AMT Alw lway ays in in pur pursuit t of of in innov ovativ - - PowerPoint PPT Presentation

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AMT Alw lway ays in in pur pursuit t of of in innov ovativ - - PowerPoint PPT Presentation

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AMT Alw lway ays in in pur pursuit t of of in innov ovativ ive tec echnol ologie ies EndoVenous Laser Treatment (EVLT) AMT Alw lway ays in in pur pursuit t of of in innov ovativ ive tec echnol ologie ies Greater

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EndoVenous Laser Treatment (EVLT™)

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Greater Saphenous Vein Reflux

  • Treatment Aims
  • Inclusion Criteria for EVLT
  • Exclusion Criteria for EVLT
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Treatment Aims

  • Eliminate source of reflux
  • Incompetent saphenofemoral or saphenopopliteal

junction

  • Incompetent perforator connections to the above
  • Ablate incompetent venous segments
  • Offer an alternative to traditional treatment

– ligation & stripping

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Inclusion Criteria

  • Varicose veins due to SFJ/SPJ incompetence

and GSV/SSV reflux as demonstrated by bi- directional continuous wave doppler and duplex ultrasound imaging

  • At least 18 years of age
  • Either gender
  • EVLT chosen by patient over surgery or other

MIS techniques

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Exclusion Criteria

  • Concomitant peripheral arterial disease
  • Inability to ambulate
  • Deep venous thrombosis
  • Pregnancy or breast feeding
  • General poor health
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AMT

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EndoVenous Laser Treatment

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Step-by-Step Guide

  • Pre-operative examination
  • The Procedure
  • Post-operative care
  • Follow-up
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Pre-operative Examination

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Pre-operative Examination

  • Patient describes symptoms
  • Physical exam of extremities
  • Ultrasound exam using duplex scanner
  • Transverse measurements of GSV/LSV
  • Photography of legs for comparison
  • Patient signs consent form
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The Procedure

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The Procedure

  • Patient Placed on Treatment Table
  • Head-up (Reverse Trendelenberg)
  • Sterile Prep and Drape leg
  • Anaesthetise entry point with local
  • Make small skin nick at entry point*
  • Needle entry into GSV under U/S control

*May be done after Guide Wire inserted but before sheath

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SLIDE 12

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The Procedure

  • If difficult access use Micro Introducer Kit
  • Guide wire passed through needle and up

GSV

  • Remove needle from patient/guide wire
  • Load dilator into sheath avoiding kinking
  • Sheath/dilator passed over guide wire
  • Remove dilator and guide wire
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The Procedure

  • Aspirate via side arm to check for venous

blood and flush sheath with saline

  • Insert fiber into sheath up to first mark
  • Position tip of sheath & fiber using

ultrasound (1-2cm below SFJ/SPJ)

  • If epigastric vein enters GSV near the

junction position sheath tip below this

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SLIDE 14

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The Procedure

  • Hold fiber still and withdraw sheath over

fiber back to 2nd marker

  • Confirm fiber tip position with U/S (1-2cm

below SFJ/SPJ or epigastric vein entry point)

  • Secure fiber to sheath with friction lock
  • Pass proximal end of fiber to assistant for

attachment to Laser

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The Procedure

  • Patient placed head down (Trendelenberg

Position)

  • Anesthetise length of leg along the line of

the GSV with tumescent solution

  • This should be done under U/S control to

ensure anaesthetic surrounds the GSV

  • Anaesthetic compresses vein over the

fiber tip and provides cooling + analgesia

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SLIDE 16

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The Procedure

  • Issue safety glasses to ALL people in

treatment area including the patient

  • Activate the laser
  • Check the patient for transillumination of

the aiming beam at the groin* *NOTE: The aiming beam is not a substitute for Ultrasound in confirming fiber position

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The Procedure

  • There are two alternative treatment

modes:

– Pulsed and Continuous

  • For Pulsed technique:

– Set Laser in ‘repeat pulse’ mode:

  • 12 Watts
  • 1 second pulse
  • 1 second pause
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The Procedure

  • Turn down room lights
  • Fire laser and withdraw fiber & sheath:

