrasound investigation and vein mapping . . . . . . . . . . . . . . . . . . . . . . . . . Management in operating theatre . Anaesthesia

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8 8

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Target vein puncture, guide-wire, introducer sheath and laser fibre introduction . . . . . . . . . . . . . . . . . . . . . .

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Anaesthesia in track of the target vein . EVLA .

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EVLA of GSV.

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EVLA of SSV .

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Postoperative monitoring and further treatment . References .

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P R A C T I C A L A S P E C T S O F E N D O V E N O U S L A S E R A B L AT I O N O F VA R I C O S E V E I N S

Introduction Vein surgery has undergone significant changes in the recent years – varicose vein endovenous thermal ablation has been introduced internationally and has become standardized since 1999. The application of this method allows for replacing the classical vein surgery – crossectomy and stripping of the insufficient segments of the great and small saphenous veins. Initially, endovenous laser ablation (EVLA) was performed by lasers, the emitted energy of which absorbed the haemoglobin in blood (lasers with wavelengths from 810 nm to 980 nm). After the therapy patients operated with these lasers typically not only had strong bruising, but also experienced long-term pain along the treated veins. In 2006, there was a new generation of lasers developed; the energy emitted by these lasers is absorbed by water in the vein wall, wavelength from 1320 nm to 1550 nm. These new lasers provided the possibility to significantly reduce pain and bruising following the ablation. Further, a very important step in the development of laser technology was achieved in 2008, when radially emitting laser fibres were introduced, as opposed to the frontward-emitting laser fibres (Bare fibres). The new fibres, instead of punctual or linear distribution, now distribute the laser beam in the vein radially, thus more homogeneously spreading the laser energy within the vein wall during the EVLA procedure. This gave another opportunity to minimize bruising and pain after EVLA. 6

At present, the gold standard of EVLA is lasers with water absorbing laser wavelengths (in practice, the most frequently used is the 1470 nm diode laser) and radially emitting fibres. After undergoing treatment with this technology, more than 90% patients do not feel pain after the ablation, so no pain relieving medication is required and EVLA can be performed without using compression therapy after surgery. This outpatient surgery provides for an even enhanced cosmetic effect, a lower risk of complications and better quality of life following the surgery. Moreover, it can be performed on more elderly patients and on patients with serious medical conditions, because it is done using only ultrasound (US) guided local anaesthesia. It should be noted that due to EVLA a patient needs to stay in the clinic only for 1 to 2 hours and may continue their daily and professional activities on the same day. EVLA definition: Laser energy thermally denatures vein wall collagen, resulting in an inflammation of the vein wall, then fibrosis, and finally a closure of the vein with further vein resorption and transformation into the scar tissue.

I have conducted EVLA using only a 1470 nm laser and different laser fibres since 2007. In the clinic where I work more than 3 thousand EVLA are carried out every year. On the basis of this experience I will describe in this paper the practical aspects of EVLA when using this technology. 7


The application of this technology allows to achieve a complete transformation of the treated vein into scar tissues in 96% cases within a year following the surgery. At the same time, it is characterized by a minimal level of pain in the postoperative period; it is possible to treat both very small diameter and very large diameter (of more than 2–3 cm) veins, as well as to treat short vein segments – starting from 2–3 cm. EVLA with a 1470 nm laser and radially emitting fibres is extremely universal. At the same time the results are accompanied with only a minimal risk of side effects and complications.

The most significant difference in planning the surgery that has occurred in the recent years be in the fact that due to the use of the new 2ring laser fibres it is now possible to treat also very superficial venous segments, with a low level of pain in the track of the treated vein and a reduced risk of adverse events in the postoperative period. Therefore, all straight insufficient segments of veins, from the proximal to the distal insufficiency point, along the axial reflux are included in planning the EVLA, thus significantly reducing the need for miniphlebectomies after EVLA. The treatment is usually performed in two steps: firstly, EVLA is done for axial reflux of intrafascial parts of saphenous veins and straight extrafascial vein branches and, secondly (usually after 3 months), varicose vein branches are treated, if necessary.

