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

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 Saphenous Vein Reflux • Treatment Aims • Inclusion Criteria for EVLT • Exclusion Criteria for EVLT

AMT Alw lway ays in in pur pursuit t of of in innov ovativ ive tec echnol ologie ies 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

AMT Alw lway ays in in pur pursuit t of of in innov ovativ ive tec echnol ologie ies 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

AMT Alw lway ays in in pur pursuit t of of in innov ovativ ive tec echnol ologie ies Exclusion Criteria • Concomitant peripheral arterial disease • Inability to ambulate • Deep venous thrombosis • Pregnancy or breast feeding • General poor health

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

AMT Alw lway ays in in pur pursuit t of of in innov ovativ ive tec echnol ologie ies Step-by-Step Guide • Pre-operative examination • The Procedure • Post-operative care • Follow-up

AMT Alw lway ays in in pur pursuit t of of in innov ovativ ive tec echnol ologie ies Pre-operative Examination

AMT Alw lway ays in in pur pursuit t of of in innov ovativ ive tec echnol ologie ies 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

AMT Alw lway ays in in pur pursuit t of of in innov ovativ ive tec echnol ologie ies The Procedure

AMT Alw lway ays in in pur pursuit t of of in innov ovativ ive tec echnol ologie ies 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

AMT Alw lway ays in in pur pursuit t of of in innov ovativ ive tec echnol ologie ies 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

AMT Alw lway ays in in pur pursuit t of of in innov ovativ ive tec echnol ologie ies 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

AMT Alw lway ays in in pur pursuit t of of in innov ovativ ive tec echnol ologie ies 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

AMT Alw lway ays in in pur pursuit t of of in innov ovativ ive tec echnol ologie ies 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

AMT Alw lway ays in in pur pursuit t of of in innov ovativ ive tec echnol ologie ies 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

AMT Alw lway ays in in pur pursuit t of of in innov ovativ ive tec echnol ologie ies 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

AMT Alw lway ays in in pur pursuit t of of in innov ovativ ive tec echnol ologie ies 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

AMT Alw lway ays in in pur pursuit t of of in innov ovativ ive tec echnol ologie ies The Procedure • For Continuous technique : – Set Laser in ‘continuous’ mode: • 14 Watts Power • Turn down room lights • Activate the laser

AMT Alw lway ays in in pur pursuit t of of in innov ovativ ive tec echnol ologie ies 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

AMT Alw lway ays in in pur pursuit t of of in innov ovativ ive tec echnol ologie ies The Procedure

AMT Alw lway ays in in pur pursuit t of of in innov ovativ ive tec echnol ologie ies Post-operative Care + Bandage Compression

AMT Alw lway ays in in pur pursuit t of of in innov ovativ ive tec echnol ologie ies 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

AMT Alw lway ays in in pur pursuit t of of in innov ovativ ive tec echnol ologie ies 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.

AMT Alw lway ays in in pur pursuit t of of in innov ovativ ive tec echnol ologie ies Follow-up Duplex Ultrasound

AMT Alw lway ays in in pur pursuit t of of in innov ovativ ive tec echnol ologie ies Follow-up • Examinations done with ultrasound to confirm vein staying closed: – At one week – At one, three and six months – Yearly thereafter

AMT Alw lway ays in in pur pursuit t of of in innov ovativ ive tec echnol ologie ies 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

AMT Alw lway ays in in pur pursuit t of of in innov ovativ ive tec echnol ologie ies EndoVenous Laser Treatment • The Results • Combined Results • Long Term Results • Potential Advantages • Conclusions

AMT Alw lway ays in in pur pursuit t of of in innov ovativ ive tec echnol ologie ies Pre-EVLT 2 Wks Post-EVLT

AMT Alw lway ays in in pur pursuit t of of in innov ovativ ive tec echnol ologie ies EVLT The Results • 195 GSVs treated in 172 patients • 100% technical success • Well tolerated by all patients under strictly local anesthesia

AMT Alw lway ays in in pur pursuit t of of in innov ovativ ive tec echnol ologie ies EVLT The Results 126 Women 46 Men Gender Range: 23-77 yrs Mean: 42 yrs Age 110 Left 85 Right Side Range: 4.4-28 mm Mean: 10 mm Diameter Range: 15-48 cm Mean: 36 cm Length

AMT Alw lway ays in in pur pursuit t of of in innov ovativ ive tec echnol ologie ies 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 other adverse reactions

AMT Alw lway ays in in pur pursuit t of of in innov ovativ ive tec echnol ologie ies EVLT The Results Follow-Up Ratio Closed % Reduction (Months) (% Closed) In Diameter 1 195/195 (100%) 30% 52% 3 158/160 (99%) 6 114/115 (99%) 73% 9 72/74 (97%) > 85% 12 59/59 (100%) > 85% 18 43/43 (100%) > 85% 21 19/19 (100%) > 85%