View
222
Download
1
Category
Preview:
Citation preview
Endovenous thermal ablation for varicose vein
Joint Hospital Surgical Grand Round16-4-2011
Wong Kwok Kei, Kwong Wah Hospital
Endovenous great saphaneous vein thermal ablation
• Laser• Radiofrequency
Potential advantages of Endovenous thermal treatment
• “Minimally invasive”• LA, day case• Earlier return to normal activities
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
Endovenous thermal Treatment
Endovenous thermal therapy
Thrombosis
Organization of thrombus
Recanalization Fibrous cord
Endovenous laser therapy (EVLT)
• A laser is a device that emits light (electromagnetic radiation) through a process called stimulated emission
Endovenous Laser Therapy: mechanism
Direct thermal: → carbonization of vein wall
on direct contact → vein wall destruction → thrombosis → fibrosis
Indirect thermal:→ absorbed by Hb / water in blood (chromophore) → steam bubbles
→ vein wall destruction → thrombosis → fibrosis
Radiofrequency Ablation(RFA)
• Bipolar radiofrequency current
• Resistive heating – transmural death → thrombosis → fibrosis
Endovenous thermal ablation Procedure
Bola Pratt P&S MS 4
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 fibreNeed phlebectomy/ sclerotherapy for
thigh and calf varicosities
Early technical successEVLT- duplex findings < 6 months
Study end point
Early technical successRFA - duplex findings < 6 months
Study end point
GSV thermal ablationlong term results
Study end point
Endovenous therapies of lower extremity varicosities: A meta-analysisRenate van den Bos, MD,a Lidia Arends, PhD,b,c Michael Kockaert, MD,a
Martino Neumann, MD, PhD,a and Tamar Nijsten, MD, PhD,a Rotterdam, The Netherlands(J Vasc Surg 2009;49:230-9.)
RCT RFA vs surgeryPerälä J, Rautio T, Biancari F et al
Lurie F, Creton D, Eklöf B, et al
Stötter L, Schaaf I, Bockelbrink A, et al
Hinchcliff RJ, Ubhi J, Beech A, et al
Number of patient
28 85 20 16 (bil recurrent VV after HL)
Follow up 3 years 2 years 1 year 1 year
Less pain RFA RFA RFA RFA
Less minor complication eg. Bruise, edema
RFA RFA RFA
Better QOL RFA
Faster recovery RFA 6.5 days; HL/S 15.6 days
RFA RFA
Total societal costs
RFA $1401; HL/S $1926
Operative time RFA 25mins, HL/S 40mins
RCT EVLT vs surgeryDe Medeiros CAF, Luccas GC
Vuysteke M, Bussche DVd, Audenaert EA et al.
Rasmussen LH, Bjoern L, Lawaetz M, et al
Ogawa T, Hoshino S, Makimura S, et al
Kalteis M, Berger I, Messie-Werndl S, et al
Darwood RJ, Theivacumar N, Dellagrammaticas D, et al
Number of patient 20 164 121 92 100 103
Laser 810nm 810nm 980nm 980nm 810nm 810nm
Follow up 2 years 9 months 2 years 6 months 4 months 1 year
Less pain similar similar similar EVLT
Less minor complication
EVLT similar EVLT similar
Return to routine activities
EVLT 8.6, HL/S 22.4
HL/S 14, EVLT 20
EVLT
QOL at FU similar similar similar
Hospital stay EVLT 1.5 HL/S 2.7
RCT RF vs EVLTMorrison N Almeida J,
Kaufman J, Makhoul R, et al
Goode S, Crockett M, Richards T, et al
Gale SS, Lee JN, Walsh WE et al.
A. C. Shepherd,M. S. Gohel, L. C. Brown et al.
Patient 50, bil VV
87 22, bil VV 119 131
EVL 980nm 810nm 600nm 980nm
RF Closure-Fast Celon RFiTT Closure Plus ClosureFAST
Follow up 1 year 30 days 14 days 1 year 6 weeks
Less pain Similar RFA RFA RFA RFA
Less minor Cx similar RFA RFA RFA RFA
Procedure time similar EVLT 19mins, RFA 13 mins
QOL at FU similar similar
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. DemirkilicEur J Vasc Endovasc Surg (2010) 40
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
Advancement in EVLT: fibre
• jacket-tip fibers• Glass• Ceramic• Radial• Tulip-tip
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
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
The ClosureFAST catheter and the RFGPlus™ generator.
2nd generation RFA catheter
Conclusion
• Endovenous thermal ablation:1.Occlusion rate comparable with surgery2.Perform under local anesthesia;3.same - day procedure;4. less pain, discomfort and complications;5.earlier return to normal activities
Conclusion
• RFA was associated with less postprocedural pain, minor complication (eg. Bruising, phlebitis) than EVLT.
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 satisfaction
Disability and QOL– Use standardized disease-specific scales for these
outcomes (VCSS, AVVSSS)– Cost-effectiveness data.
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)
Thank you!
Recommended