Treatment guidelines

In the standardized sites (for GSV: 3 cm, 25 cm, 50 cm from the saphenous junction, and the puncture level, for SSV: 3 cm, 20 cm from the saphenous junction and punctures level), the vein diameter should be measured to calculate precisely the required energy amount for the target vein ablation at different vein sites.

Pre-operative duplex ultrasound (DUS) investigation and vein mapping Prior to the surgery, with the patient in a standing position, DUS for the veins selected for treatment is performed and marking on skin is done in DUS guidance. The saphenous vein insufficient segments: the great saphenous vein (GSV) and small saphenous vein (SSV), as well as straight, insufficient intrafascial veins: anterior accessory saphenous vein (AASV), posterior accessory saphenous vein (PASV), superficial accessory saphenous vein (SASV) and thigh extension of SSV/Giacomini vein (VG), as well as extrafascial venous segments and perforating veins are marked on the patient’s skin. 8

Particular attention during the planning of the operation should be paid to the following:

1. tortuous vein segments, as it may be difficult for a guidewire and laser fibre to pass through this part of a vein;

2. aneurysmal dilatations of vein segments, marking them

on the skin is recommended, because these parts of a vein will require the application of more energy for successful ablation, depending on the diameter of the vein; 9


3. vein segments with postphlebitic webs inside, because

there may be a difficulty in the guide-wire and laser fibre advancement into the vein, moreover, postphlebitic vein segments need more energy application for a successful ablation;

in the case of a venous spasm, or if small diameter veins need to be treated in order to enhance venous filling and to make the puncture and laser fibre advancement easier. EVLA is usually performed by the surgeon and two assistants. Figure 1 shows a typical situation in the operating theatre during the performance of the vein surgery.

4. the relationship of nerves with the target vein should be analyzed: saphenous and sural nerves, if distal segments of the GSV and SSV are to be treated and sciatic nerve and its major branches (tibial and peroneal nerves), if the SSV is to be treated;

5. the distance from the target vein to the skin where the

vein segments should be treated, if the vein is localized close to the skin, then, by using an anaesthetic solution the surgeon should ensure a safe distance from the skin (using a cold (4–5oC) anaesthetic solution it is entirely satisfactory to have a 5 mm distance between the skin and the target vein) to reduce the risk of skin damage during the ablation.

Management in operating theatre

Figure 1 Operating theatre equipped for the performance of vein surgery

Following the completion of a pre-operative vein mapping and marking on the skin, the patient is placed on the operating table. Preferably, the operating table should be adapted not only by height, but also so that the patient can be put into the Trendelenburg position and into the reversed Trendelenburg position. The reversed Trendelenburg position can be very useful 10

11


One of the assistants working under sterile conditions helps the surgeon in carrying out the operation, while the other assistant working under non-sterile conditions, takes care of a patient during surgery, monitors the patient’s vital signs, as well as services the ultrasound machine and laser generator (Figure 2).

Anaesthesia EVLA is usually performed only under local tumescent anaesthesia, using only a very lightly diluted Lidocaine solution, usually 0.05%. By using the local tumescent anaesthesia, it is possible to exclude complications that can be attributed to general or spinal anaesthesia. Moreover, the choice of the right anaesthetic method plays a very important role in the EVLA qualitative performance, since as a result of the tumescent anaesthesia:

1. the blood is squeezed out of the vein (an empty target

vein is reached) and thus the potential energy absorption by blood is reduced;

2. a good contact between the laser fibre and the vein wall is achieved, and the laser energy transfer to the vein wall is improved;

