Combined techniques : How to ablate varices during endovenous surgery ?

R.Milleret , D.Valean , M.Fodor

To treat During or After ?

• Conflicting studies but a majority is in favor of simultaneous treatment .• It’s true that tributaries directly connected to the trunk will shrink, but we have no predictive technique which could be applied to an individual patient.

Treating Saphenous Tributaries

• 4 techniques available : Invasive : --- Mini-Phlebectomies --- Cryo-Phlebetomy Non Invasive : --- Foam sclerotherapy --- Steam Phlebectomy

Methods

• Mini – Phlebectomies : --- Tumescent anesthesia --- Needle puncture --- Hook grasping --- Sub cutaneous dissection , Varady spatula --- Suture or no suture ?

Cryo-Phlebectomy

• 1,5 mm rigid probes• 10 to 15 cm length• Incision with N°11 blade• Tumescent anesthesia• Catheterization when possible • OR extraction by external freezing

Foam sclerotherapy

• Less concentration than usual , 0,5% to 1% Aetoxy .• Echo guided , from the thigh to the ankle• Catheter delivered if straight segments• Compression Tumescence after injection • ( Start technique , AA Ramelet )

Steam Phlebectomy

• Steam will travel through the tortuosities• All introducers in place before heating• General anesthesia or sedation more adapted• Cooling tumescence before and after steam injection : compression of the vein .* Large veins can be treated

Catheter in the 17 G Venflon

Results

• NO STUDIES ABOUT RE OPENING OF VEINS 3 TO 6 MONTHS AFTER : --- Foam Sclerotherapy --- Mini Phlebectomies --- Cryo-Phlebectomy

* Thousands of papers on Saphenous Trunks …

Steam : Trib vein study

• 3 centers : Nicolini , Hartung , Milleret• 30 members on 26 patients

• Age : 54 +- 13 years• Sexe : 55,2% women• Anesthésie : General = 67,9%

Material

• 92 tributaries• Diameters 6,4 +- 3,1 mm• Length 8 cm+- 5,1• Pulse/cm 2,3 +-0,9

• Entry Points : 4,9 +6 2,4 If Phlebectomies 13,1 +- 6,4 (P<0,0001)

Results

• Post Op Pain : 0,7/10 • Occlusion : 95,7 % 3 months 95,7 % 6 months• Patient’s evaluated cosmetic results : 92 % 3 months 100 % 6 months

Randomized study of Steam Phlebectomy versus Foam obliteration of superficial tributaries

Material

• 2 groups of 20 patients each,randomized .• Location of varices : Anterior Accessory , Internal Calf Posterior Calf* Diameter of varices : 3 to 10 , mean 6 mm .

Methods

• Foam : 1% Polidocanol , Tessari tourbillon technique, 6 to 10 cc in one session (Tegernsee)

• Steam : 3 to 6 pulses/location 3 to 6 18G / 20 G infusion catheters* Eccentric compression .

Post Op at 8 days

Foam Steam

Inflammation 6/20 0/20

Pain ( scale of 10 ) 2,4 0,5

Results at 1 month

Foam Steam

Blood extraction 12/20 6/20

Pigmentation 12/20 4/20

Results at 6 months

Foam Steam

Pigmentation 4/18 2/19

Cosmetic result 10/18 15/19(patient’s evaluationGood/very good)

Elements of choice

• Young woman , thin legs : Mini-Phlebectomies / Cryo phlebectomies

Because risk of pigmentation with foam , Vein still palpable for some months after steam .

Opposite case

• Man with big bulging varicose veins

Steam best option , painless , no diameter limit . Phlebectomies can be added as these veins are quite resistant and we can ablate long segments through one incision

Foam

• Combined with phlebectomies when all the veins cannot be removed : Accessory Anterior Saphenous trunk for intance .• Foam then Tumescence then Phlebectomy• Thus excess foam is removed through the phlebectomy incisions = less risk of pigmentation .

Specific problems

• Lipodermatosclerosis : avoid incisions , Steam = less inflammatory reactions can obliterate perforators• Superficial thrombosis : phlebectomy thrombectomy but trunk can be treated by heating technique .

V Box : 1 Box , 2 techniques

• Segmental Radio-Frequency ablation for Saphenous trunks ,

• Low Pressure Steam for Tributaries

• Just plug in to the mains , and connect the RF catheter or the Single Use Steam hand-piece

THE V box single use hand piece

Conclusion

• Choice of technique depends on the availability of the equipment : cryo , steam .• Phlebectomy combined with Foam offers a cheap way to treat these veins .• Scientific studies are far behind in this area as compared with Saphenous vein ablation.