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Endovenous thermal ablation for varicose vein

Endovenous thermal ablation for varicose vein. Joint Hospital Surgical Grand Round 16-4-2011 Wong Kwok Kei, Kwong Wah Hospital. Endovenous great saphaneous vein thermal ablation. Laser Radiofrequency. Potential advantages of Endovenous thermal treatment. “Minimally invasive”

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Endovenous thermal ablation for varicose vein

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  1. Endovenous thermal ablation for varicose vein Joint Hospital Surgical Grand Round 16-4-2011 Wong Kwok Kei, Kwong Wah Hospital

  2. Endovenous great saphaneous vein thermal ablation • Laser • Radiofrequency

  3. Potential advantages of Endovenous thermal treatment • “Minimally invasive” • LA, day case • Earlier return to normal activities

  4. Limitation of Endovenous thermal treatment • Not for vein >12mm diameter (?result inferior to surgery) • Too tortuous • Patient not ambulatory • pacemaker, internal defibrillator, active implanted device for RFA • EVLT & RFA mainly for GSV • ? Perforator

  5. Endovenous thermal Treatment Endovenous thermal therapy Thrombosis Organization of thrombus Recanalization Fibrous cord

  6. Endovenous laser therapy (EVLT) • A laser is a device that emits light (electromagnetic radiation) through a process called stimulated emission

  7. Endovenous Laser Therapy: mechanism Indirect thermal: → absorbed by Hb / water in blood (chromophore) → steam bubbles → vein wall destruction → thrombosis → fibrosis Direct thermal: → carbonization of vein wall on direct contact → vein wall destruction → thrombosis → fibrosis

  8. Radiofrequency Ablation(RFA) • Bipolar radiofrequency current • Resistive heating – transmural death → thrombosis → fibrosis

  9. Endovenous thermal ablation Procedure GSV entered at the knee under USG guidanceLongitudinal US visualization of sheath 1-2 cm distally to the SFJ Tumescent anesthesia Pull back of laser/ RFA fibre Need phlebectomy/ sclerotherapy for thigh and calf varicosities Bola Pratt P&S MS 4

  10. Early technical successEVLT- duplex findings < 6 months Study end point

  11. Early technical successRFA - duplex findings < 6 months Study end point

  12. GSV thermal ablationlong term results Study end point

  13. Endovenous therapies of lower extremity varicosities: A meta-analysisRenate van den Bos, MD,a Lidia Arends, PhD,b,c Michael Kockaert, MD,aMartino Neumann, MD, PhD,a and Tamar Nijsten, MD, PhD,a Rotterdam, The Netherlands(J Vasc Surg 2009;49:230-9.)

  14. RCT RFA vs surgery

  15. RCT EVLT vs surgery

  16. RCT RF vs EVLT

  17. Is laser really inferior to RF in terms of post operative pain and minor complication? • Comparison of 980 nm Laser and Bare-tip Fibre with 1470 nm Laser and Radial Fibre in the Treatment of Great Saphenous Vein Varicosities: A Prospective Randomised Clinical Trial S. Doganci*, U. Demirkilic Eur J Vasc Endovasc Surg (2010) 40

  18. Advancement in EVLT: wavelength Wavelengths; 810, 940, 980, 1319, 1320,1470nm. Type of laser; • Diode; 810, 940, 980,1470. • Nd:YAG; 1319, 1320. Dominant chromophore; • Hemoglobin; 810, 940, 980 • Water (collagen in vein wall) ; 1319, 1320,1470

  19. Advancement in EVLT: fibre • jacket-tip fibers • Glass • Ceramic • Radial • Tulip-tip

  20. Advancement in RFA • 1999: Use of Radiofrequency to heat up long saphenous vein • 2003: 2nd G RFA Cath (VNUS ClosurePlus) commercially a/v in HK • 2006: FDA Approval of 3rd G RFA VV(VNUS ClosureFAST) • 10/2007: first 3rd G RFA VV cath(VNUS ClosureFAST) in HK

  21. Advancement in RFA • 2nd generation VNUS ClosurePlus • 85 degree Celsius • Pull back 1cm per min for 5 min then 2-3 cm per min for remainder • Impendence: 8Fr >100 OM • 6Fr >150 OM • Power 3-4 Watt • VNUS ClosureFAST: • 120 degree Celsius • Automatic impedance and power • 5-40watt • 7cm treatment site 2nd generation RFA catheter The ClosureFAST catheter and the RFGPlus™ generator.

  22. Conclusion • Endovenous thermal ablation: • Occlusion rate comparable with surgery • Perform under local anesthesia; • same - day procedure; • less pain, discomfort and complications; • earlier return to normal activities

  23. Conclusion • RFA was associated with less postprocedural pain, minor complication (eg. Bruising, phlebitis) than EVLT.

  24. Conclusion: Ideal RCT • RCT comparing ablation of the incompetent GSV using surgery vs RF (Closure-Fast) vs laser (Jacket-tipped?1470 nm?) vs foamsclerotherapy. • Participants stratified by the severity of symptoms and signs eg, CEAP classification • Long follow-up, at least 5 years; • Assess patient - important outcomes: • Varicose vein recurrence • Patient satisfactionDisability and QOL • Use standardized disease-specific scales for these outcomes (VCSS, AVVSSS) • Cost-effectiveness data.

  25. The Comparison of LAaser, Surgery andfoam Sclerotherapy (CLASS) trial • HTA funded – started Summer 2008 • UK multi centre RCT – 5 centres • Outcomes; 6 wks, 6 mths & 5 yrs • Primary: disease specific and general QoL changes • Secondary: technical success, clinical success, cost effectiveness • Sample size = 1015 pts (203 / centre)

  26. Thank you!

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