3. the surrounding tissue is separated from the target

vein, thus reducing the potential thermal damage of the surrounding tissue (nerves and lymphatic vessels) during the ablation;

o 4. the use of a cold tumescent solution (4–5 C – bottles

Figure 2 Laser tower, from top to bottom: the monitor for the patient’s vital signs monitoring, LEONARDO® laser, infiltration pump, Ceralas® laser 12

of anaesthetic solution are stored in the refrigerator and removed from it shortly before the surgery), allows to further preserve the tissue around the vein and to absorb the laser energy residue. 13


Target vein puncture, guide-wire, introducer sheath and laser fibre introduction After sterile preparation of the area to be operated on, the vein is punctured at the distal insufficiency point. The vein can be punctured in longitudinal or transverse planes under US guidance. We usually perform the vein puncture in the transverse plane, as this technique facilitates small diameter vein puncture. In this case, the ultrasound probe is positioned along the vein, at the distal insufficiency point, the target vein is positioned in the centre of the probe and the vein puncture is carried out in distance from the probe for about 1–1.5 cm with a 18GA needle or a 17GA short catheter. For a fast and accurate performance of the vein puncture it is essential to take into account the depth of the vein from the skin when calculating the angle at which the puncture must be performed. When the venous blood appears in the puncture needle/catheter, the vein puncture is continued for a few mm under US guidance, attempting a needle tip into the centre of the vein lumen, to ensure a safe venous access. After the vein puncture, the guide-wire (45 cm long) is gently inserted through the needle into the vein. After removing the needle a slight local anaesthesia of the puncture site with a tumescent solution is carried out.

14

Tumescent solution composition: Sol. NaCl 0.9% – 1000 ml Sol. Lidocaini 2% – 25 ml Sol. Adrenalini 0.01% – 1 ml Sol. NaBic 8.4% – 12 ml

It is followed by an insertion of a 6Fr introducer sheath (11 cm long) and a dilator through a guide-wire. After the dilator and guide-wire have been removed, the laser fibre under US guidance is introduced into the target vein through the introducer sheath and the position of the fibre tip at the saphenous junction is controlled by US guidance. The laser fibre tip is usually placed at the level of the deep vein, usually either at the level of the terminal vein valve or immediately below the superficial epigastric vein for GSV.

Anaesthesia in track of the target vein After positioning the laser fibre, anaesthesia with a cold tumescent solution in the track of the target vein is performed. It is recommended to start the infiltration of anaesthesia from the puncture site moving up gradually. The average amount of the tumescent solution required for anaesthesia of the target vein is 8 ml per a cm of vein. For instance, for treating a 50 cm vein segment approximately 400 ml of the tumescent solution are needed. This should also be taken into consideration when planning the amount of treated veins for ablation, as the administered 15


anaesthetic solution substances should not exceed the maximum allowed dose per kg of body weight. If you need to treat many veins in both legs, the volume of the solution required for anaesthesia and the quantity of the anaesthetic substance may easily exceed the upper limit, and in this case it would be recommended to perform EVLA on two or more separate days. CAVE If adrenaline is added to the anaesthetic solution, Lidocaine can be applied up to 7 mg / kg of body weight: Maximal volume of the tumescent solution for a patient with 50 kg weight – 350 mg Lidocaine = 700 ml of 0.05% tumescent solution Maximal volume of the tumescent solution for a patient with 70 kg weight – 500 mg Lidocaine = 1000 ml of 0.05% tumescent solution

Large amounts of the anaesthetic solution may be complicated to infiltrate manually (especially when carrying out many operations per day), so it is advisable to use an infiltration pump. The infiltration pump provides the most rapid application of the cold anaesthetic solution around the vein – the average time it takes to anesthetize a 50 cm vein is approximately 5 minutes. The faster the anaesthetic solution is applied, the colder it will be and the better the tissues around the vein during the EVLA will be protected; moreover, the better the energy residue will be absorbed from the treated vein. 16

CAVE The faster the cold tumescent solution is administered in the track of the treated vein, the colder it will be during ablation and the better will be its protection for the tissues close to the vein.