– Deliver 5 – 7 pulses of laser energy per cm of vein treated – Ideally deliver ~70 Joules of energy per cm of vein treated

  • Check the above parameters were met
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The Procedure

  • For Continuous technique:

– Set Laser in ‘continuous’ mode:

  • 14 Watts Power
  • Turn down room lights
  • Activate the laser
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The Procedure

  • Withdraw fiber & sheath in a continuous

action:

– Withdrawal rate of 4 – 6 seconds per cm of vein treated – Ideally deliver ~70 Joules of energy per cm of vein treated

  • Check the above parameters were met
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SLIDE 21

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The Procedure

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Post-operative Care

+

Bandage Compression

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Post-operative Care

  • Dress leg with compression bandage:
  • Variety of types used
  • Personal preference of Clinician
  • Class II compression stocking:
  • Must be fitted correctly
  • Not worn at night
  • Up to a 20 minute walk before leaving
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Post-operative Care

  • Resume normal activities:
  • Light exercise recommended
  • Avoid hot baths
  • Avoid vigorous gym workouts
  • OTC non-aspirin analgesics for any pain:
  • Pain usually after 3 – 4 days
  • Some clinicians give prophylactic anti-inflammatory

drugs for ~I week post op.

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SLIDE 25

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Follow-up

Duplex Ultrasound

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Follow-up

  • Examinations done with ultrasound to

confirm vein staying closed:

– At one week – At one, three and six months – Yearly thereafter

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Follow-up

  • Additional treatment as needed
  • Phlebectomy:
  • Usually done at the same time as EVLT
  • Usually under GA but can be done under local
  • Sclerotherapy
  • Done as separate treatment after 4-6 weeks
  • Only treats vein which are still visible
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EndoVenous Laser Treatment

  • The Results
  • Combined Results
  • Long Term Results
  • Potential Advantages
  • Conclusions
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Pre-EVLT 2 Wks Post-EVLT

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EVLT The Results

  • 195 GSVs treated in 172 patients
  • 100% technical success
  • Well tolerated by all patients under

strictly local anesthesia

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EVLT The Results

126 Women 46 Men Range: 23-77 yrs Mean: 42 yrs

Gender Age Side Diameter Length

110 Left 85 Right Range: 4.4-28 mm Mean: 10 mm Range: 15-48 cm Mean: 36 cm

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EVLT The Results

  • 187/195 (96%) of GSVs successfully closed

following initial EVLT

  • 7/195 (4%) GSVs closed following re-treatment

with EVLT

  • 190/195 (97%) GSVs remain closed at 1-21 month

f/u with duplex ultrasound (+color doppler) evaluation

  • There have been no skin burns, paresthesias, or
  • ther adverse reactions
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EVLT The Results

Follow-Up (Months) Ratio Closed (% Closed) % Reduction In Diameter 1 3 6 9 12 18 21 195/195 (100%) 158/160 (99%) 114/115 (99%) 72/74 (97%) 59/59 (100%) 43/43 (100%) 19/19 (100%) 30% 52% 73% > 85% > 85% > 85% > 85%

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EVLT The Results

Combined Results (Min, et al.)

  • > 1000 GSVs treated with endovenous

laser

  • Up to 21 month follow-up
  • > 97% of GSVs have remained closed
  • Bruising & mild tenderness (< 2 wks)
  • No other minor or major complications
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EVLT The Results

Long Term Results (Min & Khilnani, 2005)

  • 1000 GSVs treated with endovenous laser
  • Up to 60 month follow-up
  • > 98% Success rate
  • Ecchymosis resolved in all cases(< 4 wks)
  • No other minor or major complications
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Pre-Treatment Post-Treatment

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Potential Advantages

  • Safe in-office procedure
  • Well-tolerated with local anesthesia
  • Non-scarring with minimal access site

size

  • Immediate return to daily activities
  • Lower treatment costs compared to

surgery

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Conclusions

  • Extremely favorable long-term results with

EVLT

  • Appears to be a very safe and well

tolerated in-office procedure

  • Effective closure of incompetent GSV

segments

  • The future looks bright