In order to perform the tumescent solution infiltration, it is recommended to use a long needle (12 cm), thus reducing the number of punctures required for anaesthesia. Typically, the strongest patient discomfort and pain during the treatment is associated with the anaesthetic solution application, rather than the laser ablation itself. A patient feels the most pain during the punctures through the skin, rather than during subcutaneous or intrafascial anaesthetic solution infiltration, which is usually characterized by patients as only a sensation of pressure. The anaesthesia solution application should be mandatorily performed under US guidance, continuously monitoring the localization of the needle tip, preventing unguided tumescent solution intravenous application or unnecessary collateral tissue traumatisation. During the administration of anaesthetic solution, the operator should try to make circular, smooth spreading around the vein: squeezing out the blood from the vein, thus achieving good contact between the vein wall and the laser fibre. When anaesthetizing the venous segments localized close to the deep veins, nerves and skin, it is advisable to make some effort to achieve a distance from these sensitive structures by application of anaesthetic solution to protect them from thermal damaging during the laser ablation. 17


EVLA When infiltration of the anaesthetic solution in the track of the target vein is completed, the final laser fibre tip positioning under US guidance must be performed. This is due to the fact that the surgeon’s or assistant’s movements, as well as the tumescent solution application may often result in a laser fibre dislocation: moving it to the deep vein, or on the contrary – pulling it distally, hence, before starting ablation of the target vein it must be definitely re-visualized and its proper placement should be verified to reduce possible deep vein damage. Usually the laser fibre tip is positioned at the deep vein level (at the terminal valve level or immediately below the superficial epigastric vein), or maximum 2 cm distal from the saphenous junction. The closer to the deep vein the ablation of the target vein can be fulfilled, the lower the possibility of recanalisation of the treated vein in the future. Before activating the laser generator, the pilot beam visibility should be monitored (Figure 3): if the pilot beam is not visible through the skin, it is possible that the laser fibre tip has been dislocated into the deep vein – the laser fibre tip position must be rechecked again. CAVE If the pilot beam is not visible through skin: Check the laser fibre tip localization under US guidance Check for possible laser fibre damage 18

Figure 3 Pilot beam in the groin

19


Then the laser generator is activated, and the patient, the surgeon and assistants put on appropriate protective glasses depending on the laser wavelength selected. At this point the target vein ablation with laser starts. The laser energy that is required to be delivered per cm of the target vein during the ablation should be calculated prior to the surgery, while making preparations for the operation, thus the adequate amount of energy for the treated vein will be calculated and delivered. The necessary amount of energy for the ablation is calculated depending on the vein diameter at different sites multiplied by 7 for radially emitting (Radial, Radial 2ring, Radial slim) laser fibres and by 10 when the operation is performed with the Bare fibre. CAVE Ablation energy amount calculation for 1 cm vein ablation: The diameter of the vein multiplied by 7: Radial, Radial 2ring, Radial slim laser fibres The diameter of the vein multiplied by 10: Bare laser fibre

The differences in the diameter of the vein at various sites of the vein and venous aneurysmal dilatations along the vein should definitely be considered at this point. Usually, the vein proximally has a larger diameter, while distally the vein diameter decreases. Pre-operative vein marking of the skin into 10 to 15 cm long segments and ablations energy calculation and delivering for each segment depending on the diameter of the vein at the respective segment will facilitate the exact energy applications. 20

For instance, for the treatment of a 45 cm long GSV segment, with the average diameter of the proximal 15 cm of the vein being 10 mm, the average diameter of the middle 15 cm of the vein being 8 mm and average diameter of distal 15 cm of the vein – 6 mm, the following amount of energy should be delivered for the ablation with radially emitting laser fibres of this particular vein: for the proximal part of the vein approximately 70 J/cm, for the middle part of the vein approximately 60 J/cm and for the distal part – approximately 40 J/cm. The average linear endovenous energy density (LEED) will be 60 J/cm in this particular case, but we will not have treated the entire vein with 60 J/cm, but very precisely and differentially applied energy in each vein part according to the respective diameter of the vein. The average endovenous fluence equivalent (EFE) in this case will be about 30 J/cm2 per each vein part and the total treatment energy of about 3000 J. This amount of ablation energy using radially emitting laser fibres provides for a very low level of postoperative pain and complete resorption of the vein and the transformation into a scar in 96% of cases during the year. The average time required for a 50 cm vein ablation is about 7 minutes. The next essential issue is as follows: what laser power to perform EVLA with? Maximum power of the laser generators used for vein treatment usually does not exceed 30W. At the early stage of the laser vein treatment era it was initially recommended to use power of 30W for conducting EVLA with Bare fibres, because that allowed for a better vein occlusion. Later studies revealed that a similarly good vein occlusion could be achieved 21


by treating veins with a lower power; however, patients treated with lower power for similar ablations final energy had a significantly lower level of pain after surgery in the track of the treated vein. Currently EVLA is performed using a 1470 nm laser and Radial and Radial 2ring fibres with 10W power. CAVE Laser power for different fibres used for EVLA with 1470 nm laser: Radial slim fibre: 7W Radial, Radial 2ring fibre: 10W Bare fibre: 15W

Finally, to delivering the calculated energy. Energy during EVLA is usually delivered in a continuous mode because the pulse mode is associated with a higher possibility for a perforation of the vein during the ablation and leads to more pain and bruising after the operation. Precise energy delivery is facilitated by Signal mode of laser generator and cm marks on the laser fibre. It is possible to adjust the calculated energy for the ablation to every cm of the treated vein during the ablation under the Signal mode, and each time when the pre-set amount of energy is reached, an acoustic signal is emitted. The harmonization of these signals with the cm markings on the laser fibre can help provide precise energy deliveries to the vein wall. 22

Very essential in this process is vein compression at the level of the laser action with an ultrasound probe during the ablation of the target vein, in order to improve the contact between the laser fibre tip and the vein wall during the ablation, as well as continuous monitoring of the ablation effect (circular spread of steam bubbles in the vein wall) during the entire operation. At the beginning of EVLA it is usually monitored in the longitudinal plane: the vein is lightly compressed with an ultrasound probe and then the laser generator is activated by the footswitch. It is very important not to start laser fibre pullback immediately after the laser activation, but instead wait until the steam bubbles in the vein wall appear at the point of contact between the laser fibre tip and the vein wall. Steam bubbles in the vein wall indicate that we have reached the temperature required for ablation (irreversible denaturing of the vein wall) – approximately 100 °C, usually one Signal mode cycle is required for this. Only at that moment do we start the smooth pullback of the laser fibre, permanently following the laser fibre tip location by US and performing it with a mild compression of the ultrasound probe. It is also important to ensure a smooth pullback speed of the laser fibre during the entire ablation. 10 J of laser energy is delivered to the vein wall in 1 second during EVLA with 10W power. So, if we need to deliver 50 J to a 1 cm vein, the laser fibre pullback speed should be 2 mm/sec, or a 1 cm vein ablation requires 5 seconds. It is relatively easy to ensure this for small veins, but in the case of an aneurismatically transformed vein (> 15 mm) it can be quite difficult – if more than 100 J need be delivered for a 1 cm vein and the pullback speed than is slower than 1 mm per second, which is difficult to ensure manually; also, the laser 23


fibre tip may begin to stick to the vein wall (an increased risk for the carbonization of the laser fibre tip). In this case, the energy delivery necessary for the target vein will facilitate the movement of the laser fibre back and forth within one cm of the vein between two acoustic signals in the Signal mode, after which the laser fibre is pulled back by 1 cm and the next vein cm can be treated.

laser and 2ring laser fibres) without compressions stockings is only 0.9±0.9 in a comparative study of EVLA with and without compressions therapy. Therefore patients do not require additional compression therapy after EVLA, which facilitates the treatment of patients during the summer season or in hot weather conditions.

When the vein is treated up to the introducer sheath through which the laser fibre was introduced into the vein, it is required to pull out the introducer sheath from the vein in order to be able to ablate the vein’s last part. This process is facilitated by the appearance of the first black label on the laser fibre; moreover, the laser generator needs to be disabled by the time the end of the second black label (2 cm long) appears in order to prevent burning of the skin. After withdrawing the laser fibre, one should make sure that the laser fibre has not been damaged during EVLA. If during the ablation laser fibre fragmentation has occurred, it is necessary to locate these fragments by means of US guidance and a surgical evacuation of the fragments from the patient should be performed. Next, a small local compression bandage is applied onto the puncture site to be kept there until the next morning. In the case of a 1470 nm laser in combination with a 2ring laser fibres, patients do not need any additional therapy in the postoperative period. The intensity of pain measured by verbal visual analogue scale (0–10), during the first week after EVLA (1470 nm 24

25


EVLA of GSV

Figure 5 Introducing a guide-wire

Figure 4 US guided vein puncture 26

Figure 6 Guide-wire is introduced 27


28

Figure 7 Slight local anaesthesia at the puncture site

Figure 9 Removing the dilator and guide-wire

Figure 8 Introduction of dilator and introducer sheath (CAVE: guide-wire control (do not lose guide-wire))

Figure 10 Dilator and guide-wire are removed 29


LF

TV

30

Figure 11 Introducing the laser fibre

Figure 13 US: laser fibre (LF) tip positioned at the terminal valve (TV) level

Figure 12 Laser fibre tip positioning under US guidance at the femoral vein level

Figure 14 US guided tumescent solution infiltration around the GSV: around the distal part of GSV 31


LF TIP

IN

FV

Figure 15 US guided tumescent solution infiltration in the track of GSV: around the GSV in knee area

Figure 17 US: infiltration needle (IN) between the femoral vein and GSV – distance is gained between the femoral vein (FV) and GSV

IN

LF

Figure 16 US guided tumescent solution infiltration at the sphenofemoral junction 32

Figure18 US: infiltration needle above the GSV (GSV maximally compressed around the laser fibre) 33


SB

Figure 19 US guided laser fibre tip position control and start of ablation

Figure 21 US: start of laser ablation – formation of steam bubbles (SB) in the vein wall

LF TIP

TV

FV

Figure 20 US: laser fibre tip position at the terminal valve level after tumescent solution application 34

Figure 22 US guided EVLA in the proximal part of GSV 35


36

Figure 23 US guided EVLA of GSV in knee area

Figure 25 Removing the introducer sheath

Figure 24 First black marking of laser fibre

Figure 26 Introducer sheath is removed 37


38

Figure 27 US guided EVLA of the last part of GSV

Figure 29 Removing laser fibre

Figure 28 Second black marking of laser fibre, end of ablation

Figure 30 Right leg before EVLA of GSV

Figure 31 Right leg 2 weeks after EVLA of GSV with 1470 nm laser and 2ring fibre 39


EVLA of SSV

GW

40

Figure 32 US guided vein puncture

Figure 34 US: guide-wire (GW) is introduced into SSV

Figure 33 Introduction of guide-wire

Figure 35 Guide-wire is introduced into SSV 41


42

Figure 36 Slight local anaesthesia at the puncture site

Figure 38 Dilator and introducer sheath are introduced

Figure 37 Introduction of dilator and introducer sheath (CAVE: guide-wire control (do not lose guide-wire))

Figure 39 Removing the dilator and guide-wire 43


LF TIP

44

Figure 40 Introducing the laser fibre

Figure 42 US: laser fibre tip positioned at the level of the terminal valve

Figure 41 US guided laser fibre tip positioning at the level of the popliteal vein

Figure 43 US guided tumescent solution infiltration in the track of SSV: around the distal part of SSV 45


LF

TS

PV

IN

Figure 44 US: tumescent solution (TS) infiltration into intrafascial space around SSV, circular spread along SSV

Figure 46 US: infiltration needle below SSV: between the popliteal vein (PV) and SSV – SSV distance from the popliteal vein is achieved

IN TIP

LF TIP Figure 45 US-guided tumescent solution infiltration at the level of the saphenopopliteal junction 46

Figure 47 US: infiltration needle above SSV (SSV maximally compressed around the laser fibre) 47


Figure 48 US guided laser fibre tip position control and start of ablation

Figure 50 US guided EVLA for the proximal part of SSV

SB

Figure 49 US: start of laser ablation – formation of steam bubbles in the vein wall 48

Figure 51 First black marking of laser fibre 49


50

Figure 52 Removing the introducer sheath

Figure 54 US guided EVLA for the distal part of the SSV

Figure 53 Introducer sheath is removed

Figure 55 Second black marking of laser fibre, end of ablation 51


52

Figure 56 Laser fibre is removed

Figure 58 Small local compression bandage applied to the puncture site

Figure 57 Sterile absorbent material for eccentric compression over the puncture site

Figure 59 Situation at the end of surgery 53


Postoperative monitoring and further treatment The next morning the patient himself/herself removes the local bandage at the puncture site and is allowed to take a shower. The first postoperative visit is carried out on the 7th–14th day after EVLA, when the clinical and technical/anatomical therapy outcome should be monitored:

1.

FV

TH

Has a complete occlusion of the treated vein been achieved?

If the treated vein is not occluded or the occlusion of the vein is incomplete, there is a possibility to repeat EVLA or to perform foam sclerotherapy for the treated vein segment and to achieve the primary assisted ablation before a clinical recurrence has developed.

2.

GSV

Figure 60 US: PASTE I, thrombus (TH) propagation up to femoral vein

Are there any complications after the ablation?

Post ablation superficial thrombus extension (PASTE): synonymously the term endovenous heat induced thrombosis (EHIT) – a special type of deep vein thrombosis (DVT) after ablation: an extension of the thrombus to the saphenous junctions and further into the deep vein. It is classified into 4 PASTE stages: I – thrombus propagation up to the deep vein level; II – thrombus propagation in the deep vein with the narrowing of the vein to a maximum of 50%;

TH

FV

Figure 61 US: PASTE II, transverse view, thrombus propagation into the femoral vein from GSV 54

55


TH

GSV

FV

Figure 62 US: PASTE II, longitudinal view, thrombus propagation into the femoral vein from GSV

TH

Figure 63 US: PASTE III, longitudinal view, thrombus propagation into the femoral vein from GSV 56

III – thrombus propagation in the deep vein with the narrowing of the vein of more than 50%; IV – complete thrombotic occlusion of the deep vein. A complete DUS investigation of the deep venous system is also performed to search for DVT in other locations. PASTE and DVT after operation have been observed in less than 1% of patients. In the case of Grade I, the patient is monitored with an interval of 2 weeks without any medical treatment, while Grades II–IV require therapeutic anticoagulation and DUS controls with a 2 week interval. Monitoring and anticoagulation therapy is continued until a full resorption of the DVT. It usually takes 2–4 weeks. The second postoperative visit is usually done 3 months after EVLA when a duplex ultrasound investigation is performed for the target vein occlusion and possible complications (DVT), but the main focus is on the evaluation of the clinical, technical/anatomical and particularly cosmetic outcome after surgery: does the patient need any additional therapy for varicose veins superficial side branches? Our studies show that 80% of patients are satisfied with the outcome after EVLA and do not want additional treatment in 3 months period after performed EVLA. This approach makes it possible to reduce significantly the number of unnecessary phlebectomies carried out in onestep operations. If the patient is dissatisfied with the cosmetic outcome, the varicose side branches are usually treated with foam sclerotherapy, and only very rarely – by miniphlebectomy. A next patient visit is recommended after a year or upon new patient complaints. 57


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Van den Bos, R, Neumann M, de Roos, K-P, Nijsten T: Endovenous Laser Ablation–Induced Complications: Review of the Literature and New Cases. Derm Surg 2009; 35: 1206–1214 Schwarz T. von Hodenberg E. Furtwangler C. Rastan A. Zeller T. Neumann FJ: Endovenous laser ablation of varicose veins with the 1470-nm diode laser. J Vasc Surg 2010; 51: 1474–1478 Doganci S, Demirkilic U: Comparison of 980 nm Laser and Bare-tip Fiber with 1470 nm Laser and Radial Fiber in the Treatment of Great Saphenous Vein Varicosities: A Prospective Randomised Clinical Trial. Eur J Vasc Endovasc Surg 2010; 40: 254–259

Rasmussen LH, Lawaetz M, Bjoern L, Vennits B, Blemings A, Eklof B: Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose veins. Br J Surg 2011; 98: 10

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Pannier F, Rabe E, Maurins U: First results of a new 1470-nm diode laser for endovenous ablation of incompetent saphenous veins. Phlebology 2009; 24: 26–30

Bakker NA, Schieven LW, Bruins RMG, van den Berg M, Hissink RJ: Compression Stockings after Endovenous Laser Ablation of the Great Saphenous Vein: A Prospective Randomized Guidanceled Trial. Eur J Vasc Endovasc Surg 2013; 46: 588–592

Disselhoff BC, der Kinderen DJ, Kelder JC, Moll FL: Five-year results of a randomised clinical trial of endovenous laser ablation of the great saphenous vein with and without ligation of the saphenofemoral junction. Eur J Vasc Endovasc Surg 2011; 41: 685–690 Pavlovic MD, Schuller-Petrovic S, Pichot O, Rabe E, Maurins U, Morrison N, Pannier F: Guidelines of the First International Consensus Conference on Endovenous Thermal Ablation for Varicose Vein Disease – ETAV Consensus Meeting 2012. Phlebology. 2014. [Epub ahead of print] DOI:10.1177/0268355514524568 Proebstle TM, Moehler T, Gül D, Herdemann S: Endovenous treatment of the great saphenous vein using a 1,320 nm Nd:YAG laser causes fewer side effects than using a 940 nm diode laser. Derm Surg. 2005; 31: 1678–1683 58

Pannier F, Rabe E, Rits J, Kadiss A, Maurins U: Endovenous laser ablation of great saphenous veins using a 1470 nm diode laser and the radial fiber-follow-up after six months. Phlebology. 2011; 26(1): 35–9 Pannier F, Rabe E, Maurins U: 1470 nm diode laser for endovenous ablation (EVLA) of incompetent saphenous veins – a prospective randomized pilot study comparing warm and cold tumescence anaesthesia. Vasa. 2010; 39(3): 249–55 Maurins U, Rabe E, Pannier F: Does laser power influence the results of endovenous laser ablation (EVLA) of incompetent saphenous veins with the 1 470-nm diode laser? A prospective randomized study comparing 15 and 25 W. International angiology: a journal of the International Union of Angiology 03/2009; 28(1): 32–7 59

Smart Laser Treatment for Varicose Veins!

Dr. Maurins Vein Clinic Kokneses prospekts 18A LV-1014, Riga Latvia tel: + 371 67 315 316 fax: + 371 67 315 317 www.venucentrs.lv www.youtube.com/user/VeinCenter

This book offers a short and concise summary of the practical information necessary for a successful performance of EVLA. This booklet contains detailed information on the basics of EVLA and its practical aspects and has been published by Uldis Maurins, President of the Baltic Society of Phlebology. This publication may serve as a significant help for starting to apply EVLA as well as a source of additional knowledge for the colleagues with experience in EVLA wanting to start applying water absorbing lasers with radially emitting laser fibres.

ISBN 978–9934–14–363–2